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The JSH Practical Guidelines for Hematological Malignancies, 2018 expanded edition, newly adopted brentuximab vedotin, doxorubicin, vinblastine, dacarbazine(A+AVD)protocol as a standard treatment for advanced-stage classical Hodgkin lymphoma(CHL). Therefore, this retrospective analysis compared 15 patients who received A+AVD therapy with 21 patients who received doxorubicin, bleomycin, vinblastine, dacarbazine(ABVD)therapy. All patients were newly diagnosed with CHL and received induction therapy between April 2015 and June 2022 in our hospital. All except 1 patient of the A+AVD group had advanced-stage CHL. The median age was 63(23-85)years. The estimated 2-year overall survival of the A+AVD group was better than that of the ABVD group which included 6 patients with clinical stage Ⅲ or higher CHL (100% vs 66.7%, p=0.047). In contrast, there was no significant difference in the complete response rate(53.8% vs 100%, p=0.109)between the 2 groups. The overall response rate after first-line treatment(69.2% vs 100%, p=0.255), and the estimated 2-year progression-free survival(70.1% vs 66.7%, p=0.321)between the A+AVD and the ABVD groups were similar.

Injuries of the spine and nerve root may occur during spine or spinal cord surgery, which can induce serious neurological deficits. Intraoperative monitoring plays important roles in monitoring the nerve function in various surgical manipulations, such as surgical positioning, mechanical compression, and tumor removal. This monitoring issues a warning to neuronal injuries at an early stage, and surgeons are able to prevent postoperative complications. The appropriate monitoring systems should be chosen with compatibility to the disease, surgical procedure, and lesion localization. The team should share the significance of monitoring and understand the timing of stimulation to perform a safe surgery. In this paper, we overview various intraoperative monitoring techniques and pitfalls in spine and spinal cord surgeries based on cases from our hospital.

Superficial temporal artery-middle cerebral artery(STA-MCA)bypass surgery is a common operation in neurosurgery. There are several variations of this surgical method. We conducted a questionnaire survey on the details of surgical procedures in 171 neurosurgical institutes in Japan. Contrary to expectations, wide variations emerged in some surgical procedures, including the shape of skin and muscle incisions, the site of the temporary clip at the donor artery(STA), and the cutting method of the donor end. Western Japan institutions tended to vary more in terms of skin incision methods and donor cutting methods. It will likely be useful in the future to be aware of the numerous variations in surgical methods.

The patient was a 68-year-old woman, diagnosed with acute myelomonocytic leukemia with normal karyotype and FLT3-ITD-negative status in May 2019. She had achieved complete remission (CR) after "7+3" intensive induction chemotherapy and maintained CR by consolidation chemotherapy. However, she relapsed with swelling of the lips and gums in January 2020. She did not achieve CR by salvage chemotherapy with cytarabine-aclarubicin-G-CSF regimen. Comprehensive genomic analysis of leukemic cells revealed the presence of FLT3-N676K mutation, which was undetectable by companion diagnostics at the time. Complete remission with incomplete count recovery was obtained on day 28 after initiation of gilteritinib monotherapy, and the lip and gum swelling improved rapidly. However, she relapsed on day 106 after gilteritinib administration, and gilteritinib was discontinued. Genomic analysis at recurrence revealed NRAS mutation for the first time. Finally, the patient died of the uncontrolled primary disease. This is a case in which comprehensive gene mutation analysis was useful in determining a treatment strategy.

The patient developed Stage Ⅳ transverse colon cancer at the age of 72 years and was treated with an 8-course XELOX regimen(capecitabine and oxaliplatin)every 3 weeks after resection. Six years and 9 months after the end of treatment, at the age of 79 years, WBC levels were found to have markedly increased to 10×104/µL in the patient, and acute leukemia was suspected; subsequently, the patient was hospitalized. Bone marrow was aspirated and analyzed, and the results showed that 95% of leukemic cells were positive for esterase staining. Chromosomal examination revealed t(6 ; 11)(q27 ; q23), ie, the diagnosis of therapy-related acute myeloid leukemia(t-AML)with 11q23 abnormality. CR was achieved by chemotherapy, but the disease soon recurred; the patient died 7 months after the onset of t-AML, with the cause being t- AML with 11q23 abnormality that developed 6 years and 9 months after treatment for colorectal cancer with oxaliplatin and capecitabine without undergoing MDS. Since there is a possibility of leukemia induction following oxaliplatin treatment, more such cases need to be monitored in the future.

A determination method for tributyltin (TBT) and triphenyltin (TPT) in fish and shellfish using an accelerated solvent extractor (ASE) and LC-MS/MS was developed. The chromatographic separation was conducted on a Poroshell 120 EC-C18 column using an isocratic mobile phase of 0.1% formic acid in 70% methanol. Sample preparation was performed using ASE at 125℃ with n-hexane and a cleanup using a Florisil cartridge. Internal calibration curves using deuterium-labeled TBT and TPT were employed for quantification. For both TBT and TPT, the calibration curves were linear in the range of 0.2-250 ng/mL, and the method quantification limits were 0.8 ng/g for both TBT and TPT. A National Institute for Environmental Studies certified reference material, No. 15 (adductor muscle of scallop), was analyzed to assess the performance of the developed method. The trueness, relative standard deviations of repeatability, and within laboratory reproducibility of this method, evaluated using a recovery test with four spiked fish species and one shellfish, ranged from 89.3 to 105.3%, 1.0 to 4.5%, and 1.3 to 7.6%, respectively.

We examined the expansion of target food products for the analysis of polychlorinated biphenyls (PCBs). From our studies in fish using an accelerated solvent extractor (ASE) and GC-MS/MS, we found that recovery of low-chlorinated PCBs (some isomer of 3 or 4 chlorinated PCBs) in specific food products was low. Therefore, we attempted to improve the analytical method. In Japanese sea perch (Suzuki) and milk, freeze drying before extracting with ASE did not sufficiently improve the recovery of low-chlorinated PCBs; however, it was significantly improved by changing the column to a silica gel/H 2 SO 4 silica gel multilayer column. To evaluate this method for other food products, PCBs in fish, meat, eggs, milk, and dairy products were analyzed. The samples were extracted using ASE at 125℃ with n-hexane, cleaned up using a silica gel/H 2 SO 4 silica gel multilayer column, and analyzed by GC-MS/MS for 3-7 chlorinated PCBs. The limit of quantification for this method was was 0.03-0.16 μg/kg for the 3-7 chlorinated PCBs. The recovery and the coefficient of variation of 3-7 chlorinated PCBs from each of the food products (n=5) was in the range of 84%-112% and 1%-9%, respectively.

We examined the clinical characteristics and outcomes of patients who had fallen from ladders and statistically analyzed the prognostic factors, highlighting the impact of the coexistence of head injuries on their prognoses. The clinical records of patients who had experienced ladder-related falls who were admitted to the Advanced Emergency Medical Service Center at Kurume University Hospital between April 2013 and August 2015 were retrospectively reviewed. A total of 86 patients were enrolled. The mean patient age was 69.2 years, and 82 patients were male. The median fall height was 2.55 m. Sixty patients fell during non-professional use of the ladder. Forty-four patients experienced some type of head injury. Although the older patients had more frequent complications with head injuries, the height of the fall was not related statistically. The group of patients with head injuries exhibited trends of older age, lower Glasgow Coma Scale scores, higher Injury Severity Score, and poorer outcomes than those of the group of patients without head injuries. Multivariate analysis showed that head injury and non-professional use were independent risk factors for poor outcomes. Our results revealed that ladder-related falls with head injury can occur when older people are working at home, even if they have fallen from a low height. Especially when older men work with the ladder at home, local community-based education and guidance for the prevention of ladder-related fall injuries are needed.

An analytical method for PCBs in fishes using an accelerated solvent extractor (ASE) and GC-MS/MS was evaluated. After the extraction of ASE at 125℃ with n-hexane and clean-up with an AgNO 3 silica gel/H 2 SO 4 silica gel multilayer column, samples were analyzed by GC-MS/MS. This method was fast, effective and easy to operate. The limit of quantitation of the method was calculated to be 0.78 μg/kg for total PCBs. The recovery and the coefficient of variation of PCBs (n=5) from 6 fishes (Japanese sea perch, chub mackerel, yellowtail, salmon, pacific saury, and sardine) of total PCBs were 91-108% and 1-3%, respectively.

An 84-year-old man, who had received artificial pneumothorax for pulmonary tuberculosis 67 years previously, complained of severe chest pain. Chest CT revealed chronic pyothorax with multiple heterogeneously enhanced cavity lesions in the wall of the right intrathoracic space. 18 FDG-PET revealed that the lesions showed an abnormal uptake. CT-guided biopsy was performed and he was diagnosed with pyothorax-associated lymphoma (PAL); the histological diagnosis was diffuse large B cell lymphoma (DLBCL). Furthermore, immunohistochemical staining revealed that the tumor cells were positive for EBNA-2 and LMP-1, suggesting that the latent gene products of Epstein-Barr virus were associated with the development of PAL. The patient was treated with chemotherapy, including rituximab; however, the treatment was discontinued due to the development of severe delirium after chemotherapy. We should keep in mind that elderly patients with a long history of chronic pyothorax are at risk of developing malignant lymphoma. We report the present case with a brief review of the literature.

Background: Several reports have examined meth- ods to control pain after a laparoscopic cholecystec- tomy (LC) and have shown regional anesthesia to be an effective method. We had been performing LC using simple general anesthesia (G); however, in 2013, we adapted a rectus sheath block (RSB), and in 2014, we used a combination of RSB and a subcostal transversus abdominis plane block (TAPB) on the right side. We report on the transition from G to regional anesthesia in LC and its effect on postoperative pain., Methods: We anesthetized three groups of patients undergoing LC. Group 1 received G (n =32) ; group 2 received RSB (n=28); and group 3 received a combination of RSB and TAPB (n=31). Patients used the numeric rating scale (NRS) to record their levels of postoperative pain, and the scores were compared for each group., Results: No significant differences were noted in NRS scores between the G and RSB groups; however, the scores in the RSB group tended to be lower. NRS scores were significantly lower in the RSB-TAPB group than in both the RSB and G groups., Conclusions: This study showed that the combina- tion of RSB-TAPB effectively controlled pain after LC and lowered NRS scores.

We report a case in which unilateral thoracic para- vertebral block was used to effectively control pain in a 78-year-old male patient with Child's A liver cirrhosis and esophageal cancer. Epidural anesthesia was con- sidered risky in this case because of the low platelet count from cirrhosis. Therefore, we performed a unilat- eral thoracic paravertebral block and cannulation under general anesthesia. We administered 0.33% levobupi- vacaine 10 ml through the catheter for intraoperative analgesia. After the operation, we confirmed the place- ment of the catheter with a chest X-ray image : then, the patient was extubated and returned to the ward. Three hours after the operation, the patient com- plained of pain in his wound : hence, 0.33% levobupi- vacaine 5 ml was injected through the catheter, which effectively controlled pain for 10 hours. Further injec- tions were done 13 and 21 hours after the operation, and the catheter was removed 21 hours after the operation. While the catheter was in place, the patient scarcely complained of pain. The unilateral thoracic paravertebral block covered the wide range of wounds and provided good analgesia for the patient.

We herein report the cases of two elderly patients with acquired hemophilia A (AHA) for whom treatment was difficult.An 89-year-old woman (Case 1) was admitted to our department with subcutaneous hemorrhage and melena. Her activated partial thromboplastin time (APTT), factor VIII activity, and factor VIII inhibitor level were 127.7 seconds, 1.0%, and 48 BU/mL, respectively, which was suggestive of AHA. The administration of prednisolone (PSL 0.5 mg/kg) was initiated. After 3 weeks, PSL was combined with cyclophosphamide (CPA 50 mg). Two months after the start of treatment, her factor VIII inhibitor level decreased to 3.4 BU/mL. However, hemorrhagic signs were repeatedly observed during the discontinuation of recombinant activated factor VII (rFVIIa) preparation; bleeding control became insufficient, and pneumonia developed, thus leading to a fatal outcome.An 81-year-old woman (Case 2) was admitted to our department with subcutaneous hemorrhage, anemia (Hb: 9.2 g/dL), and a prolonged APTT (78.7 seconds). Her factor VIII activity was reduced to 0.9%, and her factor VIII inhibitor level was markedly increased to 1,364.9 BU/mL, suggesting AHA. Treatment with PSL (0.5 mg/kg) was initiated. After one month, it was combined with CPA (50 mg); however, her hemorrhagic signs were protracted, and her Hb level decreased to 8.0 g/dL. Subsequently, pneumonia occurred. However, weekly rituximab therapy (375 mg/m 2 ) for 4 weeks decreased her factor VIII inhibitor level, leading to the disappearance of the inhibitor at 1 year and 5 months. During this period, there were no episodes requiring the administration of bypassing agents, such as rFVIIa.

Objectives: After bills to launch the Social Security and Tax Number System were enacted in 2013, health and political officials have considered the Healthcare Number System (the System). However, little is known about doctors' awareness and concerns about the System. This study aimed to measure how many doctors disagree with the System, examine the doctors' characteristics, and analyze the benefits and harms of the System that they identified., Methods: A cross-sectional survey was conducted of doctors via the Internet. The participants were selected from a convenience sample of a panel of doctors based on stratified sampling including four groups: working at a hospital and <45 years; working at a hospital and ≥45 years; working at a clinic and <45 years; and working at a clinic and ≥45 years. The main outcome was how many doctors agreed or disagreed with the System. The prevalence was calculated for each group, and their characteristics were examined using multivariable logistic regression analysis. The responses to open-ended questions concerning the Systems' benefits and harms were analyzed using qualitative content analysis., Results: There were 562 respondents (68%). By group, 16/143 (11%), 25/138 (18%), 31/132 (23%), and 43/149 (29%) doctors, respectively, thought that the System was unnecessary. The variables that correlated with the main outcome were age (per 5 years; odds ratio [95% confidence interval], 1.14 [1.01-1.29]) and type of medical facility (working at a clinic; 1.99 [1.30-3.08]). The doctors identified that unifying information could decrease administrative duties, facilitate inter-facility collaboration, and prevent inappropriate medical consultations. This could result in decreased healthcare costs and personalized healthcare. However, the doctors also identified that integrating information and dealing with big data could increase information leakage and information management, cause over-monitoring of doctors, and enable the inappropriate use of integrated information. This could result in deteriorating healthcare. Since some information should not be integrated, the System raises ethical considerations about privacy., Conclusion: Among the doctors surveyed here, 10-30% thought the System was unnecessary. These respondents tended to be older and work at a clinic. The System could decrease the cost of healthcare and enable personalized healthcare but could also increase information leakage and information management, cause over-monitoring of doctors, and enable the inappropriate use of integrated information. Prior to System introduction, we should facilitate consensus-building about protecting and utilizing personal information as well as consider the related ethical issues, and doctors' characteristics and concerns.

Tyrosine kinase inhibitors (TKIs) are highly effective in the treatment of chronic myelogenous leukemia (CML), but there have been a few adverse event reports describing gastrointestinal bleeding. We clinically analyzed two patients who developed intestinal bleeding during the administration of TKIs for CML. Platelet counts of both patients were normal. The patients showed endoscopic findings characterized by mildly hemorrhagic mucosa. The imatinib patient was diagnosed by capsule endoscopy of the small intestine, and required frequent blood transfusions. The dasatinib patient showed occult bleeding due to CD8-positive colitis. We should adequately recognize that gastrointestinal bleeding may occur during the administration of TKIs.

In this paper we report our clinical investigation of three cases with acquired hemophilia A treated in our department. These patients were all elderly males (79, 77, and 68 years old), and presented with subcutaneous bleeding, a prolonged activated partial thromboplastin time (APTT), and anemia. On the basis of these findings as well as decreased factor VIII activities (0.9~3.1%) and the presence of factor VIII inhibitors (57.1~173 BU/ml), we made a diagnosis of acquired hemophilia A. In cases 1 and 2, a recombinant activated factor VII was used to achieve hemostasis. The factor VIII inhibitor disappeared with prednisolone (PSL) alone in case 1 and a combination of PSL and cyclophosphamide in case 2. In case 3, treatment involving five courses of weekly rituximab (RTX) reduced the activity of factor III inhibitor to 3.5 BU/ml (and subsequently to zero). During this time, the patient achieved hemostasis without using a specific hemostatic agent, and was again referred to the previous hospital for the treatment of hepatocellular carcinoma. Although PSL is often chosen as a first-line therapy to suppress the production of factor VIII inhibitor, which may cause acquired hemophilia A, RTX may be another therapeutic option in some patients.

Since the liver has a duplicate blood supply through the hepatic artery and portal vein, hepatic infarction is considered a rare disease. A 51-year-old male with acute myeloid leukemia and diabetes mellitus developed fulminant hepatic infarction only a few days after administration of FLAGM chemotherapy. Our case was considered to have been caused by the almost complete obstruction of both the hepatic artery and portal vein by thrombi during a short period. Hepatic infarction should be recognized as a complication that may develop after salvage chemotherapy such as FLAGM inducing marked myelosuppression. Hepatic infarction after chemotherapy requires further analysis by evaluating a larger number of cases.

An elderly woman with chronic myeloid leukemia-chronic phase (CML-CP) aged at 67 underwent imatinib therapy. Ph chromosomes gradually decreased, but imatinib was discontinued after 10 months because of aggravated skin eruptions. Three months later, myeloid blast crisis (MBC) occurred. DXR+VCR+PSL chemotherapy and imatinib therapy was administered, and return to CP (RTC) was achieved with the disappearance of Ph chromosomes and a marked decrease of BCR/ABL (FISH). Although imatinib therapy was continued, a second MBC was diagnosed, 13 months after RTC. Chemotherapy, using mainly VCR+PSL was performed and imatinib was discontinued. RTC was achieved, and Ph chromosomes and BCR/ABL again disappeared. One year later, a 3rd MBC developed, and chemotherapy using Ara-C+DNR was performed. A 3rd RTC was achieved, and BCR/ABL decreased. This CML case was resistant to imatinib, but chemotherapy was effective in all 3 episodes of MBC, and BCR/ABL decreased or disappeared.

Among cases of therapy-related acute myeloid leukemia (t-AML) due to DNA topoisomerase II inhibitors, 11q23 abnormality is often detected. The usefulness of paclitaxel as a key drug in chemotherapy for breast cancer has been demonstrated. Few studies have reported t-AML due to paclitaxel. In this study, we report a patient who developed t-AML with 11q23 abnormality and bone marrow metastasis after breast cancer treatment with paclitaxel. The patient was a 61-year-old female who developed breast cancer at the age of 54 years. Four years after resection, lung and bone metastases were detected. Weekly therapy with paclitaxel at 80 mg/m2 was administered for 10 weeks (total dose: 1,200 mg), and radiotherapy was performed; thereafter, the extent of bone metastasis increased. Pancytopenia was noted 3 years after paclitaxel therapy. Bone marrow aspiration suggested AML (M4) with (11;19)(q23;p13) chromosome abnormalities. Histopathologically, bone marrow metastasis from breast cancer was detected in the same bone marrow specimen. This patient had not received any other anticancer drugs. Based on the clinical course, t-AML may have developed after paclitaxel therapy.

At present, the etiologic relationship between pernicious anemia and H. pylori infection remains unknown because different rates of positivity have been reported. To investigate the relationship of these two entities, 16 Japanese patients diagnosed with pernicious anemia were examined for H. pylori infection. Serological tests for H. pylori-IgG antibody and gastric biopsy were performed. These 16 patients ranged in age from 34 to 93 years, with a mean age of 68.1 years. They were all negative for H. pylori-IgG antibody and H. pylori on gastric biopsy. Considering that the H. pylori-positive rate in the Japanese population of the same age (60 years) is 70-80%, the findings of this study suggest that the rate of H. pylori positivity in patients with pernicious anemia is low.

Background: We examined the effect of landiolol hydrochloride, a selective beta1-adrenoreceptor antagonist, on the incidence of atrial fibrillation(AF)., Methods: The incidence of AF after lung resection was evaluated retrospectively in patients with intraoperative treatment with landiolol hydrochloride or those without it. Landiolol hydrochloride (5 microg x kg(-1) x min(-1)) was administered intravenously from the beginning of anesthesia induction to the end of operation., Results: In non-treatment group with landiolol hydrochloride (224 patients), the incidence of AF after surgery was 14.2%, peaking on postoperative day 2, and the average peak day was day 3.5. Older age, removal of the lymph nodes, lengthy surgery, and ischemic heart failure were risk factors. In treatment group with landiolol hydrochloride (77 patients), the incidence of AF after surgery was 5.2%, which was significantly lower than that in non-treatment group. Increased numbers of risk factors led to the high incidence of AF. But the administration of landiolol hydrochloride suppressed the incidence of AF., Conclusions: Landiolol hydrochloride is effective for the preventionof AF and it is safe without causing a severe decrease in blood pressure and bradycardia in high risk patients.

Generation of neural precursors persists throughout life in the forebrain subventricular zone (SVZ) and dentate gyrus (DG) subgranular zone (SGZ) in rodent and human brains. In addition, newborn granule cells in the hippocampal DG are important for learning and memory formation. Brain injuries such as seizures or trauma could trigger endogenous programs for adult neurogenesis. Although brain ischemia also increases proliferation of neural progenitor cells in SVZ and SGZ, most neural progenitor cells are dead within 2 weeks after brain ischemia. In addition, there is no therapeutic agent to promote neurogenesis in the adult brain following brain injury. Here we found that intraperitoneal administrations of vanadium compounds, a stimulator of phosphatidylinositol 3-kinase (PI3K)/Akt and extracellular signal regulated kinase (ERK) pathways markedly enhances brain ischemia-induced neurogenesis. Thus, vanadium compounds are potential therapeutic agent to enhance ischemia-induced neurogenesis through PI3K/Akt and ERK activation.

An 82-year old, elderly woman who had been found to have myelodysplastic syndrome (MDS)-refractory anemia three years previously, complained of fever and abdominal pain, and was hospitalized. Abdominal CT images resulted in a diagnosis of renal subcapsular hematoma thus conservative treatment, including blood transfusions of platelet, was initiated. However, the hematoma enlarged, and she also had a spiking fever. After the hematoma was punctured and we drained an abscess caused by Klebsiella Pneumoniae, the hematomal legion subsided, and the inflammatory symptoms improved. There has been no recurrence for more than one year. This case is thought to be the first in which a renal subcapsular hematoma developed with MDS. Although the cause of the renal subcapsular hematoma has not yet been identified, the vulnerability due to aging of the small vessels along with a decrease in the number of platelets have been considered as contributing factors in this elderly case.

A patient with fulminant idiopathic interstitial pneumonia was treated by sodium siverlestat and steroid pulse therapy following extracorporeal lung assist (ECLA). On arriving at the emergency room, Pa(O2) was 44.5 mmHg under oxygen with 10 l reserver mask, and emergency intubation was performed. X-ray showed honeycomb lungs, and strong fine crackle was audible. Sodium siverlestat (14 days) and steroid pulse therapy (3 days) were started. P/F ratio was 187, but decreased to 56 the next day. After ECLA for 3 days, P/F ratio decreased to 248. On day 29, X-ray showed much improvement, and the patient was weaned from ventilator. But on day 33, the patient deteriorated. And treatment with sodium siverlestat (14 days) and steroid pulse therapy (3 days) was performed again. The patient was weaned from ventilator again on day 66. Steroid pulse therapy was not effective shown by KL-6 of over 2000 IU l(-1), but sodium siverlestat was effective. We consider that sodium siverlestat is effective for fulminant idiopathic interstitial pneumonia.

We report the results of a retrospective study of antithymocyte globulin (ATG) treatment in 17 adult patients with aplastic anemia (AA). We evaluated 24 ATG treatments which included re-treatment with ATG in patients who had not responded to the first ATG treatment or who had relapsed after the first remission. The median age was 66 years, and the median follow-up period was 52 months. The response and relapse rates of ATG treatment were 70.8% and 23.1%, respectively. The response rate of ATG re-treatment was 57.1%. Overall survival and event-free survival at 10 years were 66.7% and 50.7%, respectively. The shorter duration from diagnosis to ATG treatment, the higher reticulocyte count before ATG treatment, and being female independently correlated with the efficacy of ATG treatment. Two patients developed monosomy 7 clonal abnormality. These results suggest that ATG treatment can achieve a high response rate and long-term survival among patients with adult AA. However, we have to pay attention to the development of the clonal diseases.

A 70-year-old man was admitted to the hospital with left ankle pain, also exhibiting severe consciousness disturbance. Laboratory findings showed not only hypercalcemia, but also increased serum levels of PTHrP and a few of proinflammatory cytokines, such as TNF-alpha, and IL-6. The X-ray and CT examinations revealed multiple osteolytic lesions, including the left tibia and fibula. Bone marrow aspiration revealed increased lymphoblasts (48%), and the patient was diagnosed as having acute lymphoblastic leukemia (ALL, L2). The hypercalcemia was successfully treated with calcitonin and bisphosphonate, and subsequently his consciousness status recovered rapidly. The bone marrow lymphoblast count decreased following combination chemotherapy, and a tendency towards improvement of the left ankle pain was also noted. However, he died of acute pneumonia and gastrointestinal bleeding. The postmortem findings showed leukemic cell involvement of the left tibia. The present case suggested that not only humoral hypercalcemia or local osteolytic hypercalcemia, but also proinflammatory cytokines were associated with multiple osteolysis and hypercalcemia.

Objective: In addition to overactive bladder (OAB) and sleep disorders (disturbance of additional sleep induction), nocturnal polyuria has been reported as an etiology of nocturia in elderly people. To investigate the influence of heart function on nocturnal polyuria in elderly people, we examined the association with nocturnal polyuria using brain natoriuretic peptide (BNP), which are useful for evaluating the prognosis of heart failure., Patients and Methods: The patients were 128 patients (92 males, 36 females) who were treated for nocturia in Kohsei general hospital and other relative hospital between October 2002 and September 2005. We measured BNP levels at physical examination. Simultaneously, the patients were instructed to write a frequency volume chart (FVC) for 4 days. 24-hour urine volume, Daytime urine volume, nocturnal (sleep) urine volume, nocturnal polyuria index (NPi) were calculated from FVC. The association was examined. However, alphal-blockers or anticholinergic agents that had been prescribed to treat urination disorders were continuously administered., Results: Overall, the mean BNP level was high, 46.3+/-39.6 pg/ml. The mean 24-hour urine volume was 1,555+/- 458 ml. The mean daytime urine volume was 935+/-322 ml. The mean nocturnal urine volume was 624+/-251 ml. The mean nocturnal urine volume rate was high, 40.1 - 10.5%. However, there was a close association between BNP and the 24-hour urine volume (p = 0.0215), the daytime urine volume (p = 0.0004), the NPi (p = 0.0003). The daytime urine volume decreased with the BNP level. The NPi increased with the BNP level. Patients were divided into 2 groups, a group with a BNP level less than 50 pg/ml and a group with a BNP level of 50 pg/ml or more. In the group with a BNP level less than 50 pg/ml, the nocturnal urine volume rate was 38.14+/-10.07%. In the group with a BNP level of 50 pg/ml or more, the rate was significantly higher (43.97+/-10.48%, p<0.0029)., Conclusions: These results suggest that many elderly patients latently have mild heart failure, and that relative nocturnal polyuria reduces cardiac load. Therefore, in patients with a high BNP level, administration of antidiuretic hormone to decrease nocturnal urine volume is risky. Administration of diuretics during the afternoon or evening may be safer.

Background: Propofol and droperidol decrease the incidence of postoperative nausea and vomiting (PONV). We investigated the incidence of PONV after total intravenous anesthesia (TIVA) with propofol alone versus combined use of droperidol and propofol., Methods: Eighty three patients, who had undergone laparoscopic gynecologic surgery with TIVA using propofol and fentanyl, were retrospectively evaluated whether droperidol had affected the incidence of early (up to six hours postoperatively) and late (6-24 hours postoperatively) PONV. Group D (46 patients) received droperidol intravenously at the end of surgery. Group N (37 patients) received no droperidol., Results: The incidences of early nausea were 27% in Group N and 4% in Group D (P<0.01). The incidences of early vomiting were 0% in Group N and 8% in Group D. The incidences of late nausea were 14% in Group N and 13% in Group D. The incidences of late vomiting were 3% in Group N and 7% in Group D., Conclusions: Droperidol was useful in reducing the incidence of early nausea and vomiting after total intravenous anesthesia with propofol and fentanyl in the patients undergoing laparoscopic surgery.

In this study, we focused on acceptance of memory impairment and satisfaction with life in patients with mild to moderate Alzheimer's disease (AD). We interviewed 71 consecutive patients with AD and asked (1) whether they had memory loss, (2) whether they found trouble in life, and (3) how their daily life was. We categorized the patients into three groups based on awareness of memory loss and reference to the cause of memory loss. Cognitive functions were lower in patients who were not aware of memory loss. The rate of satisfaction with life was the highest in patients who were not aware of memory loss, and was the lowest in patients who complained of memory loss with reference to the cause of memory loss, indicating that patients could hardly accept their lives when memory impairment was a serious issue. However, in these patients, depression scores were not high, suggesting that they may somehow adapt themselves to their current status by defining the reason for memory loss. In patients who complained of memory impairment but did not refer to the cause of memory loss, there was a variation in awareness of memory loss and satisfaction with life. The present study indicated that we have to provide individual care and support for AD patients considering their level of acceptance of memory impairment.

Treatment guidelines for patients with idiopathic thrombocytopenic purpura (ITP) have been changed recently due to the clinical application of Helicobacter pylori (H. pylori) eradication but there has been no detailed multi-center analysis of the hematological effects of H. pylori eradication. The Clinical Hematology Forum consists of 11 large hematological departments and divisions in the Hokkaido area. We sent questionnaires to these 11 hematological departments and divisions in March 2003 to obtain information on current treatment strategies for patients with ITP and hematological results after the eradication of H. pylori. Questionnaires were returned by 9 (81.8%) of the 11 departments. Doctors in all hospitals had experience in diagnosis and treatment of H. pylori infection. Diagnostic examinations for H. pylori infection were performed in 54.3% of the registered cases. H. pylori infection was detected in 68.1% of the examined cases, and eradication treatment was performed in 87.7% of H. pylori-positive patients. H. pylori was eradicated in 52 (83.9%) of the 62 patients in whom the results of treatment could be evaluated. Among the patients whose platelet counts were less than 10.0 x 10(4)/microl, platelet recovery was observed in 48.8% of cases with successful eradication, a percentage similar to previously reported percentages in Japan. There was no prognostic factor to predict good responders before eradication treatment. Since the side effects of eradication treatment, including gastrointestinal symptoms and skin eruptions, were not serious, this method might become a front-line treatment for patients with ITP. Patient selection for eradication as an up-front treatment, analysis of the pathophysiology of platelet recovery after eradication and long-term effects should be investigated to make new treatment guidelines for newly diagnosed patients with ITP.

Seven patients with stage I and II primary testicular lymphoma (PTL) have been treated since 1990 to the present at Kawasaki Medical School. All patients, whose median age was 56 yrs, had initially complained of swelling of the scrotal contents. The lesions were on the right in two patients, on the left in five, and no patient had bilateral lesions. The histological diagnosis was diffuse large B-cell type in all patients. Five patients were classified as Ann Arbor stage I, and two at stage II. After high-orchiectomy for resection of tumor, two patients received chemotherapy alone, with a combination of chemotherapy and irradiation of the contralateral testis in the remaining five. Complete remission was achieved in all seven patients, but relapse occurred later in one. As it is recognized that, even in localized stage or low risk group PTL patients, the relapse rate in the central nervous system (CNS) and contralateral testis is quite high, chemotherapy, prophylactic CNS treatment and radiation of the contralateral testis after tumor resection should be included in the management of PTL.

We report a case of a patient with a spontaneous carotid-cavernous sinus fistula (CCF) who was successfully treated by the facial vein approach. This 66-year-old female had a 3-month history of right chemosis and exophthalmos. Angiograms showed a spontaneous right CCF with primary drainage via the superior ophthalmic vein. As both inferior petrosal sinuses were hypoplastic, the transvenous approach could not be used to gain access to the right cavernous sinus. With effort, we were able to traverse the sharp angle at the corner of the angular vein and the superior ophthalmic vein with a microcatheter. Thereafter, it was easily navigated into the right cavernous sinus. Successful placement of Guglielmi detachable coils resulted in complete closure of the fistula. When it is difficult to gain access to the cavernous sinus via the inferior petrosal sinus, the facial vein approach is a useful alternative.

Facial arteriovenous malformations (FAVM) are difficult to treat because of their highly vascular networks. Intravascular treatment using liquid material to occlude the FAVM occasionally results in skin necrosis after embolization. The use of particulate materials to obliterate the nidus often fails to obtain a permanent cure due to arterial recanalization. We report two patients with FAVM who were successfully treated with endovascular embolization using a new type of particulate material. One patient was treated with embolization only, the other was treated with embolization followed by surgical resection. Both patients showed clinical and angiographic improvement. Intravascular treatment using particles with a smooth surface and optimal size is safe and effective in the treatment of patients with FAVM.

Fifteen cases with hormone-refractory metastatic carcinoma of the prostate were treated by the combination therapy of LH-RH analogue and low-dose glucocorticoid. Prior treatments of the patients were composed of maximum androgen blockade (MAB) therapy (14 cases) and bilateral orichiectomy (1 case). Nine of 15 cases underwent estramustine based treatment or anti-cancer chemotherapy as the second-line therapy. As a glucocorticoid (steroid) therapy, 1.5 or 2.0 mg of dexamethasone or 10 mg of predonisolone were given for a median period of nine months. Clinical responses were evaluated by the determination of serum PSA, EOD score and QOL scales. PSA responses were classified as CR, PR and PD according to the following categories; CR : PSA level decreased to less than 2 ng/ml, PR : PSA level decreased to less than half values of pretreatment level, PD: 20% or more increased to pretreatment level. PSA responses (CR + PR) were observed in eight of 15 patients for a median period of six months. Responses are seemed to be correlated with the Gleason scores. No apparent improvement on EOD scores by bone scintigraphy was seen, however, definite improvement of bone pain was identified in eight of 11 cases. The steroid therapy was considered as one of the useful treatment choice for patients with hormone-refractory prostate cancer.

A family (a brother and a sister) of the familidal isolated hyperparathyroidism (FIH) was reported. The older brother with age of 58 year-old was pointed out hypercalcemic while examining his hypertension and proteinuria. He had high levels of serum total and ionized calcium, intact-PTH and gastrin, and hypophosphatemia. His neck CT scan revealed swelling of the two parathyroid glands in each side. He underwent resection of the tumors and the auto-implantation of the glands under diagnosis of primary hyper parathyroidism. Histopathology was diagnosed to be hyperplasia of the parathyroid glands. The younger sister with age of 52 year-old was referred to our clinic because she was suffering from recurrent urolithiasis. Biochemical examination of her blood sampling resulted in very resemble values of her brother mentioned above. Her neck CT scan showed three tumors consisting of each one at the bilateral parathyroid glands and one in the thymic region. She underwent resection of the tumors and the auto-implantation of the glands and histopathological diagnosis was hyperplasia as same as her brother's one. The postoperative courses of these cases have been uneventful for four years. FIH is a low significant disease of which ten lineages have been reported in Japanese literature although it should be differentiate with such a disease of multiple endocrine neoplasms.

We report a case of Cushing's syndrome due to bilateral adrenal adenomas. A 45-year-old woman was found to have Cushing's syndrome during the course of treatment for diabetes mellitus. The diagnosis of Cushing's syndrome was based on the absence of a diurnal rhythm in plasma cortisol and failure to suppress plasma cortisol by 1 or 4 mg of dexamethasone. The plasma level of adrenocorticotropic hormone (ACTH) was below the normal range, and plasma cortisol responded normally to rapid ACTH injection. Abdominal computed tomography revealed bilateral adrenal tumors. Bilateral uptake of radiocholesterol by the adrenal cortex was observed in adrenal scintigraphy. Bilateral adrenalectomy was performed. Microscopic examination and analysis of steroid contents by high performance liquid chromatography showed that the tumor was cortisol-producting adenoma.

We experienced three patients with constrictive pericarditis who underwent pericardiectomy. Percutaneous cardiopulmonary support (PCPS) was carried out in two patients because of unstable hemodynamics caused by massive bleeding or cardiac compression due to surgical manipulation. In the other patient with severe tachycardia, we prepared PCPS before the induction of anesthesia, and could manage the whole course of anesthesia satisfactorily. It is suggested that PCPS is the most reliable way to support hemodynamics during anesthesia in patients with constrictive pericarditis.

Background: The object of this study is to evaluate the usefulness of the ATP sensitivity assay for appropriate selection of anticancer drugs for prophylactic bladder instillation therapy in patients with superficial bladder cancer., Methods: The ATP assay was performed using the method reported previously. The anticancer drugs examined were ADM, MMC, THP-ADM and EPI. The 5-year rate of non-recurrence in group A (32 cases) which had been treated using the results of ATP assay, was compared with that of group B (37 cases), for which the ATP assay was not performed., Results: The most sensitive anticancer drug was THP-ADM. The 5-year rate of non-recurrence in group A (80.9%) was significantly higher than that in group B (39.4%) (p < 0.001). Tumor recurrences in group A was observed within 2 years post-operatively in all cases. When the ATP assay was re-performed in 3 cases with recurrent disease, altered antitumor sensitivity was observed., Conclusion: These findings suggested that ATP assay was useful for choosing effective anti-cancer drugs for prophylactic instillation, especially for patients with primary or solitary tumor, grade 2 disease or tumor of a certain size (> or = 1 cm). It also appeared that the ATP assay should be performed for patients with primary superficial bladder cancer as a screening test for the selection of drugs for prophylactic instillation therapy.

A patient with neck lymph node metastasis from squamous carcinoma of the uterine cervix was treated by immunotherapy and neo-adjuvant intraarterial infusion chemotherapy (OK-432 ic, etoposide 25 mg/body x 7 days po, CDDP 100 mg/m2/5 hr iA, CPM 200 mg/body iv, THP 50 mg/m2/2 hr iA). Three courses of the neo-adjuvant chemotherapy were given. After the first course, the neck metastatic tumor appeared remarkably small. After the second, the neck tumor disappeared and the uterine tumor appeared small and to have good movement. Hysterectomy was performed one month after. Each tissue platina concentration (microgram/cm3) is 9.12 uterus cervix, 10.9 uterus corporis, 8.17 fallopian tube, 14.0 ovarium, 1.47-0.88 pelvic lymph node. This patient was treated with irradiation after operation, and is presently in a state of cytological complete remission. Now she continues maintenance immunochemotherapy with UFT and OK-432 with a home doctor.

Bronchofiberscopy and esophageal mannometric study were scheduled for a CHARGE association patient who complained respiratory distress and dysphagea after PDA ligation. We carried out both tracheal intubation and LMA insertion twice. LMA insertion was performed smoothly, but mask holding and tracheal intubation were very difficult. CHARGE association is a rare multiple anomaly, and presents some problems for anesthetic management. Especially, we have to consider the difficult airway management in such a patient.

Clinical features of two patients with mixed angiomas are presented. One patient with a cerebral venous angioma with arterial components was successfully treated with radiation therapy; and the other, who had a common draining vein with cerebellar arteriovenous malformation and venous angioma, was treated with surgical removal of the arteriovenous malformation. These two cases suggested that there is a similarity between the pathogenesis of arteriovenous malformation and venous angioma in the brain.

The distribution of S-100 protein positive dendritic cells (S100-DCs) inside the cancer nest and the expression of HLA-DR alpha antigen (HLA-DR) and blood group antigen (BGA) on cancer cells in 90 cases of transitional cell carcinoma (TCC) of the urinary bladder were immunohistochemically investigated in relation to the degree of malignancy and its prognosis. A dense infiltration of S100-DCs inside the cancer nest ("many", i.e. more than 10DCs/HPF) was detected in 47 (52%) out of 90 cases. The HLA-DR positive cancer cells (DR-CCs) were detected in 24 cases (27%), including in the 16 most dense cases ("many", i.e. more than 100DR-CCs/HPF). BGA positive cancer cells (BGA-CCs) were detected in 49 cases (54%) ("positive", i.e. more than 100BGA-CCs/HPF). In connection with the degree of malignancy and with the number of cases affected by S100-DCs infiltration. HLA-DR expression and BGA expression. A statistical analysis showed significant correlation between the number of cases affected by S100-DC and each clinicopathological factor including G, pT, ly, v, and showed also between that affected by BGA expression and each clinicopathological factor including G, pT, INF, but showed no significant correlation between that affected by HLA-DR and each clinicopathological factor. As regards the prognosis, the 10-year survival rates for all 90 cases were 60.4%. In the 10-year survival rate, S100-DCs "many'' (77.7%) and "few'' (39.0%), DR-CCs "many'' (85.7%) and "no'' (56.9%), DR-CCs "many'' and "few'' (43.8%), BGA-CCs "positive'' (74.3%) and BGA-CCs "negative'' (46.5%) were statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)