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Purpose: Root Cause Analysis (RCA) of reported incident reports can lead to measures to prevent the recurrence of accidents. The purpose of this study is to clarify the relationship between the occurrence of cases, causal factors, contributing factors, and the experience years of the reporters classified into three groups: less than 2 years, 3 to less than 5 years, and more than 5 years, for incident reports subject to RCA., Methods: From April 2018 to March 2023, a chi-square test was conducted between each item extracted from 239 cases subject to RCA and the experience years of the reporters, with a significance level of less than 5% considered significant., Results: Regarding the occurrence cases, radiological technologists with longer experience had more misidentified a patient and fewer errors in imaging conditions and range, while radiological technologists with 3 to less than 5 years of experience had more errors in imaging conditions (p<0.001). In terms of occurrence factors, radiological technologists with 3 to less than 5 years of experience had more cases of insufficient confirmation (p<0.05). For contributing factors, there was no significant difference between the experience year groups (p=0.19), with "Impatience" being the most common factor., Conclusion: This survey suggested that in incident reports of radiological technologists, "Impatience" is a contributing factor that can occur regardless of years of experience.

The rate of detection of various resistant bacteria has recently increased, though the development of antimicrobial agents has been delayed. In the hospital setting, an antimicrobial stewardship team (AST) works to assure that resistant bacteria do not appear, while an infection control team (ICT) works to assure these resistant bacteria do not spread. Additionally, ICT and AST work together on the appropriate use of antimicrobial agents. In order to combat infectious diseases regionally, it will be important for hospitals and pharmacies to share such information as infection control, consumption trends of each antimicrobial agent, and the susceptibility rate of antimicrobial agents. In addition, cooperation between hospitals and community pharmacies is important to assure patients can receive appropriate medical treatment after leaving the hospital. It is essential to have a common understanding of the prevalent infectious disease in order to continuously provide safe and effective drug treatment in the region. Therefore, we propose educating health care professionals about the proper use of antimicrobial drugs through cooperation between hospitals and community pharmacies. In this symposium, we will introduce those infectious control activities a pharmacist will focus on, as well as the proper use of antimicrobial agents, and regional cooperation activities.

We performed this study with the aim of clarifying the geographical features of areas of difficult-to-access foods in mountainous regions, using GIS, altitude data, and future population projections. With QGIS, we mapped altitude data, future estimates of the old age population(mesh), and retail store data, and we extracted the altitude at the mesh center point. We also draw straight lines connecting the retail stores and the mesh center point. Meshes located in areas with high altitudes had significantly more meshes not occupied by humans than meshes located in low-lyingareas (p<0.01). At least 95% of the retail shops and mesh center points were separated by more than 500 meters, and thus are considered difficult to access. The number of non-residential areas increases in mountainous regions because of the sharp gradient and the long distance to retail stores. By visualizingusingGIS, future resources can be considered more realistically.

In this research, we constructed a prediction model for the number of service providers for home-visit care, home-visit nursing, and home-visit bathing by using the population in the Hokushinetsu region and the current number of providers, and considered the validity of the model. Using the model, we estimated the number of providers in 2025, and subsequently, visually confirmed geographical features using a geographic information system. The adjusted R2 value of the prediction model was 0.93 for home-visit care, 0.87 for home-visit nursing, and 0.63 for home-visit bathing providers. The number of providers for home-visit care, home-visit nursing, and home-visit bathing were estimated to decrease by 67%, 67%, and 28%, respectively. The colored map by the predicted number of providers suggested a significant decrease in home-visit care in Northern Nagano, home-visit nursing in Fukui-Reihoku region, and home-visit bathing in Middle Nagano.

In order to clarify the characteristics of the area where the visiting nursing station is located, we conducted a study to identify the regional characteristics of the visiting nursing station in Ishikawa Prefecture, using geographical information system(GIS). We mapped the elderly population, aging rate, and location data for the visiting nursing station using QGIS, and created trade areas(Voronoi diagrams). The aging rate for each trade area is 22.4%(min 8.8% to max 44.6%), about 5 times. The difference in area is about 850 times as large as the central value of 9.2 km2(min 0.5 km2 to max 423.2 km2). In addition, there was a tendency for stations with a large trade area to have a higher aging rate than that of smaller stations. Understanding the characteristics of the area surrounding visiting nursing stations using GIS facilitates the clarification of potential needs and opportunities for providing visiting nursing services that are suitable for each area.

There has been a noticeable population decline in the Noto area. The Ministry of Land, Infrastructure, Transport and Tourism has determined the population size necessary for the establishment of daily living-related service businesses and, if the population falls below this, there is a possibility of businesses withdrawing from the area. In this research, we examine the number of home visit and daycare businesses established in the Noto area in 2025, using the geographic information system (GIS). The number of sites of businesses established was calculated using data published by the National Institute of Population and Social Security Research, and the Ministry of Land, Infrastructure, Transport and Tourism. Next, I depicted a buffer with a radius of 15 km from the establishment and confirmed the blank area of the service. Under the condition that the placement of sites is 80%, almost all the municipalities have exceeded the number of home visit care facilities and the number of daycare facilities. In the buffer analysis, blank areas were found in the north. To maintain these services, efforts by groups other than profit-oriented organizations are necessary, especially in the north of Noto. Route analysis by GIS and the consideration of population distribution and location of business establishment will be needed.

Matsui-Kitamura stent-graft (MKSG) is a home-made device for thoracic endovascular aortic repair (TEVAR) developed in Japan. A 76-year-old man who had been treated by TEVAR (zone 3) with a MKSG for ruptured thoracic aortic aneurysm was diagnosed as having type Ia endoleak caused by suture disruption and aneurysmal sac expansion 6 years later. He underwent TEVAR (zone 1) with debranching and type Ia endoleak disappeared. MKSG had been the effective device especially for acute aortic emergencies in the descending thoracic aorta until the stent-grafts became commercially available, but careful observation and appropriate re-intervention is mandatory for the continued life-saving contribution.

Objective: The purpose of this study was to evaluate early and long term outcomes of surgery for acute type A aortic dissection complicated with organ malperfusion., Method: From January 2001 to October 2015, 336 consecutive patients (mean age 68.6±12.2, male 172) underwent surgery for acute type A aortic dissection at out center. Early and late outcomes were compared between patients accompanied with and without organ malperfusion., Results: Preoperative organ malperfusion was observed in 76 patients( 22.6%). That consisted of 38 neurological systems, 13 coronary, 8 visceral, and 26 extremities. Nine patients had 2 organ malperfusion. In-hospital mortality was 22.4% and 6.5% in patients with and without organ malperfusion, respectively. Multivariate logistic analysis showed preoperative organ malperfusion was a significant risk factor for in-hospital mortality (Odds ratio 3.59, 95% confidence interval 1.56~8.28, p<0.01). Five year survival rate of hospital survivors were 84.5±5.5% and 80.9±3.3% with and without organ malperfusion (p=0.51)., Conclusions: Although organ malperfusion is still associated with high mortality, however, acceptable long term outcomes could be obtained if organ malperfusion is treated appropriately. Ischemic organ oriented approach might be very important to improve surgical outcomes of these critically ill conditions.

A 42-year-old woman with a history of old myocardial infarction was admitted to our hospital with complaints of worsening orthopnea. Doppler echocardiography exhibited severe functional mitral valve regurgitation. Because of the tethered mitral valve, we performed mitral valve annuloplasty concomitantly with papillary muscle relocation procedure. The patient recovered well. Postoperative echocardiography had not exhibited recurrent mitral valve insufficiency. Moreover, postoperative left ventricular torsion using 2-dimentional speckle tracking imaging, improved at rest and at peak exercise, and this findings suggest that the reversal of left ventricular remodeling in relocation patients following preserved and connected mitral subvalvular apparatus may result from restoration of the global sequence of left ventricular twist mechanics. The analysis of left ventricular torsion may provide a more comprehensive evaluation of left ventricular mechanics and may help understand the effects of papillary muscle relocation with preserving mitral subvalvular apparatus.

Interview and questionnaire surveys were conducted with bus drivers in Japan, with the goal of developing an educational program for better control of emotions among bus drivers. The interviews aimed at identifying stressors and ways in which stress negatively influenced bus services. The questionnaire survey. which was being developed as a self-diagnosis tool, further provided bus drivers with the opportunity to understand their own emotional tendencies. Factor analysis identified six factors underlying work-related stress: anger at unsafe behaviours of nearby road users, irritation caused by complaints from passengers, time pressures, anxiety about traffic accidents, impatience with slow passengers, and resentment of bad-mannered passengers. The influence of stress on the drivers comprised four factors: cognitive failure, sullen behaviour, abrupt acceleration/deceleration, and aggressive driving. Moreover, drivers with lower stress were relatively older and more experienced. Based on these results, educational materials were proposed with the aim of enhancing bus drivers' understanding of their emotional processes and coping skills.

Background: For management of postoperative bladder spasm by the ureteral reimplantation, general anesthesia and epidural anesthesia are selected in many hospitals, but epidural anesthesia is not a common technique for various complications and risks. We examined whether postoperative bladder spasms can be prevented by general anesthesia combined with single shot caudal anesthesia., Methods: We studied 18 patients undergoing ureteral reimplantation. Premedicated by diazepam syrup (0.5 mg x kg(-1), maximum dose 10 mg). In combination with caudal anesthesia with 0.3% ropivacaine (3 mg x kg(-1), maximum dose 60 mg), general anesthesia was maintained with oxygen, nitrous oxide and sevoflurane. For the evaluation of pain relief we used face pain scale when the patients returned to the ward, postoperative 5 hours, 24 hours and at discharge., Results: At postoperative 5 and 24 hours, some patients had a pain scale of above 3. But, those under pain scale 1 was 83%. At discharge, all patients were evaluated as pain scale 0 or 1., Conclusions: General anesthesia combined with single shot caudal anesthesia suppressed postoperative bladder spasm. All patients were discharged within 3 postoperative days.

Malignant pleural mesothelioma carries a poor prognosis, for which no standard therapy has been established. We report 15 cases of malignant pleural mesothelioma experienced since 2000 focusing on their clinical features. They included 14 male and 1 female aged 38 to 81 (62.8 on average) years. All patients were diagnosed by pleural biopsy under thoracoscopic guidance. Histology of the pleural biopsy specimen showed epithelial mesothelioma in 8 patients, biphasic mesothelioma in 3, sarcomatous mesothelioma in 2 and desmoplastic malignant mesothelioma (DMM) in 2. Twelve patients received chemotherapy. Of these, 3 were followed by surgery. In addition to 2 of these 3 patients, 2 underwent extrapleural pneumonectomy (EPP) without adjuvant treatment. Remaining 1 received palliative treatment only. As a result, 6 patients are surviving, 7 died of primary diseases and 2 died of other diseases. The longest survival time with chemotherapy is 41 months in a surviving patient with epithelial mesothelioma and that with EPP is 25 months in a surviving patient with DMM. The 2-year survival rate of the 14 patients was 44.4% and the median survival time in patients with epithelial mesothelioma was 30.6 months.

A 36-year-old woman was diagnosed with type 3 advanced gastric cancer with multiple liver metastases in March 1992. The patient was treated with systemic chemotherapy of 5'-deoxy-5-fluorouridine and cisplatin. After 4 courses of chemotherapy, the primary lesion responded and the multiple liver metastases disappeared. Therefore, total gastrectomy with perigastric lymphadenectomy and splenic preservation was performed. Two additional courses of the same chemotherapy were administered after the surgery. The patient has been alive without recurrence for 10 years after the curative resection.

Purpose: To increase the management of self-catheterization in children of school age, a catheter kit consisting of hydrophilic catheter and a packet containing sterilized water was developed. We evaluated the lubricating characteristic and clinical efficacy of this new catheter kit., Materials and Methods: The catheter kit used in the study was a pocket-size plastic container in which a polyurethane catheter coated with hydrophilic polymer and a packet containing sterilized water were packed in combination. The lubricating characteristic of catheter was assessed by the measurement of friction value. For clinical assessment, male children aged over 6 years old who were doing self-catheterization at 17 medical institutions nationwide were selected as the subjects. The 32 children who had given informed consent (mean age: 11.6 years old) were asked to use the catheter kit continuously for 1 week. The results were investigated by a questionnaire survey in which the assessment before and after the use was expressed in scores. At the same time, urinalysis and urine culture were examined., Results: The friction value of hydrophilic catheter was equivalent to or less than that observed by applying a lubricant to the conventional catheter. The comparison of conventional catheter with the kit indicated significantly higher scores (assessment in 5 grades expressed in scores) for the portability and operability of the kit. Though there was no significant difference in the ease of insertion between the two catheters, there were several comments that the kit got stuck in the urethra when it was withdrawn. The global assessment gave a significantly higher score to the kit and 30 (94%) of the 32 children wanted to use the kit continuously. No increase in hematuria which caused a clinical problem or no new apparent urinary tract infection occurred after the use of the kit., Conclusions: Compared with the conventional catheter, the hydrophilic catheter kit highly satisfied a large number of children at the time of self-catheterization. Depending on the condition of children, the kit is considered useful for continued self-catheterization for a long term.

We present a case of tumoral multiple sclerosis in a 66-year-old male and emphasize two clinical features: (1) Multiple well-demarcated massive enhanced lesions except for the central area, which was accompanied with severe perifocal edema, occurred within the cerebral hemispheres and should be strongly considered in the diagnosis of mass lesions. The patient underwent partial removal of the mass lesion. The initial histopathological diagnosis of the surgical specimen was astrocytoma grade II. (2) Multiple lesions disappeared completely for one and half months after starting medication using steroid. The reexamination of the surgical specimen was compatible with that of multiple sclerosis. Again, half a month after remission, multiple enhanced lesions without perifocal edema developed in the cerebral and cerebellar hemisphere. The difficulty of the initial diagnosis of multiple sclerosis with severe perifocal edema was discussed, based on our experience.

We report a case of advanced rectal cancer accompanied by unresectable liver metastasis in which remission has been achieved for 7 years. The patient was a 64-year-old woman, and her chief complaints were a feeling of abdominal distention and melena. After low anterior resection (D3), oral administration of 600 mg/day of UFT-E and chemotherapy against the liver metastasis by hepatic arterial injection via a reservoir were started. Since the arterial injection via a reservoir became impossible due to infection, her clinical course was observed solely with oral administration of UFT-E. As a result, complete remission was achieved 7 months postoperatively, and the patient is still alive in good health without recurrences at present (7 years postoperatively). The reason why a favorable outcome has been achieved is probably that, although the initial operation resulted is non-curative resection, measures sufficient to enable the patient to lead an ordinary social life were taken at the beginning, and efforts to achieve a long-term survival were made while respecting the quality of life of the patient so that the patient would be able to coexist with the cancer.

A case of "the syndrome of the sinking skin flap" was presented. A 40-year-old-man had suffered from severe SAH 9 months before. An aneurysm of the anterior communicating artery was successfully clipped and the bone flap was removed for the purpose of the external decompression. Cranioplasty and V-P shunt were performed 1 month after SAH, but both were removed because of postoperative wound infection, viz. epidural and subdural abscess 4 months after SAH. Following this, L-P shunt was performed, and the patient was discharged with mild dementia. A concave deformity of the skin flap developed about 4 months after the L-P shunt. Neurological examination showed progressive left hemiparesis and akinetic mutism. A low CSF pressure was demonstrated, but RI cisternography revealed normal CSF circulation. Intrathecal infusion of the artificial CSF was carried out via lumbar puncture and concavity of the skin flap gradually improved. This procedure resulted in improvement of the neurological deficits. Cranioplasty with artificial bone was performed under continuous intrathecal infusion of the artificial CSF. Postoperative course was satisfactory and neurological examination revealed only mild dementia. The pathological mechanism in our case was probably due to the compression of the brain by the atmospheric pressure following the external decompression. Moreover, L-P shunt exaggerated this pathology by the overdrainage of CSF.

Background: Recent advance of perinatal ultrasound screening and/or physician's awareness of renal damage from recurrent pyelonephritis has brought about the increasing number of infants with primary vesicoureteral reflux (VUR) including refluxing megaureter which should be conceptually differentiated from simple high grade VUR. We evaluated the clinical outcome of infants diagnosed with refluxing megaureter., Patients and Methods: We retrospectively reviewed the clinical records of 15 infants (17 ureters) diagnosed as refluxing megaureter (max caliber > or = 10 mm) at our institution from 1988 to 1997. We compared the clinical outcome of refluxing megaureter with that of high grade VUR. (Results) Patients were 13 boys and 2 girls. Megaureter was unilateral in 13 patients and bilateral in 2. Fourteen infants (93.3%) presented with febrile urinary tract infection (UTI). The diameter of megaureter was 10-21 mm (average: 13.6 +/- 4.0 mm) at excretory urogram. Nine of 15 infants (60.0%) had breakthrough urinary infection. Its incidence was significantly higher than that of high grade VUR (21.3%) (p = 0.02). In 13 cases surgical treatments were performed, however 2 cases (max caliber: 16 mm, 21 mm) by Politano-Leadbetter or Paquin procedure required re-ureteroneocystostomy by Psoas-hitch procedure because of persistent reflux and recurrent UTI. On the other hand no patient required re-ureteroneocystostomy in high grade VUR., Conclusion: It is important to differentiate refluxing megaureter from high grade VUR due to high incidence of breakthrough UTI. Ureteral remodeling and/or Psoas-hitch procedure are strongly recommended for adequate length of submucosal tunnel in refluxing megaureter.

A 61-year-old male fell from a position 1 m high when building a house. An iron rod, which protruded upward from a solid base in cement, penetrated this patient's neck 15 cm to the head and was successfully extracted by himself. On admission, he complained of headache and vomiting. General examination disclosed nasal bleeding, intraoral bleeding, and L figured skin laceration in the left side of his neck at the level of the thyroid cartilage. Mild disorientation (JCS2) was noted. Otolaryngological examination disclosed hyperemia on the left side of the vocal cord as well as at the dome of the superior pharynx. Plain skull film disclosed pneumocephalus and that a piece of bone fragment of the planum sphenoidale had penetrated the brain. CT demonstrated air in the subarachnoid space, ventricular hemorrhage, intracerebral hematoma in the right frontal lobe, and subarachnoid hemorrhage in the anterior interhemispheric fissure. CAG detected neither cerebral vascular abnormalities nor cerebral aneurysm. While staying in our department, he developed mild fever and CSF rhinorrhea. The diagnosis of bacterial meningitis was made from the CSF finding and was well controlled with conservative therapy. CSF rhinorrhea stopped spontaneously with conservative treatment. Sagittal MRI continuously demonstrated contusional hematoma in the base of the right frontal lobe just above the fractured planum sphenoidale and genu of the corpus callosum following the course of the intracranially invading iron rod. The right CAG on Day 10 demonstrated vasospasm on the A1 and a 1 cm sized saccular cerebral aneurysm at the proximal right fronto-polar artery. CAG on Day 17 again showed the persistent presence of the aneurysm. For the purpose of preventing delayed rupture of the aneurysm, radical surgical treatment was planned. Microsurgical dissection disclosed that the aneurysm was located just behind the elevated fracture of the planum sphenoidale. Severe arachnoid adhesion was noted around the aneurysm. The aneurysm was successfully clipped with preservation of the parent artery without inducing new neurological deficits. From the general, otolaryngological, neuroradiological, and operative findings, this aneurysm was diagnosed as a traumatic cerebral artery aneurysm following the penetration of the skull base by the iron rod. The CAG performed at 8 months postoperatively demonstrated the patency of the parent artery and that there was no recurrence of the aneurysm. An unusual case of a traumatic cerebral artery aneurysm following the penetration of the skull base by an iron rod was thus reported.

The advent of H2-receptor antagonists (H2RA) and proton pump inhibitors (PPI) has particularly revolutionized the treatment of peptic ulcer disease. Most cases can now be successfully controlled by medical treatment with H2RA and PPI, but a high rate of ulcer recurrence remains an important problem. The quality of ulcer healing (QOUH) has therefore received increasing attention, and various investigators have attempted to define the conditions required for nonrecurrence. Ulcer scars with a good QOUH are considered to have a very low risk of recurrence. Recent studies have confirmed that recurrence of peptic ulcer can be suppressed markedly by eradication of Helicobacter pylori (H. p). Moreover, various types of endoscopic examinations (conventional observation, dye-contrast endoscopy, magnifying endoscopy, endoscopic ultrasonography, pharmacoendoscopy) have confirmed that the QOUH after eradication of H. p is better than that after conventional anti-ulcer therapy. H. p eradication therapy may become treatment of first choice for peptic ulcers.

A tuberculosis epidemic occurred among 4 relatives who live in the neighborhood of the index case. A thirty-three year old female was admitted to a hospital in July 1994 with high fever and cervical lymphoadenopathy. Culture examination of her sputum was positive for acid-fast bacilli and her chest X-ray showed diffuse small nodules. During the following sixteen months, five new patients with pulmonary tuberculosis were found among the relatives who lived in the neighborhood of the index case. The contact examination was first limited in her own family members, however, after detection of the second case, the examination was extended to other relatives living nearby, and another four patients were found. The results of PPD skin test of ten contact children showed strongly positive reaction, and chemoprophylaxis was indicated. Contacts examination is very important especially for patients with highly infectious tuberculosis.

Background: Cystinuria is an autosomal recessive disorder, and primary manifestation is the repeated formation of cystine calculi. Little information is available regarding clinical course of pediatric cystinuria having followed into adulthood. We report our experience with the management and the clinical course on cystinuria in children, who have been followed up for relatively long time., Materials and Methods: We retrospectively reviewed the records of all pediatric patients with cystinuria in whom urolithiasis was treated from 1970 to 1996., Results: A total of 15 pediatric patients with cystine calculi (9 boys, 6 girls) were treated in our hospital. Average age at diagnosis was 3 years 4 months old. Mean follow-up was 104 months. Stone location was upper urinary tract in 11 cases, bladder in 3 cases and both upper urinary tract and bladder in 1 case. Medical treatments including hydration, urine alkalization and dissolution therapy were performed in all patients. In three cases whose urinary cystine level ranged from 138 to 326 mg/gCr, cystine calculi were disappeared by medical therapy alone. In one of 3 cases vesicoureteral reflux was identified. Side effects were noticed in 30.0% of patients with tiopronin and in 85.7% of those with D-penicillamine, especially in 1 case with tiopronin nephrotic syndrome being noticed. Surgical procedures were performed in 13 patients (lithotomy: 17 calculi, endourology: 7 calculi and ESWL: 7 calculi). The stone free rate was 100% with lithotomy, 80 to 100% with endourology and 43% with ESWL at an average of 5.9 procedures. No complications were recognized after the surgical treatments. The stone events of 15 patients ranged from 0 to 1.5 (average 0.55). In all six patients followed up over the age of 20 years, stone recurrences were observed exclusively between 17 and 20 years of age., Conclusion: Dissolution therapy is more effective for cystinuric patients in whom urinary cystine excretion is less than 330 mg/gCr. For those cases with low urinary cystine level it is necessary to evaluate structural abnormalities of the urinary tract to avoid stone recurrence. ESWL and endourology should be tried for pediatric cystinuria except for neonates and infants, considering its safety. The patients and their parents must have adequate knowledge about the disease itself and its management. Prevention of cystine calculi recurrences depends on patient compliance to the therapeutic regimens necessitating close follow up according to the clinical conditions, especially for those in pubertic or postpubertic age.

Background: It is difficult to diagnose intermittent hydronephrosis and to decide the indication of surgical intervention. We investigated 23 cases of intermittent hydronephrosis., Methods: From 1978 to 1995, a total of 23 patients were diagnosed as intermittent hydronephrosis in our institution. We inspected their clinical features and treatment which had been performed to them., Results: Our study comprised 21 boys and 2 girls, whose mean age was 6 year old. Their chief complaint was intermittent flank pain (left: 21, right: 1, bilateral: 1) accompanied with gross hematuria (30%) and vomiting (39%). When they were asymptomatic, an excretory urogram revealed only mild pelvic dilatation without calyceal distension and kinking of ureteropelvic junction. Split renal function study by RI showed no difference between the affected side and the normal side except one case. When pelvic or calyceal enlargement was confirmed on ultrasonography while they were symptomatic, surgery was indicated. Surgery was performed in 17 cases (74%) including dismembered pyeloplasty in 14 cases, resection of aberrant vessel in 1, relocation of lower pole renal vessel in 1 and nephrectomy in 1. In surgical and histological view points, intrinsic stenosis was seen in 10 cases, extrinsic obstruction caused by aberrant vessels was seen in 4 and ureteral polyp was seen in 3 (bilateral polyp in 1 case)., Conclusion: They had no more symptoms after operation. Of 23 among followed up cases without surgery, we experienced 2 cases unexpectedly advancing irreversible hydronephrotic change after the last attack, 1 case of gradually progressing hydronephrotic change and 1 case of severe renal dysfunction after many attacks. Therefore intermittent hydronephrosis should be followed up carefully.

Sixty-six chemotherapy-naive patients with non-small-cell carcinoma of the lung were given two courses of systemic chemotherapy consisting of mitomycin C, vindesine, and cisplatin. The effect of the timing of administration of grannulocyte colony-stimulating factor (G-CSF) on the incidence of neutropenic fever, the nadir leukocyte count, the duration of neutropenia ( < or = 1000/mm3), and the time needed for recovery from neutropenia was studied. Patients were assigned at random to begin receiving G-CSF (50 microns/m2, subcutaneously) either when the leukocyte count was less than or equal to 1000/mm3 (group I) or when it was between 1000/mm3 and 2000/mm3 (group II), in a crossover fashion. The nadir leukocyte count was lower in group I than in group II (859/mm3 and 1215/mm3, respectively). The duration of leukopenia (defined as a leukocyte count less than or equal to 1000/mm3) was greater in group I than in group II (1.5 days and 0.8 day, respectively), as was the time needed for recovery to a leukocyte count of 2000/mm3 (1.9 days and 1.6 days, respectively) (p < 0.05). No differences were found in the incidence of neutropenic fever (group I: 44%, group Ii: 45%), in the duration of fever (group I: 2.3 days, group II: 2.8 days), or in the duration of G-CSF use (group I: 6.3 days, group II: 6.8 days). There were no treatment-related deaths in either group. We conclude that when this type of combination chemotherapy is given for non-small-cell carcinoma of the lung, administration of G-CSF can be postponed without clinical problems until the leukocyte count is less than of equal to 1000/mm3.

In order to examine the clinical characteristics and genetic background of secondary amyloidosis associated with rheumatoid arthritis, we analyzed clinical features and HLA typing of 85 patients in a multicenter study. Eighty-five patients with secondary amyloidosis associated RA were studied. The diagnosis of secondary amyloidosis were made on histological findings by biopsy or autopsy. The most common biopsy site was gastrointestinal tract (79.5%). Clinical symptom and the frequency at the time of diagnosis were; diarrhea (35 cases), abdominal pain (22 cases) and vomiting and nausea (16 cases). Abnormalities and the frequency in a laboratory test included proteinuria (49 cases), increased serum creatinine (32 cases), anemia (30 cases) and hematuria (15 cases). Twenty-eight patients were dead and 57 patients were alive at the time of the study. The average duration between diagnosis of amyloidosis and death was 19.4 +/- 18.5 (SD) months among the dead patients. The average duration after diagnosis of amyloidosis was 24.2 +/- 19.5 (SD) months in surviving patients. The causes of death were renal failure complicated with heart failure (6 patients), heart failure alone (3 patients) and renal failure alone (2 patients). Fifty-nine patients in the control group who were negative to amyloid deposition on biopsies at more than one site in the gastrointestinal tract, were clinically compared with patients in the amyloidosis group. No difference were noted in the age of RA occurrence and the stage between the two groups. As to the class, however, the number of patients with severe functional disorder (class 3 or severe) was larger in the amyloidosis group. There were no significant difference between the two groups in Lansbury's activity index. On hematology, biochemistry and urinalysis, the incidences of increased white blood cell count, anemia, increased platelet count, increased serum creatinine, hypoproteinemia, hypoalbuminemia, increased IgA, and increased urine and blood BMG were statistically significantly higher in the amyloidosis group than in the control group. HLA-A, -B, -C, and DR-locus antigens were compared in the 53 patients in the amyloidosis group and in the 59 subjects in the control group. There were no significant differences in frequency of HLA-A, and -B antigens between two groups. Frequency of CW7 antigen was significantly decreased in the amyloidosis group (13.2%) than in the control group (39.0%). Frequency of DR1 antigen was decreased in the amyloidosis group (3.8%) than in the control group (22.0%), although the difference was not significant. These findings suggest the possible involvement of genetic factors in the occurrence of amyloidosis. It is suggested that the occurrence of amyloidosis is suppressed by some genes which are linked with CW7 antigen.

An epidural hematoma associated with posttraumatic pseudoaneurysm of the middle meningeal artery is a very rare clinical entity. Only 31 such cases have been reported in the literature. A 54-year-old man was admitted with lethargy and right hemiparesis. A skull X-ray film revealed a linear fracture in the left parietal and temporal bone, extending to the base of the skull. A brain CT scan disclosed an acute epidural hematoma over the left cerebral hemisphere, contusional hematoma in the right frontal lobe and thalamus, and subarachnoid hemorrhage in the left Sylvian fissure. During an emergency craniotomy a large epidural hematoma was evacuated and external decompression was performed. Angiography, which was performed about one month after the head injury, revealed an aneurysm of the middle meningeal artery. The aneurysm was removed to avoid delayed rupture at the time of cranioplasty. Histological diagnosis was pseudoaneurysm. We discussed the pathogenesis of a pseudoaneurysm of the meningeal artery and the necessity to pay attention to the presence of a pseudoaneurysm when an active bleeding point is not observed during surgery of the epidural hematoma.

Cisplatin, 5-fluorouracil and leucovorin combination chemotherapy added radiation therapy was performed for the treatment of 62-year-old male patient with advanced esophageal cancer who had liver cirrlosis. After the treatment, esophageal lesion disappeared. Only minimal side effect occurred during the treatment. Biochemical modulation chemotherapy combined with radiation therapy is useful for advanced esophageal cancer.

Premature rupture of a cerebral aneurysm during operation is a serious hazard. Temporary occlusion of intracranial arteries has emerged as a valuable technical adjunct in the management of intracranial aneurysms. Twenty-five patients (from a group of 43 consecutive aneurysm patients treated during a 13-month period) underwent elective temporary arterial occlusion under somatosensory evoked potential (SEP) monitoring. Median nerve SEPs were used during 19 ICA and MCA aneurysm operations, while posterior tibial SEPs only were used in 7 patients with aneurysm of the ACA. Amplitude of the N20 or P40 was evaluated. A decrease in amplitude more than 50% when compared to baseline value was defined as a significant SEP change. In 11 patients of the 25 cases, SEP changes were observed. Temporary occlusion was applied to the proximal portion of the internal carotid artery 10 times, to the M1 portion of the middle cerebral artery 5 times, to the M1-M2 complex 5 times, to the A1 portion of the anterior cerebral artery 9 times, and to the A2 - A3 once. Of the 26 clipping (25 patients), 12 had SEP alterations, 14 had no SEP changes. Temporary occlusion was released within 3 minutes after disappearance of N20 (or P40) in all the patients with SEP changes except one. Nine of these 11 patients showed complete recovery of SEP and two showed partial recovery. Patients with partial recovery of SEP were associated with postoperative new neurological deficit, which was transient in one of them. There was a correlation between changes in SEP and post operative outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Duplicated uterus associated with unilateral imperforate vagina and ipsilateral renal agenesis is a very rare anomaly. We report a case of a 10-month-old female infant presenting with pus discharge from vagina, and discussed the embryologic and clinical features relevant to this interesting disease complex with a review of the past literature. Echographic and CT examinations demonstrated a right-sided cystic pelvic mass. IVP revealed a left slight hydronephrosis and non-visualizing right kidney. No right ureteral orifice was found at cystoscopy. Under anesthesia the mass and pus was aspirated. Under the diagnosis of Gartner's cystic duct and a right renal agenesis or dysplasia with or without ectopic ureter, we subsequently performed laparotomy. Surgical exploration revealed a duplicated uterus with a normal ovary, and the mass was an imperforate right-sided vagina which communicated through the uterus. The diagnosis was changed to a double uterus with right-sided imperforate vagina, then the vaginal septum was excised. The post-operative course was uneventful, and pus discharge and the left hydronephrosis have disappeared.

Scrotal calcification is a rare complication of childhood hydrocele testis. Herein, a 12-year-old boy who suffered from left hydrocele testis with intrascrotal calcification is reported. The boy had experienced scrotal pain about 6 months prior to the first visit to our hospital, and gradually noted scrotal swelling. Physical examination revealed left scrotal enlargement with transillumination. Sonographic examination revealed a left hydrocele testis, and a 1.5 cm discrete focus of calcification was found immediate cranio-lateral to the left testis, contour, size and consistency of which were palpated normally. In left hydrocelectomy, no appendix epididymidis was found. A smooth, white, spherical, firm body connecting to the head of the epididymidis was removed. A microscopic examination revealed multiple layers of collagenous tissue with the necrotic tissue in the core. We concluded that this case presented with hydrocele testis secondary to a growing calcification reacting to the infarction due to the repeated torsion of the appendix epididymidis.

We evaluated clinical effects and toxicities of a combination of fosfomycin (FOM) and clavulanic acid/ticarcillin (CVA/TIPC) for treatment of infections complicated with hematological disorders in 61 patients. Fifty-eight patients were evaluable, including 40 with acute leukemia, 13 with malignant lymphoma and 5 with other hematological disorders. Clinical efficacies were excellent in 21 cases, good in 13 cases, fair in 2 cases and poor in 22 cases. The efficacy rate was 58.6% (34 cases/58 cases). This treatment was also effective in 12 of 20 cases in which granulocyte counts were less than 500/microliters through the course of administration. No subjective side effects were observed. Abnormal values in laboratory tests were noted in 1 case. Mild elevations of GOT and GPT were observed. Thus, the combination of FOM and CVA/TIPC is an effective and safe regimen for the treatment of infections in patients complicated with hematological disorders.

Clinical data of 106 patients (177 renal units) with vesicoureteral reflux diagnosed within first year of life were reviewed to clarify its clinical feature and reflux nephropathy. 1) 82.1% (87/106) of them were boy, 83.1% (147/177) of renal units had high grade reflux (VUR grade III or more). These findings suggested that some of them were Fetal Vesicoureteral Reflux. 2) At presentation, 57.1% (101/177) of renal units showed renal parenchymal scars and 18.9% (20/106) of cases had renal dysfunction (s-Cr > or = 0.6 mg/dl). Renal dysplasia or hypoplasia was found in rather high incidence of 8.5% (15/177) suggested that normal fetal nephrogenesis is also disturbed in early infants having VUR. 3) The patients having multiple renal scarring bilaterally had significant impaired both tubular and glomerular function, showing reflux nephropathy. 4) During more than 2 years follow-up on 102 renal units, totally 29 of them (28.4%) showed new scar-formation and/or scar-advancement. Among the kidneys more than grade III reflux and undergone antireflux surgery, those with delayed surgery had the incidence of new scar-formation and/or scar-progression as high as 48.6% (18/37). On the other hand, in those with immediate surgery, the incidence was much lower of 14.3% (5/35). In addition, the incidence in case of non-surgery was 38.5% (5/13). Indication or timing of antireflux surgery for infants is still controversial however, the above results suggest that early antireflux surgery which aimed to eliminate reflux and risk of upper urinary tract deterioration from infantile immatured kidney is more beneficial in order to prevent progression of renal scarring and attain normal renal development.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of fluconazole (FLCZ), an anti-fungal agent of triazole derivatives, was evaluated in patients with systemic mycoses and suspected mycoses associated with hematologic malignancies including leukemia, myelodysplastic syndrome and malignant lymphoma. Plasma beta-D-glycan levels, the differences between the levels determined toxicolor test and in endospecy test, were also investigated. Fourteen patients with systemic mycoses and 31 patients with suspected mycotic infections were treated with intravenous administration of FLCZ at a daily dose of 400 mg. Excellent to good responses were observed in 4 of the 14 patients (28.6%) with definitive diagnosis of mycosis, and in 18 of the 31 patients (58.1%) with suspected fungal infections, with an overall efficacy rate of 48.9% (22/45). Levels of plasma beta-D-glycan correlated well with efficacies of FLCZ in 19 of 30 patients. In several cases, however, plasma beta-D-glucan levels were low during the entire course of treatment. Even in 10 cases of definite mycosis, 4 cases showed low levels of plasma beta-D-glucan (below 15 pg/ml by repeated determinations). The results indicate that FLCZ is an effective agent for the treatment of severe systemic fungal infections in patients with hematologic disorders. Deep seated mycosis cannot be ruled out even when its plasma levels of beta-D-glucan are low.

We evaluated clinical effects and toxicities of a combination in treatment with cefodizime (CDZM) and minocycline (MINO) for infections complicated with hematological disorders in 67 patients. Fifty-nine patients were evaluable, including 32 with acute leukemia, 15 with malignant lymphoma, and 12 with other hematological disorders. Clinical efficacies were excellent in 17 cases, good in 24 cases, fair in 2 cases, and poor in 16 cases. The efficacy rate was 69.5% (41 cases/59 cases). This treatment was also effective in 8 of 12 cases in which granulocyte counts were less than 500/microliter through the course of administration. No subjective side effects were observed. Abnormal values in laboratory tests were noted in 5 cases. Mild elevations of GOT, GPT, Al-P and bilirubin were observed, but none was serious. Thus, the combination of CDZM and MINO is an effective and safe regimen for the treatment of infections in patients complicated with hematological disorders.

To investigate effects of the combination of ubenimex, chemotherapy, and radiotherapy against unresectable advanced squamous cell carcinoma of the lung, a placebo controlled double-blind study was performed. Of 365 registered cases, there were 258 cases in the complete radiation group in which the treatment as specified in the protocol (irradiation of 40 Gy or more to the thorax subsequent to chemotherapy) was conducted; the 50% survival time was 449 days and 363 days in the ubenimex group and the placebo group, respectively. A significant (p = 0.0473) prolongation of the survival time was noted in the ubenimex group, and the response rate was 60.9% and 50.0% (p = 0.087). From these results it was confirmed that ubenimex, when used in combination with chemotherapy and radiotherapy, not only enhances the tumor-reducing effect but also prolongs the survival time.

We reported a case of ruptured aneurysm of the anterior communicating artery with marked dilatation of bilateral cervical carotid arteries. A 38 year old female suffered a subarachnoid hemorrhage. Angiography on admission revealed markedly dilated cervical carotid arteries with smooth lumen and a few segmental areas with mild constrictions in their entire course up to the carotid canals (their maximal sagittal diameters exceeded those of a cervical vertebral body). A saccular aneurysm was also seen at the junction of right A1, A2, and Acom. External carotid arteries were normal in size. Vertebral arteries were not examined because of failures of selective cannulation. The patient was operated upon and trapping of Acom was performed. During the operation, no definite arteriosclerotic changes were identified in the intracranial arteries. Histopathological examination of the surgical specimens revealed marked hyperplasia of the smooth muscle of the tunica media with intact internal elastic lamina both in a superficial temporal artery and a middle meningeal artery. During the operation, pneumothorax developed due to the rupture of bullae in the right lung. Past history of this patient disclosed hypertension noted a few years previously, and frequent severe bruises following minor trauma. Repeated angiography performed three months after the operation disclosed unchanged dilatation of the cervical carotid arteries as well as mild intraluminal irregularities in the proximal one third of the left renal artery. This patient died of pneumonia one year after the operation, but autopsy was not permitted. Possible diagnosis of this patient was discussed, with particular emphasis on fibromuscular dysplasia and Ehlers-Danlos type IV (arterial, ecchymotic, or Sack-Barabas type).(ABSTRACT TRUNCATED AT 250 WORDS)

Eighty-six patients with infections associated with hematological disorders were treated with sulbactam/cefoperazone (SBT/CPZ) and amikacin (AMK). Among 71 evaluable cases, 30 cases had acute non-lymphocytic leukemia, 3 acute lymphoblastic leukemia, 25 malignant lymphoma, and 7 myelodysplastic syndrome as underlying diseases. Excellent responses were obtained in 33 cases (46.5%) and good responses in 14 cases (19.7%), with an overall efficacy rate of 66.2%. The efficacy rate among cases with suspected sepsis was 72.5%. This treatment was also effective in 69.2% of cases in which neutrophil counts were less than 500/microliter through the course of administration. The eradication rate was 83.3% among 6 strains in which Gram-negative rods were detected. Side effects were minimum; skin rash in 1 case, slight elevation of APTT in 3 and slight elevation of total bilirubin in 1. Thus, this combination antibacterial chemotherapy is an effective and safe regimen for the treatment of severe infections in patients with hematological disorders.

The electroencephalographic and histopathological changes following intra-amygdaloid injection of excitatory amino acids were examined in rats. Limbic seizure status was induced after injection of kainic acid (KA), domoic acid (DA), quisqualic acid (QA), alpha-allo-kainic acid (ALLO-KA) and D-glutamic acid (D-GA). The excitatory effect was found to be in the following order: KA > DA >> QA > ALLO-KA >> D-GA. D-GA caused only a transient paroxysmal discharge on EEG. However, seizure was not induced by an injection of L-glutamic acid (L-GA), D-aspartic acid (D-AA) and L-aspartic acid (L-AA). The minimum epileptogenic doses of these amino acids were defined and intra-amygdaloid injection of these doses were performed. Seven days following the injections, histopathological study was performed. These injection resulted in various degree of degeneration and neuronal cell loss of the pyramidal cells in the ipsilateral hippocampus in the following order of severity: DA > or = KA > D-GA > ALLO-KA > QA. These results indicate absence of correlation between epileptogenicity and histopathological changes. Non epileptogenic amino acids induced no pathological changes of hippocampus or the injected site. These results suggest that the severity of hippocampal damage induced by intra-amygdaloid injection of amino acids depends not only on the magnitude of the induced limbic seizure status but also on the difference of neuropharmacological properties of those amino acids in terms of the interaction with their receptors. Further studies are necessary to elucidate the mechanism of actions of these excitatory amino acids in relation to their receptor subtypes.

Imipenem/cilastatin sodium (IPM/CS) which is a broad-spectrum agent against both Gram-positive and -negative bacteria was used in combination with fosfomycin (FOM) as a second-line chemotherapy for severe infections associated with hematologic disorders. FOM was partnered with IPM because FOM may enhance the bacteriocidal effects of IPM when given as pretreatment to IPM/CS therapy. Fifty two patients were treated with IPM/CS plus FOM. Of them, 41 were evaluated for effectiveness. Eleven patients were not evaluated: 4 were treated with a combination of other regimens such as cefixime, gamma-globulin, G-CSF and a large dose of methyl prednisolone; 2 were given IPM/CS plus FOM as a first choice; 3 were observed to have gastrointestinal side effects such as nausea which led to the discontinuation of the combination therapy; and 2 were thought to be suffering from not infectious but tumor fever. An excellent response was observed in 15 (36.6%) patients and a good response in 10 (24.4%), for a overall efficacy rate of 61.0%. Efficacies was 71.4% (5/7) in patients with sepsis, and 60.0% (9/15) in patients whose peripheral granulocyte count was below 100/microliters before chemotherapy. The elimination rates of Gram-positive and -negative bacteria were 57.1% (4/7) and 75.0% (6/8), respectively. In particular, 75.0% (3/4) of Pseudomonas aeruginosa identified were eliminated. Two patients who suffered from tumor fever, 2 who did not receive chemotherapy before the combination chemotherapy and 3 who did not receive a full course of the combination chemotherapy because of side effects, were included in the final evaluation of safety. Side effects were observed in 18 of 48 patients (37.5%). In 1 patient, skin eruption occurred 3 days after the initiation of the combination chemotherapy. In 17 patients, gastrointestinal symptoms such as nausea and vomiting were identified after a few days of IPM/CS plus FOM administration. Degree's of the symptoms were mild, however. Therefore, the treatment was not withdrawn. No abnormal laboratory results such as eosinophilia, liver disfunction or renal disfunction were observed. These results show that IPM/CS plus FOM is effective as a second-line combination chemotherapy for the treatment of severe infections in patients with hematologic disorders.

We described a case of adult respiratory distress syndrome (ARDS) likely due to measles and Mycoplasma pneumoniae. A 24-year-old, previously healthy man was referred to our hospital because of respiratory arrest. He was unconscious and cyanotic. He had erythematous and polymorphic eruptions of his extremities and trunk, but his face was spared. His chest roentgenogram showed consolidation with air bronchograms affecting the whole bilateral lungs. After mechanical ventilation with positive end-expiratory pressure and administration of intravenous hydrocortisone and protease inhibitor "urinastatin" and so on, the patient recovered from his critical condition. No attributable organisms were isolated from the specimens investigated in his acute phase. Serological examinations of the specific IgM antibody to measles during the course indicated a recent measles infection. Mycoplasma pneumoniae indirect hemagglutination test rose from a titre of less than 1/40 to 1/60. ARDS is a rare complication of measles or Mycoplasma pneumoniae infection. Moreover he received measles vaccine before 1970 in Japan, so this case was suspected to be atypical measles.

This 42-year-old man experienced a sudden onset of occipital headache. Neurological examination revealed a moderately disturbed consciousness and a moderate left hemiparesis. CT scan disclosed a hugh hematoma in the right temporo parietal lobe without intraventricular hemorrhage. A cerebral angiography demonstrated typical findings of moyamoya disease and a small saccular aneurysm at the peripheral portion of the right anterior choroidal artery, which was dilated at the collateral circulation to the parietal lobe. The hematoma was removed at once by a craniotomy. He became alert but mild hemiparesis persisted. MRI disclosed a small signal-void lesion lateral to the trigone of the right lateral ventricle. The angiography repeated three weeks after the removal of the hematoma showed the unchanged size of the aneurysm. Direct surgery for the aneurysm was performed via the right parietal transcortical approach. The aneurysm was reached under the guidance of the intraoperative angiography. Trapping of the parent artery and the excision of the aneurysm were performed. On the basis of the presence of an internal elastic lamina at the neck of the aneurysm, the surgical specimen was histologically verified to be a true aneurysm. Since the collateral circulation was well preserved during surgery, no worsening of the neurological manifestation was observed. In view of the unfavorable prognosis for a moyamoya patient with this type of the aneurysm, which often results in a massive ventricular or intracerebral hemorrhage, surgery directed to the aneurysm itself should be considered.