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Background Aldosterone has been assumed to be one of aggravating factors in diabetic kidney disease (DKD). Natriuretic peptides/guanylyl cyclase-A/cGMP signalling has been shown to ameliorate aldosterone-induced renal injury in mice. Sacubitril/valsartan (SAC/VAL) is used clinically for chronic heart failure and hypertension, in part by augmenting natriuretic peptide bioavailability. The effects of SAC/VAL on renal pathophysiology including in DKD, however, have remained unclarified yet. Methods Eight-week-old male db/db mice fed on a high-salt diet (HSD) were treated with vehicle or aldosterone (0.2 μg/kg/min), and divided into 4 groups: HSD control, ALDO (aldosterone), ALDO + VAL (valsartan), and ALDO + SAC/VAL group. After 4 weeks, they were analyzed for plasma atrial natriuretic peptide (ANP) levels, renal histology, and haemodynamic parameters including glomerular filtration rate (GFR) by FITC-inulin and renal plasma flow (RPF) by para-amino hippuric acid. Results The ALDO + SAC/VAL group showed significantly increased plasma ANP concentration and creatinine clearance, and decreased tubulointerstitial fibrosis and neutrophil gelatinase-associated lipocalin expression compared to ALDO and ALDO + VAL groups. SAC/VAL treatment increased GFR and RPF, and suppressed expression of Tgfb1, Il1b, Ccl2, and Lcn2 genes compared to the ALDO group. The percentage of tubulointerstitial fibrotic areas negatively correlated with the RPF and GFR. Conclusion In a mouse model of type 2 diabetes with aldosterone excess, SAC/VAL increased RPF and GFR, and ameliorated tubulointerstitial fibrosis. Furthermore, RPF negatively correlated well with tubulointerstitial injury, suggesting that the beneficial effects of SAC/VAL could be through increased renal plasma flow with enhanced natriuretic peptide bioavailability.

We report the case of metformin-associated lactic acidosis (MALA) exacerbated by acute kidney injury (AKI) in a 65-year-old Asian American woman who was an overseas traveler. She had vomiting and diarrhea before arriving in Osaka, Japan, from the Philippines. She suffered from worsening respiratory distress, consciousness loss and anuria the day after coming to Japan. When she arrived at our emergency room via ambulance, she appeared to be in a state shock. Arterial blood gas analysis revealed severe lactic acidosis (pH 6.681, PO2 302 Torr under O2 supplementation, PCO2 15 Torr, HCO3−1.7 mmol/L, and lactate 17.00 mmol/L). She also had renal failure (BUN 108 mg/dL and serum creatinine 8.68 mg/dL) with hyperkalemia (6.1 mEq/L). We collected medical information from family members, and found her prescription medicines including metformin, diuretics and angiotensin-converting enzyme inhibitor (ACEI). We diagnosed her with MALA due to an unintended overdose of metformin resulting from acute kidney injury that can be induced by ACEI and diuretics in the volume-depleted condition. We immediately started hemodialysis therapy. Although she had a temporary cardiopulmonary arrest at the beginning of the treatment, her physical status was gradually improved and the severe acidemia resolved. On hospital day 4, she had urine and no longer needed hemodialysis therapy. On day 14, she was discharged and returned to the United States without noticeable sequelae. This is a case report of an overseas traveler who was successfully rescued through the collection of accurate medical information and understanding of the pathological condition.

Background Polycystic liver disease is a clinical feature of autosomal dominant polycystic kidney disease, and it can sometimes cause health damage more serious than polycystic kidney. Dialysis therapy can be used for renal failure, but liver transplantation is the only method available for liver failure. Thus, giant and multiple hepatic cysts may affect mortality. However, liver transplantation is not indicated in many cases because of the preserved liver function. Case presentation A 54-year-old Japanese woman with polycystic liver disease was transferred back to our hospital for abdominal pain caused by liver cyst infection with abdominal wall herniation. She had been diagnosed with polycystic liver disease associated with sporadic autosomal dominant polycystic kidney disease 25 years earlier. Although she had several surgical interventions to reduce her liver volume, including right hepatic lobectomy and fenestration for liver cysts in another hospital, she needed further repair of the recurrent incisional herniation with patch graft surgery using fascia lata to cover the herniation site. However, new herniation sites reemerged in the fragile abdominal wall area around the patch, and therefore, she reduced the recurrent abdominal wall herniation by herself. Recurrent intestinal obstructions were luckily released by fasting with decompression treatment via nasogastric tube insertion, but multiple skin ulcers around the enlarged hernia sac gradually developed, and ascites was extremely difficult to control with any medication. At final admission, her abdominal wall was even more prominent, causing shortness of breath, and it spontaneously ruptured many times, which was accompanied by discharge of around 5 liters of ascites each time. She died from sepsis caused by drug-resistant Enterococcus. Conclusions We report a case of autosomal dominant polycystic kidney disease with ruptured abdominal wall resulting from a hepatic cyst enlargement despite multiple laparotomy operations. Throughout the entire disease course, her liver volume increased rapidly, and her quality of life was severely impaired, but she could not undergo liver transplantation after readmission to our hospital. We will discuss the therapeutic strategy for this patient, including the timing and indication for liver transplantation.

1980年（昭和55年）代において、青少年非行や校内暴力等が急激に増加する中で、「指導が不適切な教員」が顕在化した。文部科学省は、社会問題化した「指導が不適切な教員」問題に対応するため、様々な審議会等答申を得て、2000年（平成12年）度から「新しい教員の人事管理の在り方」事業を立ち上げ、都道府県・政令指定都市教育委員会に対して取組みを促進した。2007年（平成19年）度までは、各教育委員会は、個別的に人事管理システムを構築し、「指導が不適切な教員」問題に取り組んだ。しかし、教育委員会の「指導が不適切な教員」の対応が異なるとの指摘を受け、文部科学省は、人事管理システムのガイドラインを提示し指導改善研修の義務化などの関係法令を改正した。2008年（平成20年）度から各教育委員会の人事管理システムは、ガイドラインに則りほぼ統一されたものが構築され、「指導が不適切な教員」問題に取り組んだ。そこで筆者は、2008年（平成20年）度前後の要因変容を比較考慮するためシステムズ・アプローチによる要因分析を行った。その結果は、2007年（平成19年）度以前に比べ2008年（平成20年）度以降の認定者数、依願退職者数、再研修者数、学校復帰者数等の要因はいずれも減少しているが、割合でみれば、依願免職は以前の30％台から、20％前半で推移し、10％前半に至っている。学校復帰者数は、以前の30％台から40％台で推移し、50％に近接している。2008年（平成20年）度以降の同システムの活用により、指導が不適切な教員に対する人事管理という課題設定も不要となった。このシステムは、分限制度を適用するよりも容易に適用できることから、身分保障の観点からアウトプットからのフィードバックを図ることにより継続的なシステムの改善が必要となる。, In the 1980s（ Showa 55）, as juvenile delinquency and school violence increased sharply, “teachers with inappropriate guidance” became apparent. The Ministry of Education, Culture, Sports, Science and Technology（MEXT） has received reports from various councils, etc. in order to deal with the social problem of “teachers with inappropriate guidance”, and launched the “New Teacher Personnel Management” project in 2000（Heisei12）, and promoted its efforts to the prefectural and ordinance-designated city boards of education. Until 2007 （Heisei 19）, each board of education built a personnel management system individually and tackled the problem of teachers with inappropriate guidance.However, the Ministry of Education, Culture, Sports, Science and Technology has been pointed out that each board of education responds differently to “teachers with inappropriate guidance”, and presented guidelines for personnel management systems ,and amended relevant laws and regulations that require guidance and improvement training. From 2008（Heisei 20）, the personnel management system of each board of education was constructed to be almost unified in accordance with the guidelines, and tackled the problem of “teachers with inappropriate guidance”.Therefore, the author conducted a factor analysis using the Systems approach in order to compare and consider the factor changes around 2008 （Heisei20）. The author conducted a factor analysis using the systems approach.As a result, all factors such as the number of certified persons, the number of retired applicants, the number of retrainers, the number of returnees from school, etc. are all in 2008 （Heisei20） compared to before 2007 （Heisei19） is decreasing. However, the percentage of unemployed applicants has changed from the previous 30% level to the first half of 20%, reaching the first half of 10%. The number of teachers returning to school has changed from the previous 30% level to the 40% level, approaching 50%. By utilizing this system after 2008（ Heisei20）, it is no longer necessary to set the task of personnel management for teachers with inappropriate guidance.Since this system can be applied more easily than the status system, it is necessary to continuously improve the system by providing output feedback from the viewpoint of identity security.

本研究の目的は, 教育予算の策定にあたって, 知事選挙における優位性の確保のための政治的影響を摘出することである｡その研究理由としては, 知事選挙の候補者が教育費を重要視すれば, ひいては, 府民の教育の行政サービスに繋がるものであり, 知事部局理事者側にとっても, 一定の配慮もありうると考えられるからである｡研究方法については, 当初予算や教育費の経年変化の動向や, 知事選挙の状況などから, 特異な現象を摘出し, 検証しながら, 政治的要因を把握しようとするものである｡その研究結果は, 分析領域内において, 1970 (昭和45) 年度, 1974 (昭和49) 年度, 1978 (昭和53) 年度,1982 (昭和57) 年度, 1994 (平成６) 年度の教育費予算の算定については, 知事選挙における優位性の確保のため, 十分配慮したものと思われる｡つまり知事選挙の優位性の確保という政治的要因が働いたといえるだろう｡更に, 本テーマについて, 研究を継続し, 結果についても一層多面的な視角から精査し, 次回の筆者の論文に繋げる予定である｡, The purpose of this research is to extract influence for the political factor to which the authorities have influence into the decision process of an educational budget for reservation of the predominancy in a governor’s election. It is because it is thought that consideration called operation of an education expense may have the reason for reservation of the predominancy in a governor’s election, and the operation also has the merit of being connected with the administrative services of education of the citizen of prefecture if the nominee of a governor’s election thinks an education expense as important.It is grasping a political factor, extracting and verifying a nontypical phenomenon from aging of an initial budget and an education expense, a governor’s election situation, etc. about a method of research.Considering research findings, [in an analysis domain], it is surmised that the authorities did compliment influence in the following fiscal years. We can point out about the education expense of 1970 (Showa 45) fiscal years, 1974 (Showa 49) fiscal years, 1978 (Showa 53) fiscal years, 1982 (Showa 57) fiscal years, and 1994 (Heisei 6) fiscal years.