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Graphical abstract, Highlights • The contents of glabridin and medical component glycyrrhizin were analyzed in herbal medicines and health foods containing licorice. • A small amount of glycyrrhizin was detected in some of health foods. • Estrogenic activity was detected in some of health food ingredients and health foods. • Antioxidant activity was detected in all the materials. • Hepatic CYP activity, liver and uterine weights in estrogen deficient mice are also valuable for the safety evaluation of estrogenic ingredients., Focusing on licorice, a highly used raw material in health foods, quantitative analysis of functional/medicinal components and a safety and functional evaluation was carried out for herbal medicines, health food ingredients, and so-called health foods. A functional component, glabridin, was detected in herbal medicines from Glycyrrhiza glabra and G. inflata, health food ingredients, and in commercially available health foods that contain licorice. Likewise, glycyrrhizin, a medicinal component, was detected in these sources, except in licorice oil extract. Estrogen activity in vitro was detected in some of the herbal medicines, health food ingredients, and in health foods containing licorice. In the in vivo study, liver weight in ovariectomized (OVX) mice treated with licorice oil extract was significantly higher than that in OVX and sham mice in a dose dependent manner. These results suggest that excessive intake of licorice oil extract from health foods should be avoided, even though these ingredients might be beneficial for medical use in order to maintain bone health in postmenopausal women. Measurement of hepatic cytochrome P-450 (CYP) activity, reproductive organ weight, and fat and bone mass in OVX mice was considered useful for evaluating the safety and efficacy of estrogenic health food ingredients derived from herbal medicines.

Introduction: We sought to assess the effect of in-hospital targeted temperature management (TTM) on outcomes of non-shockable out-of-hospital cardiac arrest (OHCA). Methods: This is a secondary analysis of a randomized controlled trial “A Randomized Trial of Continuous Versus Interrupted Chest Compressions in Out-of-Hospital Cardiac Arrest” (NCT01372748). We included non-traumatic comatose OHCAs with non-shockable rhythm who survived to hospital admission. Outcomes of interest were survival at hospital discharge and favorable neurological outcome (modified Rankin scale 0-3). We performed multivariable logistic regression, adjusting for baseline characteristics to determine the association between TTM and outcomes, compared to no TTM, for the entire cohort as well as for the propensity matched cohort. Results: Of 1,985 OHCAs who survived to hospital admission, 780 (39.3%) were managed with TTM. In TTM patients, 7.3 % patients survived to hospital discharge and 3.9 % had a favorable neurological outcome in contrast to 10.2 % and 6.1 %, respectively, in no TTM patients. Multivariable analyses demonstrated an association between TTM and decreased probability of both outcomes, compared to no TTM (adjusted ORs for survival: 0.67 95% CI 0.48–0.93, and for favorable neurological outcome: 0.57 95% CI 0.37–0.90). Propensity score matched analyses demonstrate the similar results. Conclusion: TTM might decrease the probability of neurologically intact survival for non-shockable OHCAs.

Introduction: Intraosseous (IO) and intravenous (IV) access to the vascular system for the delivery of fluid and medication is a component of advanced pediatric resuscitation. Data describing the use of IV or IO vascular access methods and outcomes of pediatric out-of-hospital cardiac arrest (OHCA) are limited. Methods: We analyzed prospectively collected data of non-traumatic OHCA of the Resuscitation Outcomes Consortium registry in Canada and the USA (2011-2015). We included patients 17 years of age and younger who were treated by emergency medical services (EMS). We described the vascular access routes utilized, and the success rate of these attempts. We performed a logistic regression model, to evaluate the association of vascular access route and survival, adjusting for age, sex, shockable initial rhythm, witnessed status, public location, EMS arrival interval and time from 911 call to vascular access. In this model, we excluded patients with failed, multiple site or no vascular access attempts during the resuscitation. Results: Of 1549 non-traumatic pediatric OHCA, 822/895 (92%) and 345/488 (71%) had successful IO and IV vascular access attempts, respectively. IO access was more common in younger cases. Of 761 cases included in the regression model, 30/601 (5%) of IO-treated cases survived to hospital discharge, in comparison to 40/160 (25%) of IV-treated cases. Intraosseous access was associated with a decreased survival to hospital discharge (adjusted OR 0.46; 95% CI 0.21 to 0.98). Conclusion: In pediatric patients with OHCA, intraosseous vascular access was more commonly successful than IV placement and more common among younger cases. However, in cases with successful vascular access, IO use was associated with lower survival to hospital discharge.

Background Multi-slice computed tomography (CT) is frequently used to evaluate the morphology, arrangement, and other characteristics of bone. Three-dimensional volume rendering (3D-VR) has made it possible to three-dimensionally visualise tendons and other structures by arbitrarily changing CT values. In deformities of the forefoot region in rheumatoid arthritis (RA), dislocation of the metatarsophalangeal (MTP) joints results in the formation of painful calluses that require surgery; however, the toes can sometimes be displaced inwards or outwards by this dislocation. MTP joint dislocation also causes the flexor tendons to dislocate from their original positions, although the relationship with toe displacement is unclear. Objectives We therefore used 3D-VR to examine the relationship between the flexor tendons and toe displacement in the dislocated toes of RA patients. Methods Thirty-one feet (10 right and 21 left) of 24 patients (5 men and 19 women) were examined. The Tsuboi classification was used to classify MTP joint dislocation into subluxation (Grade 2) or dislocation (Grade 3). CT images taken with no load applied to the feet were used for preoperative evaluation. The mean age of the patients at the time of imaging was 59.0 (36–76) years. A Fujifilm volume analyzer (SYNAPSE VINCENT) was used for 3D-VR reconstruction and CT values were adjusted to visualise the flexor tendons and examine their relationship with the heads of the metatarsal bones. When the flexor tendons were displaced inward or outward from the base of the metatarsal bone head, this was classified as flexor tendon dislocation. Toe displacement was identified when the proximal phalanx was displaced inward or outward from the extended line of the metatarsal axis. Results MTP joint dislocation was seen in 80 toes (63 cases of dislocation and 17 cases of subluxation). The flexor tendons were dislocated in 27 s toes (15 inward and 12 outward), 27 third toes (21 inward and 6 outward) and 16 fourth toes (15 inwards and 1 outward). Of the cases of MTP joint dislocation, toe displacement was seen in 12 s toes (1 inward and 11 outward), 12 third toes (12 outward) and 2 fourth toes (1 inward and 1 outward). The flexor tendons were dislocated towards the displaced toes in all cases. No flexor tendon dislocation was seen in any of the cases of subluxation. Conclusions RA is often accompanied by hallux valgus and toe displacement is affected by retraction of the first toe. The results of this study demonstrate that the toes are displaced inwards in some cases and can become dislocated independent of the influence of the first toe. All the toes were displaced towards the dislocated flexor tendons and MTP arthritis had resulted in loosening of the joint capsule and ligaments and dislocation of the flexor tendons, which was likely to cause displacement. Disclosure of Interest None declared

Strong magnetic fields, synchrotron emission, and Compton scattering are omnipresent in compact celestial X-ray sources. Emissions in the X-ray energy band are consequently expected to be linearly polarized. X-ray polarimetry provides a unique diagnostic to study the location and fundamental mechanisms behind emission processes. The polarization of emissions from a bright celestial X-ray source, the Crab, is reported here for the first time in the hard X-ray band (~20-160 keV). The Crab is a complex system consisting of a central pulsar, a diffuse pulsar wind nebula, as well as structures in the inner nebula including a jet and torus. Measurements are made by a purpose-built and calibrated polarimeter, PoGO+. The polarization vector is found to be aligned with the spin axis of the pulsar for a polarization fraction, PF = (20.9 $\pm$ 5.0)%. This is higher than that of the optical diffuse nebula, implying a more compact emission site, though not as compact as, e.g., the synchrotron knot. Contrary to measurements at higher energies, no significant temporal evolution of phase-integrated polarisation parameters is observed. The polarization parameters for the pulsar itself are measured for the first time in the X-ray energy band and are consistent with observations at optical wavelengths., Accepted for publication in Scientific Reports, www.nature.com/srep

Background To clarify the patterns, timing and risk factors of recurrence of gastric cancer after laparoscopic gastrectomy. Methods From January 1999 to March 2012, 577 patients underwent laparoscopic or laparoscopy-assisted gastrectomy for curative resection of gastric cancer. Recurrence patterns were classified as locoregional, hematogenous, peritoneal, distant lymph node and mixed. Recurrence patterns and time to recurrence were retrospectively examined and risk factors for recurrence were analyzed. Results Recurrence occurred in 28 (4.9%) cases with patterns as follows: locoregional in 2 patients (7.1%), hematogenous in seven (25.0%), peritoneal in nine (32.1%), distant lymph node in four (14.3%), and mixed in 6 (21.4%). There was no recurrence pattern peculiar to laparoscopic surgery. Recurrence occurred at one site in 21 patients (78.6%), two in 4 patients (14.3%), and three in 2 patients (7.1%). The median time to recurrence was 384 days (range 83–1497 days). Recurrence was detected within a year in 13 cases (46.4%), within two years in 21 (75%), and within three years in 25 (89.3%). Univariate analysis revealed tumor location, tumor size, type of operation, tumor depth, and lymph node classification as risk factors for recurrence. Multivariate analysis indicated tumor depth and lymph node classification as risk factors of recurrence. Conclusions Patterns, timing and risk factors of recurrence of gastric cancer after laparoscopic gastrectomy are similar to those after open gastrectomy, with no peculiarities specific to laparoscopic gastrectomy. Thus, as long as laparoscopic gastrectomy is performed according to the present inclusion criteria, follow-up can be similarly performed as for open gastrectomy.

Endocytoscopy (ECS) is a novel endoscopic technique that allows detailed diagnostic examination of the gastrointestinal tract at the cellular level. We previously reported that use of ECS at ×380 magnification (GIF-Y0002) allowed a pathologist to diagnose esophageal squamous cell carcinoma (ESCC) with high sensitivity (94.9%) but considerably low specificity (46.7%) because this low magnification did not reveal information about nuclear abnormality. In the present study, we used the same magnifying endoscope to observe various esophageal lesions, but employed digital 1.6-fold magnification to achieve an effective magnification of ×600, and evaluated whether this improved the diagnostic accuracy in distinguishing neoplastic from non-neoplastic lesions.We examined the morphology of surface cells using vital staining with toluidine blue and compared the histological features of 40 cases, including 19 case of ESCC and 21 non-neoplastic esophageal lesions (18 cases of esophagitis, 1 case of glycogenic acanthosis, 1 case of leiomyoma, and 1 case of normal squamous epithelium). One endoscopist classified the lesions using the type classification, and we consulted one pathologist for judgment of the ECS images as 'neoplastic', 'borderline', or 'non-neoplastic'. At ×600 magnification, the pathologist confirmed that nuclear abnormality became evident, in addition to the information about nuclear density provided by observation at ×380. The overall sensitivity and specificity with which the endoscopist was able to predict neoplastic lesions using the type classification was 100% (19/19) and 90.5% (19/21), respectively, in comparison with values of 94.7% (18/19 cases) and 76.2% (16/21), respectively, for the pathologist using a magnification of ×600. The pathologist diagnosed two non-neoplastic lesions and one case of ESCC showing an apparent increase of nuclear density with weak nuclear abnormality as 'borderline'. Among the 21 non-cancerous lesions, two cases of esophagitis that were misdiagnosed by the endoscopist were also misinterpreted as 'neoplastic' by the pathologist. We have shown, by consultation with a pathologist, that an ECS magnification of ×600 (on a 19-inch monitor) is adequate for recognition of nuclear abnormality. We consider that it is feasible to diagnose esophageal neoplasms on the basis of ECS images, and that biopsy histology can be omitted if a combination of increased nuclear density and nuclear abnormality is observed.

Introduction: ST-elevation myocardial infarction (STEMI) presenting to the ED is a significant health burden. The provision of IV morphine with doses titrated to provide comfort is recommended in the AHA STEMI Guidelines, yet there is limited evidence of safety in this setting. The primary objective of this study was to measure potential harm associated with the provision of IV morphine in STEMI patients presenting to the ED. Methods: This was a two centre retrospective chart review from an urban, inner city, academic ED with an annual census of 85,000 visits, and an affiliated community hospital with 35,000 annual visits. Consecutive patients from April 2009 to January 2015 presenting to the 2 EDs with a diagnosis of STEMI were identified in the ED database. Eight trained research assistants, blinded to the study hypothesis, used standardized data collection templates. The primary investigator double collected 20% of all data to ensure completeness and accuracy. Results: We included 311 patients with STEMI (124 received morphine [M]; 187 no morphine [nM]). The ages of the two groups were similar (mean 64 yrs [M] & 67 yrs [nM]; median 63 yrs [M] & 66 yrs [nM]; IQR 45-81 [M] and 45.5-86.5 [nM]); as were the proportion of female patients (21.0% [M] & 23.5% [nM]. The pre-STEMI Charlson comorbidity scores (mean 2.6), median time to first ECG (11 min [M] & 16 min [nM]), and mean time-to-needle for PCI (96.8 min [M] & 92.0 min [nM]) were similar between groups. The mean CCU length of stay (LOS) (9.3 days vs 6.3 days) and hospital LOS (7.4 days vs 4.6 days) were longer for patients receiving morphine than those not receiving morphine. Rates of congestive heart failure, acute kidney injury and cardiac arrest in hospital were unchanged between the groups. Unadjusted mortality was similar (10.5% [M] vs 13.3% [nM]) between groups. Binary logistic regression controlling for age, Charlson score, first and peak troponin values demonstrated an association between receiving morphine in the ED and an increased risk of death at 30 days (OR 8.1; 95% CI 7.1.-9.1). Conclusion: The provision of morphine to patients with STEMI in the ED may be associated with increased CCU and hospital LOS. When controlling for age, pre-STEMI Charlson score, first and peak troponin values, receiving morphine was associated with an increased risk of death at 30 days. Further research to elucidate this association is warranted.

Introduction: Amiodarone may be used for shock-refractory ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), but the effect of prehospital use upon neurological outcomes still unclear. Methods: A prospective province-wide, population based observational study was conducted from January 2006 to March 2016. Adult emergency medical service-treated non-traumatic OHCA patients who received at least one electric defibrillation were included. Amiodarone was administered to patients with VF/ pVT by paramedics based on their clinical assessment, according to provincial guidelines. The outcome of interest was favorable neurological outcomes to hospital discharge, defined as modified Rankin scale of 3 or less. Multivariable logistic regression was performed to compare the proportion of patients with the primary outcome between amiodarone and non-amiodarone groups, further stratified by the number of electrical defibrillation. In addition, to mitigate the potential selection bias, the same logistic regression was conducted in 1:1 propensity score matched groups adjusting for baseline covariates. Results: Of 3,374 overall OHCA patients, 915 (27.1%) were managed with amiodarone. In the amiodarone group, 150 / 915 (16.4 %) patients had a favorable neurological outcome, compared to 455/2,459 (18.5%) in the non-amiodarone group (crude odds ratio [OR] 0.86, 95% CI 0.71 to 1.06). In the multiple logistic regression model, prehospital amiodarone was associated with increased probability of favorable neurological outcomes (adjusted OR 2.11, 95% CI 1.46 to 3.05). With stratification by the number of electrical defibrillation performed, amiodarone treated group showed higher probability of favorable neurological outcomes (1 or 2: adjusted OR 2.71, 95% CI 1.33 to 5.50, 3 and more: adjusted OR 1.67, 95% CI 0.99 to 2.39). Similarly, in 1:1 propensity matched cohort including 882 OHCA patients, the adjusted association persisted (adjusted OR 2.14, 95% CI 1.33 to 3.44). Conclusion: Prehospital administration of amiodarone to non-traumatic OHCA patients was associated with better neurological recovery, especially in those who received fewer electrical defibrillations.

The palisade vessels present at the distal end of the esophagus are considered to be a landmark of the esophagogastric junction and indispensable for diagnosis of columnar-lined esophagus on the basis of the Japanese criteria. Here we clarified the features of normal palisade vessels at the esophagogastric junction using magnifying endoscopy. We prospectively studied palisade vessels in 15 patients undergoing upper gastrointestinal endoscopy using a GIF-H260Z instrument (Olympus Medical Systems Co., Tokyo, Japan). All views of the palisade vessels were obtained at the maximum magnification power in the narrow band imaging mode. We divided the area in which palisade vessels were present into three sections: the area from the squamocolumnar junction (SCJ) to about 1 cm orad within the esophagus (Section 1); the area between sections 1 and 3 (Section 2); and the area from the upper limit of the palisade vessels to about 1 cm distal within the esophagus (Section 3). In each section, we analyzed the vessel density, caliber of the palisade vessels, and their branching pattern. The vessel density in Sections 1, 2, and 3 was 9.1 ± 2.1, 8.0 ± 2.6, and 3.3 ± 1.3 per high-power field (mean ± standard deviation [SD]), respectively, and the differences were significant between Sections 1 and 2 (P= 0.0086) and between Sections 2 and 3 (P < 0.0001). The palisade vessel caliber in Sections 1, 2, and 3 was 127.6 ± 52.4 µm, 149.6 ± 58.6 µm, and 199.5 ± 75.1 µm (mean ± SD), respectively, and the differences between Sections 1 and 2, and between Sections 2 and 3, were significant (P < 0.0001). With regard to branching form, the frequency of branching was highest in Section 1, and the 'normal Y' shape was observed more frequently than in Sections 2 and 3. Toward the oral side, the frequency of branching diminished, and the frequency of the 'upside down Y' shape increased. The differences in branching form were significant among the three sections (P < 0.0001). These results indicate that the density of palisade vessels is highest near the SCJ, and that towards their upper limit they gradually become more confluent and show an increase of thickness. Within a limited area near the SCJ, observations of branching form suggest that palisade vessels merge abruptly on the distal side. We have demonstrated that palisade vessels are a useful marker for endoscopic recognition of the lower esophagus.

SUMMARY Endocytoscopy has the potential to reduce the need for histologic examination of biopsy specimens in cases of esophageal squamous cell carcinoma. Up to now, two types of endocytoscope have been used: the probe type and the integrated type. In this study we examined the utility of a newly developed endocytoscope, the ‘GIF-Y0002,’ which has a single lens allowing consecutive magnification from the conventional endoscopy level up to ×380. Using the GIF-Y0002, we examined 24 examples of normal esophageal mucosa to clarify the appearance of the microvasculature of the normal squamous epithelium in vivo. We also examined 11 cases of esophageal cancer in the same way, employing methylene blue as a vital dye to stain the surface cells. In normal squamous epithelium, we clarified the relationship between the subepithelial capillary network, IPCLs and subepithelial venules. With methylene blue staining, we observed typical squamous cells (low nuclear density and low N/C ratio without nuclear abnormality). When cancerous lesions were observed using lower-power magnification, we were able to visualize their microvascular architecture to the same extent as when conventional magnifying endoscopy was used. Furthermore, at higher magnification, we were able to visualize the features of blood flow in both superficial and advanced cancer. Methylene blue staining revealed an increase of nuclear density in all cases of cancer. The pathologist agreed to omit biopsy histology in 81.8% (9/11) of cancer cases considering the nuclear density and nuclear abnormality. The GIF-Y0002 provides information on cell abnormality in addition to the features revealed by currently available magnifying endoscopy.

The mammalian target of rapamycin (mTOR), a Ser/Thr protein kinase that mediates intracellular signalling related to cell growth, proliferation, and differentiation, has received considerable interest as a possible target for cancer treatment. We evaluated the correlation of mTOR expression with clinicopathological features, outcomes, and the expression of Akt, an upstream regulator of mTOR, in gastric cancer. Tumour samples were obtained from 109 patients with gastric adenocarcinomas who underwent a radical gastrectomy. The expressions of phosphorylated mTOR (p-mTOR) and phosphorylated Akt (p-Akt) in the cytoplasm and in the nucleus were analysed by immunohistochemical staining. Cytoplasmic p-mTOR expression positively correlated with the depth of tumour invasion (T1 vs T2–4, P=0.003), involved lymph nodes (P=0.010), and tumour stage (I vs II–IV, P=0.002). In contrast, nuclear p-mTOR expression negatively correlated with these variables (P

痔瘻根治手術を受け再発し来院してきた39症例と，膿瘍切開を繰り返し来院してきた19症例の摘出瘻管について検索した．再発痔瘻では，膿瘍併存型痔瘻を示した症例は74%あり，膿瘍切開を繰り返した症例では63%に認めた．再発症例のうち組織検索可能例は22例あり，膿瘍切開を繰り返した症例は9例あった．術後痔瘻再発例に肛門腺を認めた症例は14%あり，膿瘍切開再発症例では56%に認めた．組織学的所見は双方ともに被膜様線維化組織に囲まれた好中球とリンパ球，形質細胞を主体とした膿瘍と周囲線維組織間を拡散する炎症性細胞の浸潤を認めた．脂肪組織と筋肉組織内は線維化が著明でリンパ球，形質細胞と少数の好酸球の慢性炎症性細胞の浸潤を認めた．このことから再発の原因は，一次口の位置を誤認して手術した場合と線維化組織に囲まれた分岐あるいは併存する炎症拡散性の膿瘍を遺残させた場合と考えられた．

術後遅発性出血は，創傷治癒過程の増殖期を中心に組織再構築期までおこる合併症である．その原因は創傷治癒障害，血中の凝固異常，線溶系機能の亢進によるものではなく，術後の正常の創傷治癒過程において細胞外マトリックス内の血管増殖因子活性により血管が新生されるときプラスミノゲン·アクチベータが活性され，この時期に一致して出血がおこると考えられる．血小板の変動は，創傷治癒サイトカインの変動と強い相関を持ち，特に組織再構築に関与し，血小板の機能障害がおこると治癒期に至るまで出血を経験する事がある．痔核血管は動静脈吻合と露出血管部に出血がおこりやすく，術後はマトリックス内に類似血管が新生されることにより出血しやすくなると推察される．痔核切除創を肛門管内に露出させない縫合手技により出血症例を減少させ，高確率で術後出血が予防できた．

Laparoscopic gastrectomy for gastric cancer was developed in Japan and has been established as a treatment for early gastric cancer thanks not only to improvements in technology and medical equipment but also to great efforts made by surgeons. With increasing numbers of surgeons performing the procedure and extending its indication to some advanced gastric cancers, it has achieved an important position in the treatment of gastric cancer together with endoscopic mucosal resection and open surgery. In clinical practice, it has been accepted as a safe, minimally invasive and radical treatment for early gastric cancer through several clinical studies and case–control studies. A large-scale randomized controlled trial to evaluate laparoscopic gastrectomy as an acceptable procedure for early gastric cancer is being prepared. In order to extend the indication to some advanced gastric cancers, first, we need to collect more cases of laparoscopic gastrectomy for advanced cancer and start a phase II study in the experienced hospitals.

目的, 対象と方法 : 一次口を別にする瘻管を2本以上をもつ痔瘻33例 (男性31人, 女性2人) 瘻管総数67本について瘻管を完全切除し, その組織像を検索した. 結果 : 多発性痔瘻では外括約筋を貫く肛門管に対し放射状に直走する瘻管, 組織型では瘻管形成型 (37/67) が多く, 一次口の位置では6時位 (18/67) に多かった. 瘻管内に肛門腺を認める症例は49% (33/67) であり, IV型痔瘻はなかった. 瘻管組織の特徴は, 膿瘍併存型痔瘻でも脂肪組織内に炎症細胞の浸潤を認めるものの, 膿瘍を強く形成する症例はなかった. 瘻管形成型, 膿瘍併存型痔瘻にみられる肛門腺は分葉型 (20/33) を多く認めた. 円柱上皮と移行上皮で構成される管壁では腺管破壊像と粘液産生能を認めたが, 扁平上皮化生で構成される肛門腺は, 管壁の破壊像, 粘液産生能はなく, 管壁周囲の炎症は軽度あるいは消退していた. 結論 : 多発性痔瘻の瘻管は, 炎症性細胞の浸潤は弱く, 肛門腺の関与する割合は半数以下であり, 肛門腺は感染に弱いが扁平上皮に化生するため炎症は消退しやすいと推測された.

The onset of ventricular depolarization defines the start of the pre-ejection period (PEP), which is commonly used as an index of myocardial contractility. Although the fiducial point for this onset has traditionally been the onset of the Q wave of the electrocardiogram (qPEP), the Q wave is not visible in some patients. Therefore, other measurement points have also been used in the literature, including the peak of the R wave (rPEP). However, there has been little systematic examination of measurement issues associated with the selection of the fiducial point for ventricular activation.

Esophageal rupture is a potentially mortal condition. Rapid and correct diagnosis, and urgent surgical treatment with esophagectomy is indicated, but conservative and other surgical treatments have also been reported recently. The treatment strategies for esophageal rupture are discussed here, based on our experiences with four cases during the last 10 years. They were admitted urgently and each was treated by a different method. Three of them underwent emergency operations, one undergoing primary closure of the ruptured esophagus, another received a T-tube insertion from the ruptured site with omental flap, and the third an esophagogastrectomy. The fourth case was treated conservatively. All patients survived and were discharged 36-144 days post treatment. One of them was readmitted for debridement of necrotic rib. In conclusion, the prompt and accurate diagnosis of esophageal rupture is crucial for a subsequent successful treatment. Conservative treatment or operation including esophagectomy will be determined by the severity of the condition.

We evaluated dural arteriovenous fistulas (DAVF) drains into leptomeningeal vein (LMV) without the venous sinus interposition. This type of DAVF contained the extra-sinusal type DAVF and the DAVF with so-called pure leptomeningeal venous drainage (PLMVD). We studied 15 patients with DAVF that flows into LMVD without passing into the sinus. The subjects were 5 patients with DAVF in the anterior cranial fossa, 2 with DAVF in the tentorium cerebelli, and 3 with DAVF in the craniocervical junction as extra-sinusal type DAVF and 3 with DAVF in the transverse sigmoid sinus and 2 with DAVF in the superior sagittal sinus as DAVF with PLMVD. This type appears to take a very aggressive course. The arterial pressure of the shunt is directly applied to LMV, which causes bending and winding of the vein, eventually varices, inducing intracranial haemorrhage or venous ischemia in the LMV reflux area. Emergency treatment should be performed as soon as possible. Although it is recognized that interruption of the draining vein is very effective, treatment methods such as TAE, direct surgery, and g knife treatment, or their combinations should be carefully chosen for each case.

Introduction: Survival for victims of out-of-hospital cardiac arrest (OHCA) is typically between 8 and 12%. We sought to report the trends in survival in British Columbia (BC) over a 10-year period. Methods: The BC Resuscitation Outcomes Consortium prospectively collected detailed prehospital and hospital data on consecutive non-traumatic OHCAs from 2006 to 2016 within BC’s four metropolitan areas. We included EMS-treated adult patients without DNR orders. To describe baseline characteristics we organized patient characteristics in three time periods: 2006-09, 2010-13, and 2014-16 (first and last periods reported below). The primary and secondary endpoints were survival at hospital discharge and return of spontaneous circulation (ROSC). We tested the significance of year-by-year trends in baseline characteristics, and performed multivariable Poisson regression, using calendar year as an independent variable, to calculate risk-adjusted rates for survival. Results: Between January 1, 2006 and March 31, 2016 there were a total of 26 433 non-traumatic OHCAs, with 15 145 included in this study. There were significant decreases in the proportion with initial shockable cardiac rhythms (28% to 23%) and bystander witnessed arrests (42% to 39%), however significant increases in the proportion with bystander CPR (40% to 49%) and ALS treatment (86% to 97%), and the median chest compression fraction (0.81 to 0.87). There was a significant increase in the median time until termination of resuscitation in those who did not achieve ROSC (27 to 32 minutes), and a significant decrease in the proportion of patients who were transported in absence of ROSC (17% to 6.5%). There was a significant improvement in achieving ROSC (44% to 48%; adjusted rate ratio per year 1.02, 95% CI 1.01 to 1.02) and survival at hospital discharge (10% to 14%; adjusted rate ratio per year 1.05, 95% CI 1.04 to 1.06). Both subgroups of initial shockable (adjusted rate ratio per year 1.04, 95% CI 1.03 to 1.05) and non-shockable (adjusted rate ratio per year 1.08, 95% CI 1.06 to 1.12) cardiac rhythms demonstrated survival improvement. Conclusion: Despite a significant decrease in those with initial shockable rhythms, out-of-hospital cardiac arrest survival in BC’s metropolitan regions increased by approximately 40% over a 10-year period. During this time there were system changes and quality of care improvements as provided by bystanders and professionals.

Introduction: Sodium bicarbonate (SB) is still widely used for resuscitation in out-of- hospital cardiac arrest (OHCA) despite limited clinical indications but the effect on neurological recovery is unclear. Methods: From 2006 to 2016, we prospectively conducted a province-wide population-based observational study of adult non-traumatic OHCA patients managed by EMS. According to provincial guidelines, paramedics administered SB to OHCA patients based on their clinical assessment. Outcome of interest was favorable neurological outcome at hospital discharge, defined as CPC of 1 and 2 or modified Rankin scale of 3 or less. We performed multivariable logistic regression, comparing the proportion of outcome between SB and non-SB groups, further stratified by the median of the length of resuscitation. We also applied propensity score matching technique adjusting for baseline characters to the same model to reduce potential selection bias. Results: Of 13,008 OHCA patients, 4,699 (36.1%) were managed with SB. In the SB treated group, 64 / 4,699 (1.3%) patients had favorable neurological outcomes, compared to 823 / 8,309 (9.9%) in the non-SB treated group (crude odds ratio [OR] 0.12, 95% CI 0.09 to 0.16). In logistic regression model, SB was associated with decreased probability of favorable outcomes (adjusted OR 0.63, 95% CI 0.45 to 0.89). Similarly, with stratification by length of resuscitation, the SB group had a lower probability of favorable outcomes (≦24 min: adjusted OR 0.68, 95% CI 0.46 to 1.02, >24 min: adjusted OR 0.47, 95% CI 0.23 to 0.97). In 1:1 propensity matched cohort including 5,126 OHCA patients, the adjusted association also persisted (adjusted OR 0.59, 95% CI 0.39 to 0.89). Conclusion: Prehospital administration of SB to OHCA patients was associated with worse neurological outcomes and the trend persisted even after stratification by resuscitation length.

痔核は出血,血栓形成で発症し,痔核手術後にも突然多量の出血を時に来す。その原因について,Goligher分類3～4度の3ヵ所の痔核切除組織(13人)と,直腸切断術を行った患者の痔核部位(12人,コントロール群)を比較検討しその意義について推察した.切除痔核では,コントロール群に比較して動脈数では同数であるものの,径は2倍(p

The present study was designed to reveal the incidence of silent myocardial ischemia in asymptomatic elderly non-insulin-dependent diabetic (NIDDM) patients (aged over 60 years). As a first step screening, maximal treadmill exercise test was performed. Of 140 patients studied, 54 (38.6%) were unable or not expected to achieve diagnostic levels of exercise during treadmill testing. A positive exercise test was noted in 39 of 86 (45.3%) subjects. As a second step examination, dipyridamole thallium scintigraphy was performed for 93 subjects who exhibited a positive exercise test and could not perform a maximal exercise test. Abnormal perfusion pattern was found in 39 of 93 (41.9%), who were finally considered to have a silent myocardial ischemia. Coronary angiography was performed in 18 subjects with diagnosis of silent myocardial ischemia, who gave their consent. Significant coronary artery stenosis was in fact found in 17 of 18 (94.4%) subjects studied, confirming a very high positive predictive value of this diagnostic procedure. In conclusion, elderly NIDDM patients (aged over 60 years) had an extremely high prevalence (estimated 26.3%) of silent myocardial ischemia. This evidence suggests that early and intensive detection may be needed as a part of routine care for this group.

To investigate the roles of intrahepatic T cells in liver injury after Salmonella infection, we examined serum alanine transaminase (ALT), histopathology, and bacterial numbers in liver after infection with Salmonella choleraesuis strain 31N-1 in mice genetically lacking TCRalpha beta+, CD4(+), CD8(+), or NK1.1(+)T cells with C57BL/6 background. In control (+/+) mice, serum ALT reached a peak level by day 7 after an intraperitoneal inoculation of 2 x 10(6) CFU Salmonella choleraesuis 31N-1. In TCR-beta-/- mice, liver injury, as assessed by serum ALT level and histological examination, was significantly suppressed on day 7 after Salmonella infection but the numbers of bacteria in liver did not differ from those in normal mice, suggesting that alpha beta T cells are responsible for liver injury induced by Salmonella infection. To further determine which subsets in alpha beta T cells are important for the liver injury, we compared serum ALT level in mice genetically lacking CD4, CD8, beta2-microglobulin (beta2m, IAbeta, or Jalpha281 after Salmonella infection. In CD4(-/-) mice, serum ALT was significantly lower in comparison with control mice, but there was no difference in serum ALT levels in CD8(-/-) and IAbeta-/- mice from that in control mice. Notably, serum ALT levels and pathological lesions in liver were significantly decreased in beta2m-/- or Jalpha281(-/-) mice, which lacked in NK1.1(+) T cells bearing TCR Valpha14-Jalpha281 specific for beta2m-associated CD1d, following Salmonella infection. Taken together, it is suggested that alpha beta T cells bearing NK1.1 and CD4 may be main effector cells for liver injury after Salmonella infection.

Mice injected with deproteinized cell walls prepared from the strain H37rv ofMycobacterium tuberculosisdevelop a granuloma-like lesion in which NKT cells are predominant. NKT cells play a primary role in the granulomatous response, because the latter does not occur in Jα281−/−mice, which miss NKT cells. The glycolipidic fraction of the cell walls is responsible for the recruitment of NKT cells; the recruiting activity is associated with fractions containing phosphatidylinositolmannosides. These results define a powerful experimental set up for studying thein vivoinduction of NKT cell responses to microbial components.

The indications for curative endoscopic resection of oesophageal cancer are as follows: (1) mucosal cancer without gross invasion to the muscularis mucosae; (2) less than 2 cm × 2 cm in size or less than a third of the circumference of the oesophagus; (3) absence of recognizable nodal involvement. In our department, a small transparent cap is attached to the distal part of the forward-viewing endoscope. The snare forceps is passed through the working channel of the endoscope and is opened in the cap. The protruding mucosa is then snared into the cap by the suction mechanism of the endoscope. Endoscopic resection was performed in 40 cases. In all instances a complete response was obtained locally. There were a few post-operative complications. The 5 year survival rate was 95% and no recurrence has been observed.

The acute and subchronic toxicity of 1,1-dichloro-1-fluoroethane (HCFC-141b), a CFC alternative, was evaluated in several acute and subchronic studies to assist in establishing proper handling guides. Data from acute toxicity studies in rats and rabbits demonstrated that HCFC-141b has very low acute toxicity. HCFC-141b was not a skin irritant, but was a mild eye irritant, in rabbits and was not a skin sensitizer in guinea pigs. Skin application of HCFC-141b to rabbits at 2000 mg/kg body weight produced no adverse effects. Oral administration at 5000 mg/kg body weight did not cause any deaths or clinical signs of toxicity in rats. The 4-hr LC50 for HCFC-141b was about 62,000 ppm in rats. Repeated exposures of rats for 6 hr/day, 5 days/wk for up to 90 days at concentrations of 2000, 8000 or 20,000 ppm did not result in significant adverse effects. Minor, but dose-dependent, reductions in body weight were observed in male and female rats during the 90-day study. Decreased responsiveness was also observed in rats but only at 20,000 ppm. An increase in serum cholesterol or triglycerides was observed in male and female rats at 20,000 ppm, and in males at 8000 ppm. No specific organ pathology was noted in these subchronic inhalation studies. The no-observable-adverse-effect level (NOAEL) from these studies was 8000 ppm. Results from other studies demonstrate that HCFC-141b was not neurotoxic in rats. As with trichlorofluoroethane (CFC-11), a cardiac sensitization response to an intravenous epinephrine challenge occurred in dogs with HCFC-141b at 5000 ppm and higher concentrations in experimental screening studies.

Inflammatory chemical mediators, platelet-activating factor (PAF), thromboxane (TX) B2, and 6-keto-prostaglandin (PG)F1 alpha, were extracted from lung lavage fluid after conventional mechanical ventilation (CMV) and high frequency oscillatory ventilation (HFOV) to clarify the relation between mode of ventilation and lung injury in surfactant-depleted rabbit lungs. Anesthetized adult rabbits were tracheostomized, and surfactant depletion was induced by repeated saline lavage. Lung lavage for measurement of mediators was performed after 4 h of CMV at an FIO2 of 1.0 and a mean airway pressure of 15 cm H2O or HFOV (15 Hz) at an FIO2 of 1.0 or 0.21 and a mean airway pressure of 15 cm H2O. The number of total cells and polymorphonuclear leukocytes (PMN) and the levels of PAF, TXB2, and 6-keto-PGF1 alpha were measured by radioimmunoassay. Total respiratory compliance (Crs) was measured by the passive flow-volume curve method. The numbers of PMN, and the levels of PAF and TXB2 in lung lavage fluid were significantly greater during CMV than during HFOV. HFOV resulted in decreased production of PAF and TXB2 in a surfactant-depleted rabbit lung. Crs was significantly less during CMV than during HFOV. These results suggest that HFOV could prevent the release of such inflammatory chemical mediators and result in less lung injury than CMV.

Transient myeloproliferative disorder (TMD), an acute leukemia-like disorder in neonates with Down's syndrome, is characterized by spontaneous regression of abnormal blast growth. Because proliferating blasts frequently express phenotypes of megakaryocytic lineage and, as a result, this disorder resembles acute megakaryoblastic leukemia (AMKL), it would be of interest to determine whether myelofibrosis, a common complication of AMKL, is also present in TMD. Pathologic observations of four autopsy cases of TMD showed that myelofibrosis was not present in any of them, whereas intralobular diffuse liver fibrosis was present in all of them. Laboratory data of four additional cases showed hepatic dysfunction in all of them, suggesting a close association between hepatic lesions and TMD. From these results, we propose a hypothesis that the abnormal blasts with megakaryocytic properties in TMD originate from the fetal liver and cause liver fibrosis, as AMKL cells are thought to cause myelofibrosis by producing collagen-stimulating cytokines in the bone marrow. This hypothesis also seems to explain some other unique aspects of TMD.

We examined whether endocytoscopic observation of esophageal squamous cell carcinoma can replace the histologic examination of biopsy specimens. In a basic investigation, we examined 57 iodine-unstained areas in the resected specimens of the esophagus from 28 individuals. The endocytoscopic findings were graded from 0 to 3 in tandem with observations of the iodine staining. For endocytoscopic observation, we sprayed 1% methylene blue or toluidine blue as a vital dye on the surface of the esophageal mucosa, allowing 15-20 s for sufficient staining. One endoscopist observed the target lesions and decided their endocytoscopic type classification. Histological diagnoses were made by two pathologists who were unaware of the endoscopic findings. We then compared the endocytoscopic diagnosis and conventional histological diagnosis. In an in vivo investigation, we examined 71 lesions of esophageal squamous cell carcinoma. Two endoscopists diagnosed the type classification in consultation with a pathologist with regard to 'nuclear density,''nuclear abnormality,' and 'whether biopsy histology could have been omitted on the basis of endocytoscopic findings.' For the in vivo observation, we utilized XEC120U (higher magnification type [x1100]), XEC300F (lower magnification type [x450]), and XGIF-Q260EC1 (lower magnification type [x450]) instruments. In the basic investigation, among the 11 areas classified as Type 1, 10 (91%) were category 1 by the Vienna classification. Among the 39 lesions classified as Type 3, 36 (92%) were category 4 or 5. The sensitivity of endocytoscopy for malignant lesions (Vienna classification categories 4 and 5) was 94.7%, if Type 3 was considered malignant. The specificity was 84.2% according to the same criteria. In the in vivo observation, two endoscopists diagnosed more than 90% of esophageal squamous cell carcinomas as neoplasms using each type of endocytoscope. With regard to nuclear density, the pathologist considered it to be increased in 98% of cases with the XEC120U, in 94% with the XEC300F, and in 93% with the XGIF-Q260EC1. With regard to nuclear abnormality, the positivity rate was 90% with the XEC120U, 78% with the XEC300F, and 80% with the XGIF-Q260EC1. As to whether or not biopsy histology examination was considered necessary, the pathologist made a 'Yes' judgment for 84% of cases observed with the XEC120U, 66% with the XEC300F, and 67% with the XGIF-Q260EC1. Cancerous lesions diagnosed as Type 3 by both endoscopists using the XEC120U accounted for 46 (90.2%) of the 51 cases. Among these 46 cases, biopsy histology was considered unnecessary by the pathologist in 43 (93.5%). We believe that endocytoscopic observation has the potential to reduce the extent of histologic examination of biopsy specimens in cases corresponding to Types 1 and 3 of our classification.

The designated area of the columnar-lined esophagus (CLE) is anatomically defined by the distal limit of the lower esophageal palisade vessels (LEPV) and the term 'Barrett's esophagus' is equally used along with the name CLE in Japan. The aim of this study was to investigate the actual prevalence of CLE based on the Japanese criteria and to evaluate the criteria per se. A total of 42 esophagi consecutively resected at this institute were included. All subjects underwent a surgical resection for squamous cell carcinoma of the esophagus. The position of the LEPV, squamocolumnar junction, the prevalence of CLE and intestinal metaplasia were investigated both pre- and postoperatively. Preoperative endoscopy revealed CLE based on the Japanese criteria in half of all patients. In the resected specimens the distal limit of LEPV was lower than the squamocolumnar junction in 95.2%. In other words, almost all cases had CLE (equivalent to Barrett's mucosa in Japanese criteria). However, most of the CLE areas were very short and their average maximum length was only about 5 mm. In addition, no intestinal metaplasia was observed in any of the CLE cases. Almost all individuals might therefore be diagnosed to have CLE or Barrett's mucosa based on precise endoscopic observations in Japan. The CLE located in a small area, e.g. less than 5 mm, defined according to the LEPV criteria without any other factor concerning typical Barrett's esophagus such as signs of gastroesophageal reflux should therefore be excluded from consideration as a high-risk mucosa.

Vagus nerve-sparing laparoscopically assisted distal gastrectomy (Vs-LADG) for early gastric cancer has been introduced to reduce postgastrectomy syndrome, but its clinical and functional outcomes remain unclear.Of the 105 patients reviewed in this study, 75 underwent Vs-LADG and 30 underwent laparoscopically assisted distal gastrectomy (LADG) for gastric cancer between January 1999 and May 2006. The clinical and functional outcomes of these two groups were compared.The clinical and pathologic background between the two groups did not differ. The incidence of gallstone was significantly lower in the Vs-LADG group than in the LADG group (p0.05), but no differences existed in duration of surgery, intraoperative blood loss, number of retrieved lymph nodes, time to first flatus after surgery, or length of hospital stay between the two groups.As shown by the findings, Vs-LADG is a safe and minimally invasive surgery that may decrease the incidence of gallstone formation after gastrectomy.

A micro-positioning table with a 0.005 μm resolution has been developed to enhance the performance of a conventional grinding machine in the fine grinding of ceramics. A piezoelectric actuator with high stiffness and resolution has been applied to drive the table and to provide small depths of cut for the workpiece. The performance of the table is investigated with both open and closed-loop operation to drive the actuator. The accuracy and stiffness of the positioning are improved by means of the closed-loop control. Grinding experiments with ceramics, such as partially stabilized zirconia (PSZ) and hot-pressed silicon nitride (Si3N4), were carried out to demonstrate the performance of the table. The actual resolution of depth-of-cut control was determined by measuring ground groove depths on the ceramic surface. A mirror-like surface on the ceramic was easily obtained by grinding at the small depth of cut of 0.1 μm with the aid of the table.

In laparoscopic surgery, intracorporeal suturing is one of the most important and difficult techniques. Each laparoscopic surgeon trains alone to improve their techniques of suturing. However, for most average surgeons the technique of tying a knot is still a difficult procedure in laparoscopic suturing. In laparoscopic esophageal surgery such as a Nissen fundoplication, Heller–Dor operation, it is necessary to perform intracorporeal suturing. This technique, which is called the open-jaw method, is very useful for average laparoscopic surgeons and it may already be used by some surgeons. However, it is still not widely known. This simple and useful technique of intracorporeal knot tying is demonstrated in this report.

A dose-escalation study of irinotecan (CPT-11) combined with S-1, an oral dihydropyrimidine dehydrogenase inhibitory fluoropyrimidine, was performed to determine the maximum-tolerated dose (MTD), recommended dose (RD), dose-limiting toxicities (DLTs), and objective response rate (RR) in advanced gastric cancer (AGC). S-1 was administered orally at 80 mg m−2 day−1 from day 1 to 14 of a 28-day cycle and CPT-11 was given intravenously on day 1 and 8 at an initial dose of 70 mg m−2 day−1, stepping up to 100 mg m−2. The treatment was repeated every 4 weeks, unless disease progression was observed. In the phase I portion, the MTD of CPT-11 was presumed to be 100 mg m−2, because 66.6% of patients (two of three) developed DLTs. All three patients at the initial RD of CPT-11 (90 mg m−2) experienced grade 4 haematological or grade 3 nonhaematological toxicities at second course, followed by the dose reduction of CPT-11 from the third course. Considering safety and the ability to continue treatment, the final RD was determined to be 80 mg m−2. In the phase II portion, 42 patients including seven patients in the final RD phase I portion were evaluated. The median treatment course was five (range: 1–13). The incidences of severe (grade 3–4) haematological and nonhaematological toxicities were 19 and 10%, respectively, but all were manageable. The RR was 62% (26 of 42, 95% confidence interval: 47.2–76.6%), and the median survival time was 444 days. Our phase I/II trial showed S-1 combined with CPT-11 is effective for AGC and is well tolerated, with acceptable toxicity.

The authors evaluated the embolization effects on experimental aneurysm models with a liquid material. This material is a mixture of poly (HEMA-co-MMA), Iopamidol, water and a small amount of ethyl alcohol. We have satisfactorily treated over 30 cases of AVM with this material. Out of four solutions of different viscosity, we used the solution with the highest viscosity to prevent distal migration of the mixture. Glass models of aneurysms of 5 mm in diameter in pulsatile saline flow were embolized with the mixture under various conditions. When an IDC was placed in the aneurysm models, the mixture obliterated them completely and did not migrate out from the aneurysm models. In this experimental study, it is suggested that the liquid material appears to be useful in embolizing cerebral aneurysms safely.

Background: Recently, impaired fasting glucose (IFG) was redefined as fasting plasma glucose of 100-125 mg/dl, and individuals with IFG and/or impaired glucose tolerance (IGT) were referred to as having "pre-diabetes". However, there is a lack of data using the new definition of IFG and "pre-diabetes". Objective: The aim of this study was to examine associations of the metabolic syndrome components with the new "pre-diabetes" category in relatively lean Japanese. Methods: Six hundred and sixty-one Japanese study participants underwent a 75 g oral glucose tolerance test. They were classified into three groups-normal (n = 225), pre-diabetes (n = 308), and diabetes (n = 128). The metabolic syndrome was defined according to the National Cholesterol Education Program Adult Treatment Panel III, as modified for waist circumference criteria by the Regional Office for the Western Pacific Region of WHO. Results: Prevalence of the metabolic syndrome in each group was 10.7%, 27.9%, and 53.9%, respectively. Of the metabolic syndrome components, the OR for prevalent pre-diabetes was 2.00 (95 % CI, 1.73 - 2.31, p < 0.001) for fasting glucose, 1.93 (95% CI, 1.54-2.42, p < 0.001) for waist circumference, and 1.36 (95% CI, 1.10-1.68, p = 0.005) for triglycerides. Similar associations were found in prevalent diabetes. Insulin resistance assessed using Stumvoll's index was significantly associated with both pre-diabetes and diabetes. Conclusion: Pre-diabetes and the metabolic syndrome frequently coexist in relatively lean Japanese. This association seems to link with abdominal adiposity and insulin resistance.

The wear phenomenon of ultra-high molecular weight polyethylene (UHMWPE) in knee and hip prostheses is one of the major restriction factors on the longevity of these implants. Especially in retrieved knee prostheses with anatomical design, the predominant types of wear on UHMWPE tibial components are delamination and pitting. These fatigue wear patterns of UHMWPE are believed to result from repeated plastic deformation owing to high contact stresses. In this study, the elasto-plastic contact analysis of the UHWMPE tibial insert, based on geometrical measurement for retrieved knee prosthesis, was performed using the finite element method (FEM) to investigate the plastic deformation behaviour in the UHMWPE tibial component. The results suggest that the maximum plastic strain below the surface is closely related to subsurface crack initiation and delamination of the retrieved UHMWPE tibial component. The worn surface whose macroscopic geometrical congruity had been improved due to wear after joint replacement showed lower contact stress at macroscopic level.

We have constructed a multilayered neural network system that identifies brain dynamics from electroencephalogram (EEG) data by error backpropagation (BP) learning. EEG data in the rest state with closed eyes and open eyes are measured with electrodes that are placed by the international 10-20 system. The brain dynamics are embedded in the neural networks. The developed system discriminates the dynamics of the brain dynamics of the brain activities associated with open eyes from those with closed eyes.

In some cases, temporary or permanents occlusion of the arteries, which participates the cerebral blood flow, are needed during surgery. The exact and fast EEG monitoring of the brain functions and their dynamic changes is an important way to minimize the neurological deficits during surgery. The goal of this study is to develop the integrated EEG monitoring system with expandability. The system consists of a data acquisition, a waveform memory management, and a data analysis part. At the present stage, it can display waveform, spectrum and topography change of each frequency component on arbitrary electrode groups, and DRT (deviation ratio topography) in real time. In this stage, the system warns the operator by the alarm when the measured EEG changes significantly. This function makes possible to know the patient's condition without seeing the monitoring system.

Background: Gasless laparoscopy has the advantage of avoiding the risk inherent in pneumoperitoneum, but has not gained widespread popularity because of limited exposure of the operative field. Improved retraction devices are therefore needed. Methods: A loop-shaped metallic retractor was designed for planar lifting of the anterior abdominal wall. Four types of retractor (5/6-, 3/4-, and 1/2-circle with rod at 90°, and 1/2-circle with rod at 97°) were studied in 15 pigs. The device was then used for 47 patients. Results: The 1/2-circle was the most smoothly inserted retractor and was significantly safer than the 5/6-circle (p < 0.05, Fisher’s exact probability test). The 1/2-circle with rod at 97° was utilized for clinical cases. This retractor can be readied within 1 min and was used successfully for all operations. Conclusions: This new retractor for gasless laparoscopic surgery provides good exposure and has the potential to enhance the performance of advanced laparoscopic surgery.