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A 64-year-old male was referred to our hospital with both advanced rectal cancer and lung tumor with swollen lymph nodes in the lung hilum. The patient underwent laparoscopic low anterior resection followed by systematic lobectomy of the lung 2 months later. Postoperative pathological examination revealed a diagnosis of metastatic lung tumor and metastasis in the lung hilum. However, hilar lymph node metastasis is considered a poor prognostic factor for lung metastasis. Herein, we report a case of synchronous lung metastasis and hilar lymph node metastasis from colorectal cancer that achieved 20 months of recurrence free survival with surgical therapy alone.

Obinutuzumab frequently triggers an infusion reaction(IR). In the GALLIUM study, despite the use of corticosteroids, antipyretic analgesics, and antihistamines to prevent IR, IR occurred at a high frequency of 68.2% for all Grades and 12.4% for Grades 3 or higher. The dose of methylprednisolone was increased from 80 mg administered in the GALLIUM study to 125 mg, and the development of IR was investigated in 30 patients with follicular lymphoma who received the initial dose of obinutuzumab. The incidence of IR was 43.3% for all Grades and 0% for Grades 3 or higher, and no serious IR was observed. It also had no effect on infectious diseases. Increased doses of corticosteroids were well tolerated and suggested as an effective method for reducing the frequency of IR.

Guillain-Barré syndrome (GBS) is a rare neurological complication of allogeneic hematopoietic stem cell transplantation (HSCT). The pathogenesis of post-HSCT GBS is unclear. Here, we report a case of GBS coincident with Epstein-Barr virus (EBV) and cytomegalovirus (CMV) reactivation that occurred after HSCT in a patient with myelodysplastic syndrome. A 61-year-old man was admitted to our hospital because of gait disturbance due to lower limb muscle weakness, which arose during treatment for chronic graft-versus-host disease (GVHD) five months after allogeneic HSCT. He was diagnosed with GBS based on his clinical course, cerebrospinal fluid analysis, and a nerve conduction study. At that time, he exhibited EBV and CMV reactivation. GBS improved after intravenous injection of immunoglobulins. Our case suggests that reactivation of EBV and CMV during treatment for chronic GVHD may induce GBS, and that rapidly progressive muscular weakness coincident with EBV or CMV reactivation can be a diagnostic sign of GBS after allogeneic HSCT.

We investigated the findings of rectoanal lesions in 190 patients who underwent colon capsule endoscopy (CCE) at our hospital. Internal hemorrhoids were observed in 70 (36.8%) patients and rectal polyps in 19 (10%) patients. When conventional endoscopy (colonoscopy and double balloon endoscopy) was considered the gold standard, the sensitivity and specificity of rectal polyps were 75% and 93.4%, respectively, and those of internal hemorrhoids were 88.9% and 92.7%, respectively. The prevalence of constipation was significantly higher in the false-negative group for internal hemorrhoids, and the colonic transit time was significantly shorter in the false-negative and false-positive groups for rectal polyps. No adverse events occurred in any of the patients. CCE might be a useful and safe examination method for rectoanal lesions.

Long-acting beta2-agonists (LABA) are preferred add-on treatment for adult asthmatic patients whose symptoms cannot be controlled with inhaled corticosteroids (ICS) alone. However, over the last decade, long-acting muscarinic antagonists (LAMA) have gained approval for use in treating asthma, and their efficacy is anticipated. Therefore, we conducted a systematic review to investigate whether the addition of LABA or LAMA is more beneficial for the long-term management of adult asthmatic patients poorly controlled on ICS monotherapy. We extracted eight relevant randomized controlled trials (represented in 18 articles) conducted by June 2022 form the corresponding Cochrane review and additional searches through medical databases (CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, and ICHUSHI (https://www.jamas.or.jp/)). While the LAMA add-on group showed a significantly better improvement in some respiratory function tests, the difference between groups did not exceed the minimum clinically important difference (MCID). On the other hand, the Asthma Quality of Life Questionnaire, a quality of life metric, was significantly higher in the LABA add-on group, but the difference also did not surpass the MCID. Because no outcomes exceeded the MCID, we could not determine whether adding LABA or LAMA on ICS is more beneficial in the long-term management of adult asthmatic patients. Given that no significant differences were found in the incidence of adverse events (including serious ones), when specific adverse events associated with one treatment occur, switching to the other treatment (from LABA to LAMA, or vice versa) can be considered as an option.

A 41-year-old man stuck himself with needle through his pericardium during suicide attempt. Chest radiography revealed several needles in the bilateral lung fields as well. Computed tomography (CT) and echocardiography showed massive pericardial effusion and a needle penetrating the pericardium. The patient was initially treated conservatively, including pericardial drainage, and, seven days later, we removed the needle using syngo Needle Guidance in hybrid operating room. The length of skin incision was only 2 cm, and the postoperative course was uneventful. No previous studies, to the best of our knowledge, have shown the use of syngo Needle Guidance to remove a needle in the pericardial cavity. This surgical procedure is minimally invasive for the patient.

A 85-year old male with hoarseness due to distal aortic arch aneurysm underwent zone 1 thoracic endovascular aortic repair( TEVAR) with two-debranching at our hospital. Five years after the TEVAR (90 years old), computed tomography( CT) revealed typeⅠa endoleak due to migration of proximal end of the graft. Anatomically, additional TEVAR was impossible. To minimize the invasiveness, a two-stage surgery was planned. First, under deep hypothermic circulatory arrest, the ascending aorta was replaced with the brachiocephalic artery reconstruction and insertion of a stented vascular prosthesis distally through partial sternotomy to preserve the debranching bypass. Six days after the surgery, a transcatheter stent graft was placed from the stented vascular prosthesis to the native descending aorta. Postoperative course was uneventful, and CT scan showed no endoleak.

An 82-year-old woman presented to our hospital with chief complaints of lower abdominal pain and nausea. Contrast- enhanced CT showed ileus of sigmoid colon cancer and a solitary splenic tumor. A metallic stent was placed for the primary lesion. FDG-PET showed high FDG accumulation in the solitary splenic tumor, and synchronous solitary splenic metastasis was diagnosed. Laparoscopic sigmoid colectomy and laparoscopic splenectomy were performed without changing the intraoperative position or port arrangement. Postoperative progress was favorable. The patient was discharged 9 days after surgery, and no sign of recurrence has been observed to date, at 4 months after surgery. Solitary splenic metastasis of colorectal cancer is extremely rare. This is the first case report of synchronous solitary splenic metastasis of colorectal cancer treated with laparoscopic resection in Japan. This procedure is considered effective and minimally invasive. We review and discuss the Japanese literature on this rare disease.

Aim: To determine the association between physical activity and apathy in community-dwelling older adults., Methods: This was a cross-sectional study. Apathy was assessed using three sub-items from the Geriatric Depression Scale 15 (GDS-3A) on apathy syndrome. Physical activity was measured using a wrist-worn accelerometer. Exercise intensity was classified as sedentary behavior, light-intensity physical activity, or moderate-to-vigorous-intensity physical activity. A logistic regression analysis was used to examine the association between apathy and physical activity for each exercise intensity level., Results: Seven-hundred and eighty-four participants (age 72.7±5.9 years old) were included. Of those, 103 (13.1%) were in the apathy group. A multivariate analysis adjusted for demographic factors revealed that decreased total physical activity (odds ratio [OR] = 0.947, 95% confidence interval [CI] = 0.912-0.984, p = 0.005), light-intensity physical activity (OR = 0.941, 95% CI = 0.899-0.985, p = 0.009), and increased sedentary behavior (OR = 1.002, 95% CI = 1.001-1.003, p = 0.007) were associated with a greater OR of apathy, although moderate-to-vigorous-intensity physical activity was not significant (OR = 0.916, 95% CI = 1.826-1.017, p = 0.100). However, in the final model adjusted for depressive symptoms and functional factors, the association was not found to be significant, and a strong association was observed between depressive symptoms and apathy., Conclusion: Physical activity in older adults with apathy symptoms was decreased in this study. However, the associations seemed to be strongly affected by depressive symptoms, and physical activity was not independently associated with apathy.

We investigated the accuracy and operability of two ultrasound devices for the bladder. The study included 232 adult patients who underwent surgery at our hospital. Before surgery, a nurse measured the amount of urine in the bladder using Lilium α-200® and Bladder Scan BVI 6100®. The amount was measured accurately later using a catheter. The measurements by the devices were compared with the amount measured by the catheter. Both Lilium and Bladder Scan had high accuracy (correlation coefficient for Lilium is 0.56 [95% CI : 0.46-0.64], and the correlation coefficient for Bladder Scan was 0.70 [95% CI : 0.63-0.76]). However, values obtained by the two devices significantly differed from the catheter measurement. The accuracy was improved by excluding patients with 0- ml readings by the two devices (the correlation coefficient for Lilium was 0.69 (95% CI : 0.61-0.76), and the correlation coefficient for Bladder Scan was 0.81 (95% CI : 0.76-0.86). Next, the operability was evaluated using a questionnaire. Both devices had high operability, but Bladder Scan was easier to operate. Based on the above, Bladder Scan had significantly higher accuracy and operability, but both devices had a sufficiently high accuracy and operability for clinical practice.

A female in her 70s was diagnosed as sigmoid colon cancer. Laparoscopic sigmoidectomy was performed. Chylous ascites was observed after starting oral intake. As we changed the patient's diet to a low fat diet, the chylous ascites disappeared. There are certain numbers of reports of the cases improved by fasting or only fat decreased meal. It is important to prevent this complications using appropriate surgical devices.

Perampanel is an α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor antagonist that has been marked as an antiepileptic drug for partial-onset and primary generalized tonic-clonic seizures. There have been some recent reports of perampanel being effective against cortical myoclonus by Lafora disease and Unverricht-Lundborg disease. We herein report a 49-year-old man who presented with myoclonus due to Lance-Adams syndrome (LAS) after cardiopulmonary arrest caused by a severe bronchial asthma attack. Perampanel was very effective against myoclonus induced by LAS even in the chronic state, over 10 years after the remote onset. Perampanel should be considered for the treatment of extremely refractory myoclonus due to LAS.

The purpose of this study is to examine the maximum brightness of the monitor, which is suitable for radiological technologists' (hereinafter referred to as technicians) interpretation assistance and image inspection. The signal detection ability was evaluated by receiver operating characteristic (ROC) analysis using a chest X-ray image with a simulated nodule. In order to examine the ease of observation and the effect on the subjective evaluation by changing the maximum brightness, evaluation was performed by the normalized ranking method using chest X-ray images. ROC experiments were performed using images with and without simulated nodules in the chest phantom. There was no significant difference in detectability by changing the maximum brightness (p>0.05), but the average area under the curve (AUC) was higher at 350 cd/m 2 than at 100 cd/m 2 and 170 cd/m 2 . A normalized ranking method was performed focusing on simulated nodules on chest X-ray images. In the least significant difference (l.s.d.) method, there was a significant difference between the maximum luminance, and the higher the maximum luminance, the better the evaluation. From these results, the change in the maximum brightness did not significantly affect the signal detection ability of the technician's chest X-ray image, but the higher the maximum brightness, the easier it was to observe and the higher the subjective evaluation. It has been reported that the higher the maximum brightness, the shorter the signal recognition time, and a monitor with a high maximum brightness may lead to more efficient image inspection by a technician. From the results of this study, it is considered appropriate to use a medical liquid crystal display (LCD) monitor with a maximum brightness of 350 cd/m 2 for the technician's interpretation assistance and image inspection.

Purpose: The aim of this study was to evaluate the usefulness of combining post-processing scatter correction (IG) and an anti-scatter grid (RG) in chest radiography., Method: To determine the combination protocol (Hyb) that was closed to RG 12:1 (RG12), we measured the content rate of scattered radiation for each combination (RG12, IG12, RG3-12+IG3-12). Task-based modulation transfer function (MTF_Task) and SDNR were evaluated using RG12, IG12, and Hyb. Additionally, seven radiologists performed visual evaluation by using chest phantom., Result: The protocol of Hyb was RG8+IG3. In SDNR, Hyb (RG8+IG3) was equal to or higher than RG12, and MTF_Task was equal in all grid systems. Hyb (RG8+IG3) was significantly superior to RG12 in visual evaluation., Conclusion: The combining post-processing scatter correction should be useful for improving inspection throughput and reducing the risk of grid's damage.

The patient was a 73-year-old man who was referred to our hospital for increasing bilateral lung nodules. Video-assisted left S9-10 segmentectomy and right S1, S3 partial resection were performed separately for suspect of synchronous double lung cancer. Colonoscopy was performed because left lung tumor was difficult to distinguish between primary lung cancer and metastatic lung cancer. Colonoscopy did not find advanced cancer lesion. We diagnosed the left lung tumor as pT1b, cN0, cM0, Stage ⅠA2 intestinal adenocarcinoma. The right lung tumor was diagnosed as pT1c, cN0, cM0, Stage ⅠA3 papillary adenocarcinoma. Intestinal adenocarcinoma is a rare tissue subtype of lung adenocarcinoma and colonoscopy is useful modality for ruling out metastatic colorectal cancer.

Aim: To review the clinical features of the patient with cystic pulmonary light chain deposition disease(LCDD)and record high-resolution CT and histopathological findings., Patient: A 60-year-old woman who diagnosed multiple myeloma was admitted. There were diffuse proliferation of plasma cells by the bone marrow puncture that she received. And multiple cystic pulmonary tumors found in CT. We analyzed the method and result of the diagnosis. CT showed multiple cystic pulmonary tumors in the both lung which vessels traversing the cysts with thin wall ranged 5 to 30 millimeters. There were no abnormality in the heart, kidney and liver. Right upper lobe wedge resection was performed via video-assisted thoracic surgery( VATS)to establish a definitive diagnosis. Thoracoscopic findings revealed multiple white oval formed tumors in the visceral pleura. Histological HE staining findings of the surgical specimen revealed amyloid-like acidophilic material, and the immunohistochemical Congo red staining revealed monoclonal IgG with a kappa component. According to the above results these tumors had a diagnosis of pulmonary LCDD., Conclusion: VATS was effective to diagnose pulmonary LCDD in multiple cysts formation.

A nomogram is a statistical tool that can provide the specific outcomes of individual patients. In this study, we used a nomogram developed by Beppu et al to evaluate the prognoses of 38 patients who underwent hepaticresec tion at our hospital. This nomogram predicts disease-free survival(DFS)after hepatic resection for colorectal liver metastasis based on 6 clinical and oncological factors. Using this nomogram, we divided the 38 patients into 3 groups: Group N, actual DFS was almost similar to the estimated median DFS(EMDFS)provided by the nomogram; Group A, DFS was longer than EMDFS; and Group B, DFS was shorter than EMDFS. Then, we compared and analyzed clinical and oncological factors between Groups A and B. Group B patients tended to have single metastasis and non-normal levels of CA19-9. Besides, Group B patients had DFS shorter than approximately 2 years. These results suggest that if CA19-9 levels are not normalized after hepaticresec tion for single metastasis, we should consider careful observation and adjuvant chemotherapy for potential micrometastasis.

A 25-year-old woman visited our hospital with a complaint of right lower abdominal pain. As a result of the examination, she was diagnosed as having acute appendicitis. After conservative treatment, we planned an elective surgery. At 3 months after discharge, laparoscopic appendectomy was performed. We found a mass of 10mm in diameter at the body of the appendix. Histopathological examination revealed the proliferation of heteromorphic cells with small round nuclei. It was positive for chromogranin A and synaptophysin in immunostaining, so we made a diagnosis of NET G1. Tumor cells infiltrated beyond the intrinsic muscle layer, but no vascular invasion was observed, and the margin was negative. In accordance with the guidelines, we followed up the patient with imaging examination and did not find any signs of recurrence.

A 70-year-old man was admitted for lymph node metastasis detected by FDG-PET/CT showing a mass 10mm in diameter. He had a history of a distal gastrectomy for advanced gastric cancer and was administered postoperative adjuvant chemotherapy consisting of 2 courses of TS-1 with CDDP and TS-1 only for 1 year. Lymph node recurrence was diagnosed and resected 4 years after the initial surgery. Histological examination revealed lymph node metastasis of the gastric cancer. He was administered adjuvant chemotherapy using TS-1 and has been followed-up without recurrences for 17 months after the second operation. We reported a case in which FDG-PET/CT was potentially beneficial for the diagnosis of the postoperative small lymph node metastasis.

Erlotinibis known as a key drug for the treatment of non-small-cell lung cancer. It is known to interact with gastric acid suppressing medications(AS). Concurrent administration of erlotinibwith AS is reported to decrease AUC and Cmax of erlotinib. From the result of a survey on concurrent administration of erlotinib with AS in our hospital, we considered that intake of erlotinib between meals in the morning and intake of AS after dinner or at bedtime certainly reduce the chance of drug interactions to a minimum. We suggested a direction of use of erlotinibto the doctors who used to prescribe this medication in their daily medical practice. We surveyed the doctors' perceptions of drug interactions. The results of the survey showed that 29% of the doctors were not concerned about drug interactions, although 81% of the doctors approved our proposal. By providing a suggestion for drug administration by analyzing drug information, the expectations of the doctors can be met and it also demonstrates the efficiency of pharmacists.

Total cavopulmonary connection (TCPC) conversion prevents late complications after the atrio-pulmonary-Fontan procedure. However, the outcomes and effects of TCPC conversion are not fully known. We performed TCPC conversion in 31 patients (2004~2017). Concomitantly, we performed anti-arrhythmia surgery in 28 patients( 90%), atrioventricular valve surgery in 4, and pacemaker implantation in 2. There were no perioperative deaths, but one late death occurred due to protein-losing gastroenteropathy. Five-year survival was 96.8%. Eleven patients were readmitted for various reasons, including arrhythmia in 7 and heart failure in 1. The 5-year cardiac event-free rate was 67.7%. The cardiac index was significantly improved:1.58 l/min/m2 before to 3.57 l/min/m2 after surgery ( p=0.0075). Surgical and midterm outcomes of TCPC conversion were favorable. In the perioperative and late periods, therapeutic intervention was usually for atrial arrhythmia. This study demonstrated that TCPC conversion is an effective therapeutic procedure.

We herein report a 67-year-old female who presented with progressive dementia and disturbance of consciousness. Brain CT showed multiple subcortical calcifications with edema. Enhanced CT showed multiple abnormal vessels in the left hemisphere. Electroencephalography indicated diffuse spike and slow wave complex, so non-convulsive status epilepticus was diagnosed. Cerebral angiography revealed several feeder arteries with retrograde leptomeningeal venous drainage. We diagnosed her with Borden type III cerebral dural arteriovenous fistulas. Trans-arterial embolization with n-butyl-2-cyanoacrylate was performed, and she has experienced no epileptic attacks for at least ten months. Calcification changes are sometimes seen in Borden type II dural arteriovenous fistulas but not in aggressive types, such as Borden type III. It is important to suspect dural arteriovenous fistulas when we encounter patients with progressive dementia or/and epilepsy with cerebral calcification lesions, as this may be a treatable disease condition.

We report a patient who developed urinary retention due to the presence of necrotic tissues in the bladder 5 months after kidney transplantation. The patient was a 47-year-old female who had been diagnosed with immunoglobulin A nephropathy. She requested to receive a living-donor kidney transplant from her husband, and was referred to our hospital. Given that the patient had anuria preoperatively, her bladder capacity was presumed to have decreased following the transplantation. There were no events regarding vascular anastomosis during the surgery. However, since ureteroneocystostomy was difficult to perform due to the thinning of the bladder wall, the recipient's own ureter was anastomosed to the ureter of the transplanted kidney. Since the patient had difficulty voiding soon after the indwelling urinary catheter was removed, clean intermittent self-catheterization was initiated. Abdominal computed tomography revealed perforation of the bladder and extravesical urinary leakage on postoperative day 15. An indwelling urinary catheter was reinserted as conservative treatment. We removed the indwelling urinary catheter on postoperative day 25. The patient was discharged on postoperative day 30. Five months after transplantation, the patient suddenly developed urinary retention. Cystoscopy revealed some tissue hanging from the anterior wall of the bladder. The tissue was removed, and her voiding function improved. On pathology, the tissue was found to be non-specific necrotic tissue. This finding suggested that the necrotic tissue had caused urinary retention 5 months after transplantation. The symptoms of urinary retention markedly improved after the treatment.

Hepatobiliary and pancreatic surgery is recognized as technically demanding due to the complicated local anatomy and diverse anatomical variation that require precise techniques. Therefore, preoperative simulation to understand the detailed local anatomy and intraoperative navigation methods for surgical guidance are needed. Intraoperative navigation for anatomical hepatectomy originated with dye injection into the dominant portal pedicle under intraoperative ultrasound guidance to identify hepatic segments, which was reported by Makuuchi et al in 1985. In recent years, with advancing medical technology, newer medical devices that promote the safety and reliability of various surgical procedures have been developed. In this article, we will discuss the current state and future prospects of intraoperative navigation in hepatobiliary and pancreatic surgery.

Aim: To investigate the clinical course of patients with elderly-onset rheumatoid arthritis (RA)., Methods: We compared the characteristics, and clinical course of 55 patients who developed RA at over 80 years of age (elderly-onset [EO] group) with 119 patients who developed RA at 40-59 years of age (non-elderly onset [non-EO] group). We also investigated the characteristics and clinical course of 19 patients who developed RA at over 80 and who received biological disease-modifying anti-rheumatic drugs (bDMARDs)., Results: The mean DAS28-ESR (DAS) and HAQ-DI (HAQ) of the EO were significantly higher in comparison to the non-EO group (4.91±1.31 vs 4.41±1.47, p=0.043, 1.2±0.9 vs 0.5±0.6, p<0.01). For the first treatment, 87.3% in the EO group received conventional synthetic DMARDs (csDMARDs), none received MTX. The rate of prednisolone (PSL) administration in the EO group was significantly higher than the non-EO group (56.4% vs 30.3%, p<0.01). The DAS and HAQ were significantly decreased in both groups, while the HAQ of the EO group was higher than the non-EO group. The decrease in DAS and HAQ of the PSL users was significantly greater than the non-PSL users (ΔDAS: 2.55±1.83 vs 1.83±1.23, p<0.01, ΔHAQ: 0.9±1.0 vs 0.3±0.6, p=0.027). Among the 19 patients with bDMARDs, the mean DAS and HAQ at baseline were significantly decreased 6 months later., Conclusion: Early use of csDMARDs and PSL was effective for functional disability of elderly-onset RA; however, some of them required bDMARDs. Further study should be performed to investigate the effectiveness of the early induction of MTX and bDMARDs.

A 61-year-old woman was admitted to our hospital for speech disturbance and mild consciousness impairment. Despite the absence of seizures or loss of consciousness, electroencephalographic abnormalities were observed, and the cerebral blood flow scintigraphy revealed an increase in cerebral blood flow in the left temporal lobe. These findings suggested a diagnosis of non-convulsive status epilepticus. On the third day, a twelve-lead electrocardiogram showed a negative T-wave in I, II, aVf, and V2-6. Moreover, a transthoracic echocardiogram revealed left ventricular apical akinesis. However, the coronary angiography showed no evidence of vascular stenotic lesions. We expect the present case report to contribute to the identification of non-convulsive status epilepticus with Takotsubo cardiomyopathy.

We developed a reliable prediction model for colorectal cancer(CRC)patients after surgically curative resection. Using clinicopathological factors, prediction models were constructed for liver metastasis-free survival(LMFS). Between January 2004 and December 2010, 528 CRC patients were investigated. On univariate analysis of clinicopathological factors, the following factors associated with LMFS: pathological tumor invasion, lymph node metastasis, lymphatic invasion, venous invasion, and preoperative serum CEA. Using these factors, a prediction model was constructed using a Cox regression model with a concordance index of 0.824 for LMFS. These individualized prediction models could help clinicians in the treatment of postoperative CRC patients.

Clinicians frequently encounter patients experiencing a floating sensation of unknown cause, referred to as floating dizziness. We developed a clinical examination to quantify gravity perception as a first step to test our hypothesis that a gravity perception disturbance causes floating dizziness. Our preliminary experiments revealed a linear relationship between head-tilt angle (HTA) and head-tilt perception (HTP) at a head roll tilt of <30°, with correlation coefficients of 0.991 and 0.999 between HTA and HTP in the whole body and head-tilt conditions, respectively. Using these observations, we established a method to evaluate the HTP gain (HTPG), which is the slope of a linear regression line produced by the relation of subjective visual vertical (SVV) with HTA during head tilt, as an index of gravity perception. We named this method head-tilt SVV (HT-SVV). When HTPG was>1, the subjects' HTP overestimated their HTA and vice versa. HT-SVV measurements of 329 healthy subjects gave an average and standard deviation (1.02±0.12) and reference value (0.80～1.25) for HTPG, a difference between left and right HTPG (4.7%±3.7%, <10.0%), and an absolute value for SVV in the upright head position (1.1°±0.8°, <2.5°). The next step is to make the HT-SVV system easier and faster to use as well as to collect more data from patients experiencing dizziness, including floating dizziness, to clarify the clinical significance of HT-SVV.

This study examined the internal and external validity of the Japanese version of the Thinking Styles Inventory (TSI: Hiruma, 2000), which was originally developed by Sternberg and Wagner (1991) based on the framework of Sternberg's (1988) theory of mental self-government. The term "thinking style" refers to the concept that individuals differ in how they organize, direct, and manage their own thinking activities. We administered the Japanese version of the TSI to Japanese participants (N = 655: Age range 20-84 years). The results of item analysis, reliability analysis, and factor analysis, were consistent with the general ideas of the theory. In addition, there were significant relationships between certain thinking styles and 3 participant characteristics: age, gender, and working arrangement. Furthermore, some thinking styles were positively correlated with social skill. Implications of these results for the nature of Japanese thinking styles are discussed.

A study was conducted of the 1,225 Pseudomonas aeruginosa strains that were isolated at 20 medical institutions in the Kinki district between 2011 and 2013 to determine their antimicrobial susceptibility and to characterize the strains of multidrug-resistant Pseudomonas aeruginosa (MDRP) and the metallo-β-lactamase (MBL) -producing strains. The MIC50/MIC90 values (μg/mL) of the various antimicrobial agents were as follows: imipenem, 2/>8; meropenem, 1/>8; doripenem, 0.5/8; biapenem, 1/>8; tazobactam/piperacillin, 8/>64; piperacillin, 8/>64; sulbactam/cefoperazone, 8/64; cefepime, 4/16; cefozopran, 2/>16; aztreonam, 8/>16; amikacin, 4/16; levofloxacin, 1/>4; and ciprofloxacin, 0.25/>2. From the viewpoint of the annual changes in the susceptibility rates (according to the CLSI guidelines [M100-S22]), the susceptibility to tazobactam/piperacillin, piperacillin, cefepime, cefozopran and aztreonam decreased in 2013. On the other hand, two antimicrobial agents showed high susceptibility rates each year; amikacin (94.0-95.6%) showed the highest rate, followed by doripenem (80.3-82.6%). With the exception of amikacin, there were substantial inter-institutional differences in antimicrobial susceptibility. In comparison to the previous CLSI guidelines (M100-S21), the new CLSI guidelines (M100-S22) on the use of carbapenems and penicillins show that the MIC80 has been affected. The MDRP detection rates in 2011, 2012 and 2013 were 1.8% (8 strains), 1.8% (8 strains), and 2.8% (10 strains), respectively. The MBL detection rates were as follows: bla(VIM-2), 0.2% (1 strain) in 2011; bla(IMP-1), 0.9% (4 strains) in 2012, and 1.7% (6 strains, including bla(IMP-1) [3 strains], bla(IMP-2) [2 strains] and bla(VIM-2) [1 strain]) in 2013.

The recommended regimen for S-1 internal use is 4 weeks of daily medication and 2 weeks of drug holiday. However, we experience many cases where changing the regimen is ineffective because of adverse events. This time, we report a favorable case of alternate-day treatment with S-1 in an elderly patient with multiple lung metastases of colon cancer. An 84-year-old woman, performance status 2, was diagnosed as having colon cancer and multiple lung metastases. After operation of the colon, she received chemotherapy with the S-1 alternate-day treatment. The lung metastases decreased remarkably, and she was able to continue the treatment without significant adverse events. She has been receiving the treatment without progression for more than 18 months now. The alternate-day treatment with S-1 is reported as a cure with anticancer efficacy and few adverse events. This treatment seems to be a useful chemotherapy for elderly patients with colon cancer.

A 42-year-old woman visited our hospital with high fever and general malaise. A CT examination revealed that she had carcinoma of the left breast with axillary lymph node metastases and multiple bone metastases. A blood test showed anemia, thrombopenia and the existence of blast-like cells. Adenocarcinoma cells were detected in a bone marrow aspiration specimen, and the patient was diagnosed with disseminated carcinomatosis of the bone marrow. Systemic chemotherapy with paclitaxel plus bevacizumab was initiated while a blood transfusion was performed. Her symptoms improved, and the blood test results normalized. Disseminated carcinomatosis of the bone marrow is reported to have a poor prognosis, but paclitaxel plus bevacizumab is a possible effective chemotherapy.

Metabolic bone diseases such as osteopenia and osteoporosis increase the risk of bone fracture that negatively affects quality of life of individuals. Patients with inflammatory bowel disease(IBD), including ulcerative colitis(UC)and Crohn's disease(CD), have been shown to be at increased risk of decreased bone mineral density, however frequency of metabolic bone disease in IBD and identified risk factors are varied among reports.

Patients with anorexia nervosa (AN) exhibit physical and psychiatric symptoms, in addition to their behavioral problems, and often require admission to a general hospital with a psychiatric ward. There are only a few general hospitals with psychiatric wards available, and patients with AN tend to be concentrated in a small number of such institutions. Thus, it is difficult to provide adequate support for the treatment of patients with AN. In Kyoto, the number of general hospitals with a psychiatric ward is small. Patients with AN tend to be treated at the two university hospitals. However, our University Hospital cannot accept all patients with AN, especially the emergency admissions. Therefore, with respect to the inpatient treatment of AN, we established a cooperation agreement with other psychiatric hospitals. We are planning to divide the inpatient treatment of AN between our university hospital and other psychiatric hospitals, depending on the stage of AN and the severity of the patients' physical condition. With respect to the treatment of AN, it is necessary to establish a treatment system with each hospital playing a role.

Background: The ratio of elderly complicated diabetes mellitus (DM) to all hemodialysis (HD) patients has increased. The number of elderly DM patients with poor glycemic control has also increased due to complications, such as dementia. By means of appropriate glycemic control, the risk of cardiovascular disease might decrease among diabetic HD patients, and improvement of their prognosis could be expected. When glycemic control is poor when treating diabetic HD patients with oral hypoglycemic agents, insulin treatment could be indicated., Methods: Using continuous glucose monitor (CGM), we evaluated the differences in glucose variability of 3 type 2 diabetic HD patients with poor glycemic control when switching from insulin glargine to degludec., Results: Case 1 was a 72-year-old man with poor dietary self-management, whose glycated albumin (GA) level was 27%, and was administered lispro 6-6-6 U plus glargine 8 U daily. He was switched from glargine to degludec 6 U daily. Eight weeks later, his glycemic control improved as seen in his GA level (19%) and CGM. Case 2 was an 84-year-old solitary woman with dementia. Her GA level was 28.4%, and she was administered glargine 8 U (after HD, 3 times/week). She was switched from glargine to degludec 6 U (after HD, 3 times/week). Her glycemic control improved as seen in her GA level (25.1%) and CGM thereafter. Case 3 was a 65-year-old solitary man with liver cirrhosis and chronic pancreatitis. His GA level was 26.6%, and he was administered glargine 8 U (every day). He was switched from glargine to degludec 12 U (after HD, 3 times/week). His glycemic control improved as seen in his GA level (21.3%) and CGM thereafter., Conclusions: These results suggest that degludec is more effective than glargine in improving glycemic control and reducing the insulin dose in type 2 diabetic HD patients.

A 37-year-old woman who had previously been diagnosed with idiopathic chronic intestinal pseudo-obstruction (CIPO) at another hospital was admitted to our institution with severe abdominal pain. She had a history of several abdominal surgeries to treat ileus at the previous hospital, and contrast-enhanced computed tomography on admission revealed subileus without any apparent causes of obstruction. Total parenteral nutrition, a gastrointestinal prokinetic agent, and opiates reduced persistent pain;however, breakthrough pain continued. A neurologist at our hospital suggested autoimmune autonomic ganglionopathy (AAG) as a potential cause of CIPO. The patient was diagnosed with suspected AAG on the basis of seropositive results for anti-ganglionic acetylcholine receptor antibody. Intravenous immunoglobulin administration and plasma exchange were performed in combination with immunosuppressive drugs;however, her symptoms barely improved. Although percutaneous endoscopic gastrostomy and enterostomy were subsequently performed to reduce internal intestinal pressure, her pain relief was insufficient.

Left atrial free ball thrombus (LABT) after mitral valve replacement (MVR) is very rare, and sudden death may occur by thrombus impaction to the mitral valve orifice. A 81-year-old woman who underwent MVR and tricuspid annuloplasty ten years ago presented with syncope. She was admitted to a hospital, and echocardiography revealed a LABT. When she took sitting position, she fainted. The free ball thrombus possibly impacted mitral valve orifice. She was transferred to our hospital and an emergent operation was performed. There was a LABT of 4 cm in diameter, which was removed. Postoperative course was uneventful. There are 12case reports which described LABT after MVR, and anticoagulant therapy was insufficient in most of those cases. Strict anticoagulant therapy is important to prevent left atrial thrombus after MVR.

A 66-year-old woman was diagnosed with unresectable advanced gastric cancer with Schnitzler metastasis in January 2012. She was treated with combination chemotherapy comprising S-1 and docetaxel (DTX). However, in January 2013, after 13 courses of treatment, a computed tomography (CT) indicated peritoneal dissemination growth. The chemotherapy regimen was changed to a combination of S-1 and irinotecan (CPT-11), but after a single course of treatment the patient complained of stomachaches and vomiting. The patient developed ileus from the stenosis of the rectum, and a transanal ileus tube was used to decompress the bowel tract. Due to the patient's poor general condition, a metallic stent was inserted, and she could resume eating. Thereafter, we changed the chemotherapy regimen to weekly paclitaxel (PTX). However, 1 year and 4 months after starting treatment she died of regrowth of the peritoneal disseminating lesions. We recommend a combination of chemotherapy and metallic stent placement to improve quality of life and long-term survival.

The performance of individual computed tomography automatic exposure control (CT-AEC) is very important for radiation dose reduction and image quality equalization in CT examinations. The purpose of this study was to evaluate the performance of CT-AEC in conventional pitch mode (Normal spiral) and fast dual spiral scan (Flash spiral) in a 128-slice dual-source CT scanner. To evaluate the response properties of CT-AEC in the 128-slice DSCT scanner, a chest phantom was placed on the patient table and was fixed at the center of the field of view (FOV). The phantom scan was performed using Normal spiral and Flash spiral scanning. We measured the effective tube current time product (Eff. mAs) of simulated organs in the chest phantom along the longitudinal (z) direction, and the dose dependence (distribution) of in-plane locations for the respective scan modes was also evaluated by using a 100-mm-long pencil-type ionization chamber. The dose length product (DLP) was evaluated using the value displayed on the console after scanning. It was revealed that the response properties of CT-AEC in Normal spiral scanning depend on the respective pitches and Flash spiral scanning is independent of the respective pitches. In-plane radiation dose of Flash spiral was lower than that of Normal spiral. The DLP values showed a difference of approximately 1.7 times at the maximum. The results of our experiments provide information for adjustments for appropriate scanning parameters using CT-AEC in a 128-slice DSCT scanner.

Background: The outcomes of laparoscopic surgery for primary tumors of symptomatic Stage IV colorectal cancer have not been clarified.This study aimed to review the outcomes of colorectal resection in patients with symptomatic StageIV colorectal cancer, treated either by laparoscopic colorectal resection (LAC), or by open colorectal resection (OC)., Methods and Results: A total of 69 patients were included, of which 55 patients underwent LAC.The proportion of patients with ileus was higher in the OC group than in the LAC group.The conversion rate of patients receiving LAC was 13% (7 cases).No operative mortality was observed in either group.The operation time was shorter, postoperative complication rate was lower, and postoperative hospital stay was significantly shorter in the LAC group.Median survival times in the LAC and OC groups were 26.3 months and 26.8 months, respectively., Conclusion: Although the short-term outcome of LAC for symptomatic Stage IV colorectal cancer was favorable, the long-term outcomes were similar in both groups.A safe and minimally invasive surgical procedure is needed for the treatment of Stage IV colorectal patients.

An 84-year-old Japanese man was admitted with hepatocellular carcinoma (HCC). He underwent transcatheter arterial chemoembolization and percutaneous radiofrequency ablation (RFA). Three weeks later, he developed sudden-onset right pleural effusion mixed with bile. Drip infusion cholangiography-computed tomography revealed leakage of the contrast agent, which passed from the HCC to the pleural cavity through a perforation in the diaphragm. The patient's condition improved after thoracic and endoscopic nasobiliary drainage. The occurrence of pleural effusion mixed with bile is a rare complication of RFA. This case provides important information about the morbidity, prevention, and treatment of this complication.

A 77-year-old man underwent surgery for sigmoid colon cancer. He was diagnosed with Stage IIIa colon cancer; there- fore, we initiated oral administration of adjuvant chemotherapy comprising uracil/tegafur(UFT)plus Leucovorin(LV). However, chemotherapy was stopped after 21 days because of fatigue and diarrhea. He recovered after 3 weeks, and we administered the same regimen with a dose reduction. However, he again experienced fatigue and diarrhea after 20 days; therefore, chemotherapy was discontinued. Subsequently, he was hospitalized 8 times for conditions such as diarrhea, hypoalbuminemia, and fever. Computed tomography revealed thickening of the transverse colonic wall and colonoscopy revealed colitis, which we believe was induced by UFT plus LV. Twelve months after the last chemotherapy session, he was diagnosed with Clostridium difficile colitis. Therefore, we initiated the oral administration of vancomycin, which resulted in rapid recovery from colitis. However, he developed liver metastasis and died 29 months after the initiation of chemotherapy. We believe that this severe case of intractable colitis was caused by UFT plus LV. Therefore, we report this case with a review of the literature on enteritis induced by fluorouracil-based anticancer agents in Japan.

A woman in her seventies presented with bilateral hilar and mediastinal lymphadenopathy with high fluorodeoxyglucose (FDG) uptake by positron emission tomography (PET)-computed tomography (CT), small lung nodules, and uveitis. Mediastinoscopic biopsy yielded a histological finding of epithelioid granuloma and a diagnosis of sarcoidosis. A nodule, 1 cm in diameter, in the right middle lobe with moderate FDG uptake was deemed to be a sarcoidosis lesion. Steroid therapy for uveitis resulted in shrinkage of the hilar and mediastinal lymph nodes; however, 1 year later the nodule in the right middle lobe had enlarged to 2 cm in diameter. Right middle lobectomy was performed, and a histological diagnosis of lung squamous cell carcinoma was made. Six months later, right pretracheal lymphadenopathy with high FDG uptake was noted and was proved to be a metastatic squamous cell carcinoma by endobronchial ultrasound-guided transbronchial needle aspiration( EBUS-TBNA). After 7 courses of chemotherapy with docetaxel, the target lesion shrank and its abnormal FDG uptake disappeared. Small-sized lung cancer could be missed when complicated by sarcoidosis because the latter produces a background of multiple lesions, so careful diagnostic imaging and follow-up should be performed in patients diagnosed as having sarcoidosis.

A 66-year-old man underwent distal gastrectomy with Roux-en-Y anastomosis and D2 dissection for the treatment of advanced gastric cancer (pT4a, N0, M0, stage IIB) in June 2009. He was treated with adjuvant postoperative chemotherapy consisting of S-1. However, in September 2010, computed tomography (CT) showed #16a2 lymph node recurrence, which was treated with combination chemotherapy of S-1 and cisplatin. After 7 courses of this combination chemotherapy, CT revealed a significant reduction in the size of the metastatic lesion as well as a new peritoneal dissemination recurrence around the right kidney. We therefore changed the regimen to combination chemotherapy of S-1 and docetaxel. After 3 courses of this treatment, the dissemination lesion was no longer evident by CT. After 6 more courses of treatment, the lymph node and peritoneal dissemination recurrence showed no regrowth. In response to the patient's wish, we changed the chemotherapy to S-1 alone beginning in June 2012. He survived without recurrence for approximately 2 years after gastrectomy. We suggest that the taxane drug was effective as second-line chemotherapy for the treatment of patients with peritoneal dissemination recurrence.

Chemoradiotherapy before surgical treatment of locally advanced lower rectal cancer is currently uncommon in Japan. We have treated 5 patients with T3 and/or N1 and 2 patients with rectal cancer using chemoradiotherapy including capecitabine and oxaliplatin( XELOX). The treatment consisted of concomitant administration of radiotherapy( 45 Gy/25 Fr), capecitabine (2,000 mg/m2/day; 2 weeks followed by 1 week off), and XELOX (2 courses). Surgery was performed 1 month after the final dose of chemotherapy was administered. The adverse events of Grade greater than 2 observed were radiation dermatitis (n=3), peripheral neuropathy (n=1), and rash (n=1). Either laparoscopic abdominoperineal resection( n=4) or open low anterior resection( n=1) was performed for surgical treatment. Histopathological regression grading revealed Grade 1a (n=1) and Grade 2 (n=4). The combined therapy resulted in downstaging in all patients. Preoperative chemoradiotherapy followed by XELOX might be effective for the treatment of locally advanced lower rectal cancer.

Purpose: To evaluate the effectiveness and safety of radiofrequency ablation(RFA)for liver metastases from colorectal cancer after chemotherapy., Patients: From January 2006 to June 2012, 27 tumors in 17 patients with liver metastases from colorectal cancer were treated using RFA after systemic chemotherapy., Results: The median tumor diameter after chemotherapy was 12(range: 3-35)mm, and the mean number of tumors was 1.6(range: 1-4).The median time without local recurrence was 21.3(range: 2.2-61.9)months, and the median overall survival time was 38.0(range: 5.9-66.3)months. One patient had a complication(liver abscess).Of the 27 tumors, 9 were larger than 20 mm in diameter, and 4 of these 9 tumors showed local recurrence after RFA. In tumors smaller than 20 mm in diameter, only 1 showed local recurrence. The local recurrence rate was significantly higher for tumors larger than 20 mm than for tumors smaller than 20 mm(44.4% vs 5.6%,p=0.030)., Conclusion: RFA was an effective and safe method for treating liver metastases from colorectal cancer, especially for tumors smaller than 20 mm and in cases of less than 3 tumors after systemic chemotherapy.

Impairment of neuronal plasticity is important in the pathophysiology of mood disorder. Both zinc deficiency and social isolation impair neuronal plasticity. Both cause a depressive state. However, in experiments using animals, their combined loading induced manic-like behavior. Therefore, it was inferred that moderate impairment of neuronal plasticity induces a depressive state, and that further impairment of neuronal plasticity induces a manic state. However, some kind of load toward neuronal function through neural transmission can influence mood disorder symptoms without direct effects on neuronal plasticity. Our hypothesis is that mania is an aggravation of depression from the perspective of neuronal plasticity, and that multiaxial evaluation by neuronal plasticity and neuronal load through neural transmission is useful for understanding the pathophysiology of mood disorder. There are many clinical aspects that have been difficult to interpret in mood disorder: Why is a mood stabilizer or electric convulsive therapy useful for both mania and depression? What is the pathophysiology of the mixed state? Why does manic switching by an antidepressant occur or not? Our hypothesis is useful to understand these aspects, and using this hypothesis, it is expected that the pathophysiology of mood disorder and clinical mechanism of mood stabilizers and antidepressants can now be understood as an integrated story.

A 73-year-old man was found to have an intestinal tumor, approximately 10 cm in diameter, on computed tomography (CT). In September 2001, he underwent partial resection of the jejunum with partial colectomy and left nephrectomy. Pathological examination showed 2 mitoses per 50 high-power fields, and immunohistochemical analysis showed positive staining for c-kit. Based on the above findings, the tumor was diagnosed as a high-risk malignant gastrointestinal stromal tumor( GIST) of the small intestine; the patient was followed up and no adjuvant therapy was administered. In October 2005, an abdominal CT scan revealed 2 tumors with diameters of 21 and 28 mm in the S8 and S7 region of the liver, respectively, and the patient was diagnosed with liver metastases from GIST. After obtaining adequate informed consent, chemotherapy with imatinib (400 mg/day) was initiated. Although the patient experienced partial response (PR) 2 months after the treatment, grade 3 neutropenia and general fatigue were observed. Therefore, the treatment schedule was changed to 1 week of therapy, followed by 1 week of rest. At present, at 91 months after the diagnosis of liver metastases, the patient shows no signs of recurrence. Therefore, it is important that adjuvant chemotherapy should be considered for the treatment of patients with high-risk malignant GIST.