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Objectives　Interviewing people about their health behaviour in specific health checkups (SHCs) is thought to promote awareness of and help improve such behaviour. The standard questionnaire (SQ) for SHCs consists of 22 items presented in the guidelines of the Ministry of Health, Labour, and Welfare. However, using items other than those necessary for stratification for specific health guidance (SHG) is optional. We believe that clarifying the actual utilization of SQ items could contribute to improving the procedure used for the fourth SHCs and SHG, which will be initiated in 2024.　This study seeks to clarify the actual utilization of the SQ for (1) conducting SHCs, (2) planning, implementing, and evaluating SHG and health programs aimed at preventing lifestyle-related diseases, and (3) planning, implementing, and evaluating the data health plan.Methods　We enrolled 3,179 people from 1,741 departments in charge of national health insurance, 47 Japan Health Insurance Association branches, and 1,391 health insurance societies across all municipalities in Japan. One participant among the study participants was the main person in charge of SHCs and SHG at each facility. We conducted a self-reported survey on the implementation of SHCs and SHG in February 2022. This study was approved by the ethics review board of the institution to which the first author belongs.Results　A total of 1,221 (38.4%) were received. The proportions of valid responses from national health insurance departments, Japan Health Insurance Association branches, and health insurance societies were 816 (46.9%), 47 (100%), and 358 (25.7%), respectively. Over 96% of responders used the group SHCs method, and over 93% of those adopting the individual SHCs method used each of the 22 SQ items. However, 187 (18.2%) responders found it difficult to use the item "If you had the opportunity to receive health guidance for lifestyle improvement, would you take it?" The reason was that the on-request SHG system was misunderstood. Additionally, only approximately 50% of respondents used the SQ to develop, implement, and evaluate their health program.Conclusion　We believe there will be no problem in implementing the SQ even if using all its component items is required. However, the aforementioned item needs to be revised. Methods to encourage health insurers and their supporters to use the SQ for health-related data collection and health program planning should be devised.

A 49-year-old woman who had surgery for left breast cancer and subsequently underwent a two-stage deep inferior epigastric perforator(DIEP)flap reconstruction. One month postoperatively, she became aware of abdominal distention and visited a local hospital. CT scan revealed subcutaneous fluid accumulation with capsular formation in the lower abdomen. Imaging findings and physical examination showed no abdominal wall scar hernia. After multiple puncture aspirations, fluid accumulation was observed again, and the possibility of a chronic expanding hematoma was considered. Later, hematoma removal, including the capsules, was performed; pathological findings showed no evidence of malignancy. No fluid retention was observed postoperatively. In cases where imaging evaluation reveals hematoma formation with capsules, hematoma removal, including the capsules, should be performed to avert the possibility of a chronic expanding hematoma.

A 77-year-old man presented to our hospital with diarrhea and weight loss. Upper gastrointestinal endoscopy revealed advanced Type 3 gastric cancer measuring 40 mm in the lower greater curvature of the stomach. Biopsy from a gastric tumor revealed moderately differentiated tubular adenocarcinoma overexpressing HER2. Abdominal contrast-enhanced computed tomography(CT)showed multiple liver metastases in S3 and S5. We diagnosed HER2-positive gastric cancer with liver metastasis. Systemic chemotherapy was administrated, with a total of 13 courses of combination therapy with S-1, oxaliplatin and trastuzumab. After chemotherapy, the primary tumor was significantly reduced and liver metastases were almost undetectable. Laparoscopic distal gastrectomy and partial hepatectomy were performed as conversion surgery. The patient was discharged on the 9th day without any postoperative complications. Postoperative pathological findings showed no residual tumor in either gastric and hepatic specimens, and the therapeutic effect of chemotherapy was diagnosed as pathological complete response. We report a case of HER2-positive advanced gastric cancer with multiple liver metastases that achieved a pathologically complete response to chemotherapy followed by conversion surgery. Laparoscopic surgery would be one of an effective option for conversion surgery.

Von Willebrand disease (VWD) is caused by quantitative or qualitative deficiencies in the von Willebrand factor (VWF). VWF concentrate replacement therapy is required in certain situations, such as severe VWD subtype or critical bleeding, even in mild VWD subtypes. A single plasma-derived factor VIII/VWF concentrate has been available for decades in Japan. However, it has a theoretical risk of infectious disease transmission, allergic reactions, and thrombosis. A recombinant VWF (vonicog alfa) was approved by the Japanese Pharmaceuticals and Medical Devices Agency in 2020. Vonicog alfa is the only VWF product that contains ultralarge multimer, suggesting both effective bleeding control and excessive platelet plug formation. The efficacy and safety of vonicog alfa have been confirmed by three phases of clinical studies for on-demand usage, elective surgery, and prophylaxis. We also have a successful experience with vonicog alfa with minimal adverse events in two cases (hemostatic treatment in a patient with recurrent epistaxis and prophylaxis for delivery in a pregnant woman).

A 70-year-old woman was admitted to the hospital with loss of appetite and melena. She was diagnosed with multiple myeloma 7 years ago and had been on carfilzomib, lenalidomide, and dexamethasone (KRd) therapy for a month because her disease had a relapsed/refractory. On admission, her laboratory tests revealed hemolytic anemia with schizocytes, thrombocytopenia, and acute renal dysfunction. TMA (thrombotic microangiography) caused by carfilzomib was suspected. The possibility of thrombotic thrombocytopenia was considered, and steroid pulse therapy was initiated. Her condition improved significantly after she stopped taking carfilzomib, plasma exchange, hemodiafiltration, steroid pulse therapy, and abstaining from food. The previously reported cases of carfilzomib-induced TMA included fever, gastrointestinal symptoms (nausea/vomiting, diarrhea), and acute renal disorders (lower extremity edema, decreasing urine output). As far as we know, this is the first case of carfilzomib-induced TMA with bleeding as the first symptom.

We divided the patients with biliary tract cancer who underwent pancreaticoduodenectomy(PD)at our hospital into the 5-year recurrence-free and recurrence groups and investigated the prognostic factors. Additionally, we investigated the efficacy of adjuvant chemotherapy in patients with and without lymph node (LN) metastasis. There was no significant difference between the two groups for patient characteristics and perioperative factors. However, patients with LN metastasis tended to have a higher recurrence rate. For patients without LN metastasis, the median overall survival(OS)was not significantly different between the patients who received and did not receive adjuvant chemotherapy. For patients with LN metastasis, although it was not significantly different(p=0.234), the OS of patients who received adjuvant therapy was more than 3 times than that of patients who did not(58.6 months and 18.4 months, respectively). For patients with biliary tract cancer who underwent PD, positive LN metastasis may be a poor prognostic factor, and adjuvant therapy may possibly improve prognosis.

A man in his 70s was observed to have GIST recurrence 19 months after surgery. Chemotherapy was initiated with imatinib 400 mg/day orally. The dose was eventually reduced to 100 mg/day to avoid side effects. Tumor reduction was confirmed 3 months after treatment initiation. Currently, 84 months after the onset of GIST, the patient survives with continuous intake of the same dose of oral imatinib. We were able to observe long-term survival in a patient with recurrent GIST after the administration of a small dose of imatinib.

We report a case of primary breast rhabdomyosarcoma. A 16-year-old girl noticed tumor of her right breast and consulted a local clinic. From the result of core needle biopsy, breast sarcoma was suspected, so she attended our hospital. Breast ultrasonography showed a mosaic pattern tumor occupying the whole right breast. CT images revealed an axillary node metastasis and no distant organ metastasis. Immunohistochemical staining of the tumor yielded positive results for desmin, MyoD1, and myogenin. Based on reverse transcription polymerase chain reaction(RT-PCR), she was diagnosed as an alveolar rhabdomyosarcoma with PAX3-FKHR(FOXO1)fusion transcripts[t(2;13)(q35;q14)]. She underwent total mastectomy and dissection of axillary lymph nodes. After surgery, the whole-body magnetic resonance imaging(MRI) demonstrated metastases of sacrum and left foot, so she was under systemic chemotherapy.

Purpose: The purpose of this study was to clarify the predictors of efficacy of nab-paclitaxel plus gemcitabine(GnP)for patients with recurrence after resection for adenocarcinoma of the pancreas., Method: Patients who had received GnP at our hospital were divided into 2 groups; effective group and non-effective group and we compared them. In addition, we compared the therapeutic effect of patients between well-differentiated adenocarcinoma and moderately differentiated adenocarcinoma. Furthermore, we compared the efficacy depending on the time of recurrence., Results: In patients with well-differentiated adenocarcinoma, the disease control rate was 93.6% and progression free survival was 8.6 months, whereas those in patients with moderately differentiated adenocarcinoma were 57.1% and 4.4 months, respectively. Patients who recurred at 7 months or later, had a better therapeutic response than the patients who recurred within 6 months after surgery., Conclusions: GnP may be effective in patients with well-differentiated adenocarcinoma and in patients who recurred at 7 months or later.

Nowadays, approximately 90 percent of the general population in Japan uses the internet and many of them look for health-related information. However, there have been serious concerns about the contents and credibility of these information. Among "mixture of wheat and chaff", information provided by the public domains are expected as accurate and reliable ones. This article reviews five public websites that provide health or health care information for users including the general population: Minds by the Japan Council for Quality Health Care, e-health net, evidence-based Japanese Integrative Medicine (eJIM), Cancer Information Service by the National Cancer Center, Center for Cancer Control and Information Services, Information system on safety and effectiveness for health foods (HF net) by National Institute of Health and Nutrition. These websites show their running policy transparently and have constructed collaborative relationships with each domain experts, and from the people who are not related with the healthcare field including patients in some cases. Each of them is content-rich and well-organized as an individual unit. The organizations that run these websites share the common goal that provides the general population with quality health-related information, however, cooperation have been limited. To increase awareness among the public, it is worthy considering joint efforts of these organizations in future.

Emergency contraceptive (EC) pills are used to prevent pregnancy after unprotected sexual intercourse. Levonorgestrel is an EC pill, which has been only approved in Japan; it is more effective the sooner it is used after intercourse and safe without serious side effects. EC pills are already available at accessible community pharmacies in more than 90 countries around the world. In Japan, citizens have signed a petition calling for the sale of emergency contraceptives at community pharmacies. However, little is known about the thoughts of pharmacists who engage with patients and sell medicines at pharmacies. Therefore, we conducted a web-based cross-sectional survey to determine the level of preparation in community pharmacies and the awareness of pharmacists regarding the sale of EC pills. A total of 1338 pharmacists responded to the survey from November 7, 2020, to December 16, 2020. In terms of the level of preparation for selling EC pills at pharmacies, 1067 (83.9%) respondents cited "lack of preparation of medical questionnaires and explanatory materials", and 975 (76.7%) respondents cited "lack of knowledge of pharmacists" as the most common reasons that were "barriers to EC pill sales at pharmacies". In terms of confidence level, only 289 (22.7%) respondents were confident about conducting the necessary checks while administering medicine. On the other hand, 944 (74.3%) respondents agreed to be able to sell EC pills at their pharmacies. The survey revealed that most of the pharmacists who participated in the survey believe that it is possible to sell EC pills in pharmacies.

A 71-year-old woman presented to our hospital with fever and dyspnea. Computed tomography showed shadows of bilateral pneumonia and anterior vertebral mass. She was admitted to our hospital for respiratory failure. Despite treatment with antibiotics, she developed right thoracic empyema. A high level of inflammation and fever persisted, despite chest tube drainage and continued treatment with antibiotics. Therefore, thoracoscopic curettage was conducted. The histopathological findings of the curetted anterior vertebral body lesion revealed the diagnosis of chordoma. After confirming that all the culture results and inflammation findings had turned negative, the patient was discharged from the hospital. Thoracic vertebral chordoma is being treated at the department of orthopedics.

Nodal marginal zone lymphoma (NMZL) is a form of nodal B-cell lymphoma exhibiting proliferation of abnormal lymphocytes at the circumference of the mantle zone in the lymph nodes. Although the outcome of patients with this disease is often favorable, we recently encountered a patient with a CD5-positive NMZL who was resistant to chemotherapy. A 67-year-old woman complaining of systemic lymph node swelling was referred to our hospital. After biopsy of the neck lymph node, she was diagnosed with CD5-positive NMZL. Disease progression was revealed after 16 months, and she was initially treated with chemotherapy consisting of rituximab, cyclophosphamide, vincristine, and prednisolone (R-CVP). However, this therapy was ineffective. Subsequent therapy with rituximab and bendamustine also failed to induce remission. A rebiopsy revealed that the NMZL had transformed into a diffuse large B-cell lymphoma. This patient died after 2 years from the initial diagnosis due to lymphoma progression. Cases of CD5-positive NMZL are rare; thus, it is difficult to study the clinical implications of CD5 expression in this disease. Here we describe the current understanding of CD5 expression in NMZL.

An 84-year-old woman developed spontaneous recurring mutism. During the periods in which she was able to speak, she described that she had a peculiar delusion where her body was melting away. She did not obey orders although she was able to move her limbs spontaneously. Severe fluctuations in blood pressure measurements were observed; they were unaffected by postural changes. She also had urinary retention and constipation. Her psychiatric and autonomic symptoms showed marked daily and diurnal fluctuations. The brain MRI showed no abnormality in the limbic system or temporal lobes. The cerebrospinal fluid showed slightly elevated protein with normal cells counts. This case was initially thought to be an encephalopathy of unknown etiology. On subsequent testings she was shown to have positive anti-ganglionic acetylcholine receptor (gAChR) antibodies. Although the initial steroid pulse and intravenous immunoglobulin therapies markedly improved both psychiatric and autonomic symptoms, they turned ineffective in subsequent recurrences. We were not able to treat her with plasmapheresis or with other immunisuppressive drugs because of her poor general status, thus their effectiveness could not be determined. Judging from her clinical course, in which immunotherapy was effective although somewhat limited, a possible involvement of an autoimmune mechanism was suspected; however, the exact pathogenesis remains undetermined. It is possible that in this case there may have been an involvement of the immune system and that the patient might have had an encephalopathy with anti-gAChR antibodies.

A 74-year-old man with aspiration pneumonia was admitted in the internal medicine department. CT revealed progressive carcinoma of RS-Ra, which became the focus of intervention after the pneumonia was treated. After having been allowed temporary discharge, the patient was rehospitalized for surgical operation and rehabilitation. During the perioperative period of cancer patients, we use body distribution data for teaching and environment setting, which is a useful tool in rehabilitation. Rectal cancer was observed after hospitalization for pneumonia, presenting an interesting case. Therefore, care needs to be taken as body pressure distribution may be modified by comorbidity.

A 77-year-old man with a complaint of impaired consciousness was brought to our emergency department. The patient was referred to our department because of a huge retroperitoneal tumor and multiple pulmonary nodules detected on computed tomography. Owning to an abnormally high level of dehydroepiandrosterone sulfate, right adrenal cancer was suspected. Pathological examination of the retroperitoneal tumor by echo-guided pericutaneous biopsy revealed an adrenocortical carcinoma. Under the diagnosis of stage IV adrenocortical carcinoma, mitotane therapy was started in May 2013. We adjusted the mitotane dose on the basis of the clinical evidence and the adrenocorticotropic hormone and cortisol levels.The tumors had increased in size after 2 months of the mitotane therapy. However, 2 months later, the tumor had significantly decreased in size. The treatment was continued for 53 months until he could no longer take medications orally, because of his advanced age, worse condition, and disuse syndrome.

A 65-year-old man with multiple lymphadenopathy presented to our hospital and was diagnosed with StageIVA blastoid-variant mantle cell lymphoma (MCL), with a Ki-67 index of 93%. Partial response was achieved after four courses of CHASER (cyclophosphamide, cytarabine, dexamethasone, etoposide, and rituximab) chemotherapy, and complete response was achieved after autologous stem cell transplantation (ASCT). Six months after ASCT, the MCL relapsed with occurrence of tumors one on the left upper arm and one in the cerebrum, which were proved to be resistant to the conventional chemotherapy and progressed rapidly. These tumors disappeared with scarring following the local irradiation (45 Gy). However, the unirradiated regions became enlarged. The bulky abdominal lesion was treated with local irradiation (41 Gy) combined with 560 mg of ibrutinib but still resulted in progressive disease 1 month after initiating the ibrutinib treatment. Finally, the patient died 5 months post-relapse. The prognosis of patients with blastoid-variant MCL with high Ki-67 index is extremely poor. Furthermore, the risk of central nervous system (CNS) involvement is very high. Therefore, ibrutinib maintenance therapy post ASCT might be a treatment option to prevent CNS involvement. Further efforts might be needed to improve the outcomes of blastoid-variant MCL with a high Ki-67 index.

A 66-year-old male presented with fever and erythema at our hospital, and leukoerythroblastosis, anemia, thrombocytopenia, and multiple low-density lesions in the moderately enlarged spleen were detected. Skin tissue revealed CD8 + T cells with the expression of cytotoxic molecule markers involving fat lobules, and subcutaneous panniculitis T-cell lymphoma (SPTCL) was diagnosed. The bone marrow displayed no infiltration of lymphoid tumor cells, but hyperplasia of granulocytes and megakaryocytes with grade 2 stromal fibrosis. In addition, the bone marrow exhibited diffuse 18 F-fluorodeoxyglucose (FDG) accumulation on FDG positron-emission tomography/computed tomography (FDG-PET/CT). Although chemotherapy improved SPTCL, the patient died from leukocytosis with leukoerythroblastosis. We obtained negative results for the JAK2 V617F mutation, and CD34 + cells were elevated in the bone marrow compared with the levels at initial examination. The final diagnosis was concurrent myelodysplastic syndrome (MDS) with fibrosis and SPTCL. This report highlights that it is essential to consider MDS or other myeloproliferative neoplasms (MPN) as possible complications when malignant lymphoma complicates myelofibrosis in the absence of bone marrow infiltration of lymphoma cells. Perhaps, the assessment of clonal markers of MPN and FDG accumulation patterns in the bone marrow by FDG-PET/CT could enable differentiation.

An 84-year-old woman presented pancytopenia. She was diagnosed with myelodysplastic syndromes (MDS) with excess blasts-1, however, she declined treatment with azacitidine (AZA). Ten months later, bilaterally symmetrical, non-pitting edema appeared on the lower legs. A skin biopsy of the lower leg revealed lymphedema. The appearance and location of the lymphedema suggested an immunologic etiology; however, tests for autoimmune diseases yielded negative results. Therefore, a relationship between MDS and lymphedema was, therefore, speculated. Consequently, treatment with AZA was started, which led to marked improvement in both the lymphedema and pancytopenia. Based on the skin tissue pathology and the improvement in MDS after treatment with AZA, MDS-related autoinflammatory lymphedema was diagnosed.

A 69-year-old female with left atrial tumor was refered to our hospital for surgical treatment. The tumor was attached to the interatrial septum and resected completely. Histopathological analysis confirmed a myxoma with ossification(mature bone). These findings may support the hypothesis that the undifferentiated mesenchymal cells are the origin of cardiac myxoma.

A 76-year-old woman presented to our hospital with leukocytosis and abnormal lymphocytes. M protein of the immunoglobulin G (IgG) type was detected using immunoelectrophoresis. A bone marrow biopsy revealed infiltration of small mature lymphocytes, lymphoplasmacytoid cells with Dutcher bodies, grape cells, and Russell bodies. The MYD88 L265P mutation was detected in the abnormal peripheral lymphocytes, and a diagnosis of lymphoplasmacytoid lymphoma was established. MYD88 L265P mutation analysis is useful for making a diagnosis of non-IgM lymphoplasmacytoid lymphoma because it enables the differentiation from other low-grade B-cell malignancies.

This research aimed to clarify the present status and challenges of evidence-based medicine (EBM) education in schools of pharmacy. We sent a questionnaire to 268 faculty members in August 2015, and a total of 192 were completed. The educational contents by respondents differed considerably. Only about 30% of respondents self-assessed the current EBM courses they taught as "fulfilling". Challenges such as "time deficits", "lack of exercise lessons and practical training", "limited awareness and skills of teachers", "lack of appropriate educational tools", and "insufficient academic ability of students" were mentioned.

Objectives　To clarify the structure, applicability, and objectives of the current Japanese legislation for private information protection and research ethics and to examine the clauses of the related laws/regulations for academic research purposes.Methods　The research design is a descriptive study based on a systematic literature review. Using the "e-Gov" database, the laws/regulations relating to private information protection and research ethics that apply to medical research involving human subjects and human genome/gene analysis research were included in the research. The Drugs Law (Law No. 145 of 1960) and related GCP/GPSP regulations and laws/regulations on administrative organizations, management, and procedures were excluded. Furthermore, the guidelines and Q&A relating to these laws/regulations and all 47 prefectural regulations on private information protection have been selected from the websites of the related ministries, government organizations, and prefectures.Results　Our study demonstrated that the current legal system on private information protection consists of three layers and that the applicability of the laws/regulations in this area varies according to the type of research organization. Additionally, the applicability of the laws/regulations on research ethics is different depending on the research area. While the Private Information Protection Law (PIPL) for the private sector contains two objectives, PIPL for administrative organizations and PIPL for independent administrative organizations both include three objectives. For academic research purposes, PIPL for the private sector sets out a holistic exemption clause, whereas the other two PIPLs stipulate three specific exemption clauses. Furthermore, our research revealed that the clauses of the prefectural regulations demonstrated many variances.Conclusion　This study suggests that the current Japanese legal system relating to private information protection could be defined as a "mixed model," wherein the laws/regulations concerned are not necessarily consistent. The protection of medical information is solely regulated by a few specific laws with a narrow scope of application; the ethical guidelines are not directly based on any laws; and identifying applicable laws/regulations, depending on the category of research organization, is complicated, especially in the case of collaborative research involving researchers from various organizations. Therefore, in the larger framework of legislation, it is indispensable to reconsider the protection of private medical information and its effective use, including the ethics of this process because of the sensitive and useful nature of private medical information.

Evidence-based medicine (EBM) can be defined as "the integration of the best research evidence with clinical expertise and a patient's unique values and circumstances". However, even with the best research evidence, many uncertainties can make clinical decisions difficult. As the social requirement of respecting patient values and preferences has been increasingly recognized, shared decision making (SDM) and consensus development between patients and clinicians have attracted attention. SDM is a process by which patients and clinicians make decisions and arrive at a consensus through interactive conversations and communications. During the process of SDM, patients and clinicians share information with each other on the goals they hope to achieve and responsibilities in meeting those goals. From the clinician's standpoint, information regarding the benefits and risks of potential treatment options based on current evidence and professional experience is provided to patients. From the patient's standpoint, information on personal values, preferences, and social roles is provided to clinicians. SDM is a sort of "wisdom" in the context of making autonomous decisions in uncertain, difficult situations through interactions and cooperation between patients and clinicians. Joint development of EBM and SDM will help facilitate patient-clinician relationships and improve the quality of healthcare.

A 61-year-old man was admitted because of unstable angina. The patient had a history of CABG [LITA-left anterior descending artery(LAD), aorta-saphenous vein graft(SVG)-posterolateral branch (PL)-diagonal branch (D1)]4 years ago. Coronary angiography revealed an occlusion of old SVG at proximal anastomosis site and a stenosis of native high lateral artery (HL). To reduce the risk of cardiac injury and damage to the patent grafts due at sternal reentry, we performed redo CABG through left thoracotomy. The proximal site of SVG was anastomosed to descending aorta using automated proximal anastomosis system. The SVG was anastomosed to the HL and old SVG in a sequential mode. Postoperative course was uneventful and the patient was discharged on postoperative day 14. Redo CABG through left thoracotomy provides safe and effective surgical approach in patient who requires revascularization of left circumflex territory.

Objective: To evaluate the effects and tolerability of vigabatrin (VGB) in children with tuberous sclerosis (TS) with infantile spasms or tonic seizures. Methods: We examined the impact of VGB on a series of 17 children with TS visiting Tohoku University Hospital in Japan during April 2010 and May 2015. To minimize potential adverse effects, VGB was given to the patients for limited 6 months with titration from 30 mg/kg/day as an initial dose. Results: Main seizure types were classified into spasms (n=10) or tonic seizures (n=7). Seizure reduction was positively associated with seizure type of infantile spasms, lower maximum dosage, younger age on VGB administration, and earlier VGB treatment after the diagnosis. Seizure type of infantile spasm was an independent favorable predictor and also associated with long-term seizure reduction. Major adverse events included psychiatric symptoms (n=7) and electroretinogram (ERG) abnormalities (n=2). All symptoms were recovered by reducing the dosage of VGB. Conclusion: VGB is effective and well tolerated as first-line treatment for TS children with infantile spasms. Our “low dosage and limited period” protocol is efficient for improving seizure control as well as minimizing the potential risks of VGB.

A 67-year-old man presented at our hospital with severe edema on the left side of his neck, chest and brachial regions. He had a history of right radical nephrectomy due to renal cell carcinoma (RCC, clear cell subtype, stage II) 15 years earlier. Thereafter, metastases to the pancreatic tail and right lung, and left lung metastasis were removed at 8 years and 11 years, respectively, after the nephrectomy. Four years earlier, he had also undergone total gastrectomy for gastric carcinoma (poorly differentiated adenocarcinoma, stage IV) and subsequent maintenance chemotherapy for gastric carcinoma. Follow-up computed tomography (CT) disclosed bilateral lung metastases and a pancreatic head metastasis. Cytology of pleural effusion on admission suggested pleuritis carcinomatosa from RCC. Clinical diagnosis was bilateral lung and pancreatic head metastases, pleuritis carcinomatosa and left subclavian vein thrombosis due to RCC metastasis. Maintenance chemotherapy for gastric carcinoma was replaced by Sunitinib 50 mg for RCC but he died of progressive disease 20 days later. Immunohistochemical study of the tissue from autopsy revealed lung metastasis and pancreatic head metastasis from both RCC and gastric carcinoma as well as multiple visceral metastases, pleuritis carcinomatosa and left subclavian vein thrombosis due to gastric carcinoma. Cause of death was acute respiratory failure due to pulmonary tumor embolism and pulmonary edema. Immunohistochemical study from autopsy was able to reveal the exact diagnosis, and immunohistochemical studies may be helpful in diagnosing the exact origin of metastasis and selecting appropriate treatmentsin patientswith multiple cancers.

In the JSCC, recommended methods for eight items of enzymes and 9 items of non-enzyme (one item for Na, K, and Cl) have been presented since the recommended methods of activity measurements of AST, ALT, CK, and LD were prepared in 1989. These recommended methods were prepared by placing priority on the actual situation of the measurement methods of those days in Japan, and there are some differences with IFCC recommended methods or primary reference procedures. Recently, from the viewpoint of global standardization, measured values that can be shared with data overseas are required even on clinical exami- nation, and overseas inspection facilities are sometimes used to avoid differences in measurement methods in international clinical trials. With this situation, when the recommended methods of JSCC and IFCC are compared, there are the following differences: - PALP for AST and ALT: not added in JSCC method/ added in IFCC method. - Buffer solution (pH) for LD: EAE (pH 8.8) in JSCC method/ NMG (pH 9.4) in IFCC method. Buffer solution for ALP: EAE in JSCC method/ AMP in IFCC method. Free glycerol for TG: not included on JSCC method/ included in ID-GC/MS method of NIST and CDC. It is necessary to consider from various aspects whether or not these differences affect the implementation of global standardization. In consideration, it is necessary to add the point of how the method should be linked directly to the international traceability of CRMLN (Cholesterol Reference Method Laboratory Net- work) and JCTLM (Joint Committee for Traceability in Laboratory Medicine) to the domestic surveillance and to judge it. [Review].

Re-do coronary artery bypass grafting to the right coronary artery via the diaphragm is useful, especially when re-sternotomy may injure a patent internal thoracic artery graft under the sternum. When the target vessel is located on the posterior wall of the heart, however, anastomosis becomes difficult. In our case, we mobilized the liver from the diaphragm and divided the diaphragm more posteriorly. The gastroepiploic artery was successfully anastomosed to the target vessel.

The patient was a 75 year-old male. Noticing areas of hardening in the lower abdomen, and consequently feelings of systemic fatigue and difficulty in walking, the patient visited a clinic and was diagnosed with kidney failure prior to the visit to our clinic. Computed tomography and magnetic resonance imaging showed thickness of the rectus abdominis muscle and the bladder wall, and bilateral hydronephrosis was also identified. As no explicit tumor was identified in the bladder, the patient underwent biopsies of the abdominal wall and bladder membrane mucous, and was diagnosed with a plasmacytoid urothelial carcinoma primarily developed in the bladder. The patient displayed a poor general state of health and died five months after the diagnosis. It is known that plasmacytoid urothelial carcinomas progress rapidly and the prognosis is poorer than for the micropapillary variant. It is important to obtain a tissue specimen in the early stage of this disease because there are cases in which no explicit tumor can be identified. Furthermore, the value of carbohydrate antigen (CA) 19-9 of the patient was much higher than would be expected as normal at the first visit. It kept rising during the follow-up and was useful as a marker to indicate the progress of the disease.

Objectives: Early detection of cancer incidence and tobacco control are prioritized in the second-term of the Basic Plan for Promotion of Cancer Measures. However, the cancer screening rate is low and smoking prevalence high in Japan. Smokers may not participate in cancer screening, although they are a high-risk population for cancer mortality. This study examined whether smoking status, including number of cigarettes smoked per day and the Brinkman index (BI), was associated with participation in screening for lung, gastric, and colorectal cancers., Methods: In 2011, we conducted a cross-sectional study in Osaka city: 2,016 subjects aged 40 to 64 (men, N=966; women, N=1,050) were analyzed (response rate=52.4%). We used multivariable logistic regression with stratification by sex to calculate odds ratios (ORs) for participation in screening for lung, gastric, and colorectal cancers according to smoking status, such as number of cigarettes smoked per day and the BI., Results: Compared with non-current smokers, current smokers were less likely to participate in all cancer screenings. Men who currently smoke had significantly lower odds for gastric and colorectal cancer screening participation than non-current smokers (gastric : OR=0.71, P=0.036 ; colorectal : OR=0.67, P=0.012). Furthermore, compared with non-current smokers, men who smoked more than 20 cigarettes per day had significantly lower odds for all cancer screenings (lung: OR=0.61, P=0.009; gastric: OR=0.61, P=0.009; colorectal: OR=0.59, P=0.004). Similar results were observed in smokers with a BI≧600 (lung: OR=0.55, P=0.006; gastric: OR=0.62, P=0.028; colorectal: OR=0.56, P=0.006). Among the women, significant associations between number of cigarettes smoked per day, BI, and colorectal cancer screening participation were observed (more than 20 cigarettes per day: OR=0.39, P=0.004; BI≧400: OR=0.51, P=0.020)., Conclusion: Current smokers were less likely to undergo cancer screening compared with non-current smokers. These associations were stronger in men with greater numbers of cigarettes smoked per day and a higher BI score. Because smokers do not receive cancer screening, they may be at higher risk for cancer mortality. Counseling at the chance of cancer screening should be considered as a good opportunity to provide useful information on smoking cessation, as well as to promote cancer screening participation.

CD4(+) T cells play central roles to appropriate protection against pathogens. While, they can also be pathogenic driving inflammatory diseases. Besides the classical model of differentiation of T helper 1 (Th1) and Th2 cells, various CD4(+) T cell subsets, including Th17, Th9, T follicular helper (Tfh) and T regulatory (Treg) cells, have been recognized recently. In this review, we will focus on how these various CD4(+) T cell subsets contribute to the pathogenesis of immune-mediated inflammatory diseases. We will also discuss various unique subpopulations of T helper cells that have been identified. Recent advancement of the basic immunological research revealed that T helper cells are plastic than we imagined. So, we will focus on the molecular mechanisms underlying the generation of the plasticity and heterogeneity of T helper cell subsets. These latest finding regarding T helper cell subsets has pushed us to reconsider the etiology of immune-mediated inflammatory diseases beyond the model based on the conventional Th1/Th2 balance. Toward this end, we put forward another model, "the pathogenic Th population disease induction model", as a possible mechanism for the induction and/or persistence of immune-mediated inflammatory diseases.

A survey of introductory statistics courses at Japanese medical schools was published as a report in 2014. To obtain a complete understanding of the way in which statistics is taught at the university level in Japan, it is important to extend this survey to related fields, including pharmacy, dentistry, and nursing. The current study investigates the introductory statistics courses offered by faculties of pharmaceutical sciences (six-year programs) at Japanese universities, comparing the features of these courses with those studied in the survey of medical schools. We collected relevant data from the online syllabi of statistics courses published on the websites of 71 universities. The survey items included basic course information (for example, the course names, the targeted student grades, the number of credits, and course classification), textbooks, handouts, the doctoral subject and employment status of each lecturer, and course contents. The period surveyed was July-September 2015. We found that these 71 universities offered a total of 128 statistics courses. There were 67 course names, the most common of which was "biostatistics (iryou toukeigaku)." About half of the courses were designed for first- or second-year students. Students earned fewer than two credits. There were 62 different types of textbooks. The lecturers held doctoral degrees in 18 different subjects, the most common being a doctorate in pharmacy or science. Some course content differed, reflecting the lecturers' academic specialties. The content of introductory statistics courses taught in pharmaceutical science programs also differed slightly from the equivalent content taught in medical schools.

We report 2 cases of signet ring cell carcinoma of the appendix and colon. Case 1: A 61-year-old man was admitted for lower abdominal pain. Colonoscopy revealed an elevated lesion in the orifice of the appendix. Signet ring cell carcinoma was diagnosed on biopsy. The surgical findings showed multiple peritoneal dissemination nodules, while the primary tumor was unresectable owing to extensive invasion into the retroperitoneum. The histopathological findings were signet ring cell carcinoma, T4b (retroperitoneum), NX, P3, Stage Ⅳ. Although the patient received 14 courses of treatment with S-1 as postoperative chemotherapy, he died of his illness at 32 postoperative months. Case 2: A 76-year-old man was admitted for abdominal pain. Perforation of the lower gastrointestinal tract was diagnosed on abdominal CT, and an emergency operation was performed. The surgical findings demonstrated a large number of peritoneal dissemination nodules, cecal invasion of a sigmoid tumor, and perforation of the ascending colon. The primary tumor was thought to be unresectable, and the perforated segment was resected. The histopathological findings were signet ring cell carcinoma, T4b (cecum), NX, P3, Stage Ⅳ. Although 11 courses of treatment using FOLFIRI+Bev were administered as postoperative chemotherapy, the patient died of his illness at 26 postoperative months.