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Cesarean section for placenta previa accreta spectrum carries a significant risk of massive hemorrhage. Hence, it is necessary to understand the various hemostatic procedures, damage control surgery and resuscitation for massive hemorrhage, and systemic management against hypovolemic shock and coagulopathy. In cases of placenta previa with previous cesarean section, the operation should be performed in a tertiary medical facility with well-trained staff and blood availability for transfusion. Preoperative placement of an intra-arterial balloon occlusion catheter in the common iliac artery or aorta is useful for preventing massive hemorrhage.

Aims We investigated whether common iliac artery balloon occlusion (CIABO) was effective for decreasing blood loss during cesarean hysterectomy (CH) in patients with placenta previa with accreta and was safe for mothers and fetuses. Methods Of the 67 patients who underwent CH for placenta previa with accreta at our facility from 1985 to 2014, 57 patients were eligible for the study. The amount of intraoperative bleeding during CH was compared between three groups: surgery without blood flow occlusion (13 patients), internal iliac artery ligation (15 patients) and CIABO (29 patients). Additionally, multivariate analysis was performed to assess risk factors for massive bleeding during CH. Results The mean blood loss in the CIABO group (2027 ± 1638 mL) was significantly lower than in the other two groups (3787 ± 2936 mL in the no occlusion, 4175 ± 1921 mL in the internal iliac artery ligation group; P

Aim Massive obstetric hemorrhage (MOH) requires prompt transfusion of red blood cells and coagulation factors. Because MOH has a diverse pathogenesis, the shock index (SI) alone may be insufficient for determining blood transfusion. Here, we retrospectively analyzed patients with MOH to determine usefulness of the indicators of shock including the SI in evaluating the need for blood transfusion. Methods We reviewed records of 80 emergency referral patients who had received blood transfusions at our department between 1 January 2009 and 31 July 2011. The shock indicators for blood transfusion are estimated blood loss, fibrinogen level, hemoglobin concentration, the Japan Society of Obstetrics and Gynecology disseminated intravascular coagulation (JSOG DIC) score and the SI. The strength of the correlation of each shock indicator with the transfusion volume was ranked using Spearman's rank correlation coefficient-ρ and multivariate analysis. Results Although the SI showed significant positive correlation with blood transfusion volume for red blood cell concentrate (RCC) and fresh frozen plasma (FFP) in patients with dilutional coagulopathy, a stronger correlation was seen with the fibrinogen level and JSOG DIC score. In patients with consumptive coagulopathy, the strongest correlation was seen between RCC transfusion volume and fibrinogen level, and between FFP transfusion volume and JSOG DIC score followed by fibrinogen level. In multivariate analysis, only fibrinogen level was significantly associated with both RCC and FFP massive transfusion. Conclusion Because MOH has a diverse pathogenesis, various indicators should be evaluated. Among shock indicators, fibrinogen level was the best indicator of the need for blood transfusion following MOH.

Background. Since cryoprecipitate, fibrinogen concentrate, or recombinant activated factor VII is not approved by public medical insurance in Japan, we retrospectively assessed blood product usage in patients with obstetric hemorrhage at our tertiary obstetric center. Material and Methods. 220 patients with obstetric hemorrhagic disorders who underwent blood product transfusion in our institution during a 5-year period were reviewed for the types and volumes of blood products transfused. Results. There was a significant positive correlation ( 0.001) between the volume of RCC (red blood cell concentrate) transfused and that of FFP (fresh frozen plasma), irrespective of underlying obstetric disorders. The median of FFP to RCC ratio in each patient was 1.3–1.4, when 6 or more units of RCC were transfused. Conclusions. In transfusion for massive obstetric hemorrhage in terms of appropriate supplementation of coagulation factors, the transfusion of RCC : FFP = 1 : 1.3–1.4 may be desirable.

悪性線維性組織球種 (Malignant Fibrous Histiocytoma以下MFH) の,後腹膜原発例は比較的稀で,局所再発や他臓器転移等のため予後は極めて不良である.症例は, 74歳の男性で,左下腹部の腫瘤を主訴に来院した.腹部CTおよびMRIで,辺縁不整,内部不均一の10cm大の腫瘤を左下腹部に認め,血管造影検査では左総腸骨動脈造影で腫瘍濃染像を認めた.以上より後腹膜由来の肉腫を疑い腫瘍摘出術を施行した.切除された腫瘍は, 14×12×11cm, 490gで病理組織学的所見では, storiform-pleomorphic typeのMFHと分類された.術後6週目に施行した,胸腹部単純CTにて局所再発および多発性肺転移を認め,術後16週目に呼吸不全で死亡した.本疾患は,再発,転移率高く,自験例のように術後急速な経過をたどることもある.

Background and Objectives Development of the system to express a suicide gene selectively in tumor cells is essential for gene therapy. We constructed a plasmid containing the diphtheria toxin A (DTA) fragment linked to human alpha-fetoprotein (AFP) promoter and enhancer, and tested whether it can exert its cytocidal effect selectively on AFP-producing cells. Methods The chloramphenical acetyltransferase (CAT) reporter gene or DTA gene was linked to the 5′ upstream region of the AFP gene. The plasmids were transfected into AFP-producing or non-producing cells by the lipopolyamine-coated DNA method. Expression of CAT activity and effects on cell growth of transfected cells were assessed. Results When the AFP-producing cells HuH-7 or HepG2 were cotransfected with CAT reporter plasmid and pAF5.1DTA plasmid, the CAT activity was greatly suppressed. In contrast, cotransfection with pAF5.1DTA-R, the inversely inserted DTA gene, did not inhibit CAT activity. Furthermore, cell growth of HuH-7 cells transfected with pAF5.1DTA plasmid was significantly inhibited compared with HuH-7 cells transfected with DTA-R plasmid. Conclusions Our results indicate that selective killing of AFP-producing cells will be attained by introducing the DTA gene linked to the promoter and enhancer region of AFP. J. Surg. Oncol. 1999;70:145–149. © 1999 Wiley-Liss, Inc.

[14C]menaquinone-4, a therapeutic agent for osteoporosis, was administered orally to male dogs at a dose of 4 mg/kg, and the absorption, distribution, metabolism and excretion were investigated. 1. The plasma concentration of radioactivity reached the maximum level (Cmax) of 4540.4 ng eq./ml at 1 to 2 hours after administration and thereafter decreased slowly. At Tmax, the unchanged menaquinone-4 in the plasma corresponded to 79.6% of the total radioactivity. 2. Within 168 hours, 2.3 and 78.1% of the radioa ctivity was excreted into the urine and feces, respectively. Unchanged menaquinone-4 corresponded to 28.5% of the radioactivity in the feces excreted within 24 hours. 3. The liver (33164.0 ng eq./g) and spleen (12542.2 ng eq./g) showed much higher concentrations of radioactivity than the other tissues and plasma (2994.5 ng eq./ml) at 1.5 hours after administration. The concentration in bile (109392.1 ng eq./ml) was also high, suggesting that the menaquinone-4 was immediately excreted into the bile. The elimination of radioactivity from tissues was relatively slow compared to that from plasma. In bone tissues, the target organ of the drug, the marrow (1424.9 ng eq./g) and cancellous tissue (2465.7 ng eq./g) of thighbone and the marrow (3533.4 ng eq./g) of ribs showed levels as high as the plasma concentrations at 1.5 hours and were 2 to 3 times higher than that of the plasma at 24 hours after dosing. 4. The unchanged menaquinone-4 was the major form present in the plasma, liver, kidney, spleen, adrenal, adipose and cancellous tissue of thighbone at 1.5 hours after administration. The known metabolites, ω-COOH, K acid I and K acid II, were found in these tissues at 1.5 hours. In the adipose and cancellous tissue of thighbone, the unchanged menaquinone-4 was the major form up to 168 hours, while the relative amount of metabolites increased by 24 hours in the other tissues. Polar metabolites were found in the urine excreted within 24 hours and bile at 1.5 and 24 hours after administration. The unchanged menaquinone-4 was mainly found in the feces excreted within 24 hours. 5. The levels of radioactivity in the marrow and cancellous tissue of thighbone and the marrow of ribs at 1.5 and 24 hours after dosing (1.5 hours: 3.3−8.0×10-6 M, 24 hours: 1.9−3.1×10-6 M) were comparable to the pharmacologically effective concentrations of menaquinone-4 (10-6−10-5 M) in in vitro studies on bone formation. This finding suggests that menaquinone-4 distributes sufficiently into bone tissues after a single oral administration in dogs, and can be expected to maintain pharmacologically effective concentrations by repeated administration as a therapeutic agent for osteoporosis.

Massive obstetric hemorrhage (MOH) requires prompt transfusion of red blood cells and coagulation factors. Because MOH has a diverse pathogenesis, the shock index (SI) alone may be insufficient for determining blood transfusion. Here, we retrospectively analyzed patients with MOH to determine usefulness of the indicators of shock including the SI in evaluating the need for blood transfusion.We reviewed records of 80 emergency referral patients who had received blood transfusions at our department between 1 January 2009 and 31 July 2011. The shock indicators for blood transfusion are estimated blood loss, fibrinogen level, hemoglobin concentration, the Japan Society of Obstetrics and Gynecology disseminated intravascular coagulation (JSOG DIC) score and the SI. The strength of the correlation of each shock indicator with the transfusion volume was ranked using Spearman's rank correlation coefficient-ρ and multivariate analysis.Although the SI showed significant positive correlation with blood transfusion volume for red blood cell concentrate (RCC) and fresh frozen plasma (FFP) in patients with dilutional coagulopathy, a stronger correlation was seen with the fibrinogen level and JSOG DIC score. In patients with consumptive coagulopathy, the strongest correlation was seen between RCC transfusion volume and fibrinogen level, and between FFP transfusion volume and JSOG DIC score followed by fibrinogen level. In multivariate analysis, only fibrinogen level was significantly associated with both RCC and FFP massive transfusion.Because MOH has a diverse pathogenesis, various indicators should be evaluated. Among shock indicators, fibrinogen level was the best indicator of the need for blood transfusion following MOH.

The incidence of non-recurrent laryngeal nerve is claimed to be 0.3-0.9%, and this anatomical anomaly is important in thyroidectomy and parathyroidectomy. We encountered a right non-recurrent inferior laryngeal nerve, arising from the cervical trunk of the vagus and passing directly to the larynx in a 65-year-old female patient who underwent total parathyroidectomy. The anomaly of the recurrent nerve is explained by the process of nerve and blood vessel development from the embryologic branchial arches, and since it is known to be associated with anomalous origin of the right subclavian artery from the aortic arch, it is only observed on the right side. In this case, postoperative IV-DSA confirmed the right subclavian artery arising from near the peripheral site compared to the left subclavian artery. Recurrent nerve injury is one of the most important complications of thyroidectomy and parathyroidectomy, and the neural anatomy must be borne in mind especially at the right side.

Aim: Our purpose was to evaluate the effect of internal iliac ligation as a bleeding control during cesarean hysterectomy for placenta accreta. Methods: We retrospectively reviewed the cases of placenta accreta receiving cesarean hysterectomy during the period of 1987–2006 in the Saitama Medical Center. The clinical outcomes of these patients either receiving or not receiving internal iliac artery ligation were compared in terms of bleeding amount, and length of hospitalization. The bleeding amounts in the variants of placenta accreta managed with internal iliac artery ligation were also analyzed to determine whether the different pathological findings would affect blood loss during cesarean hysterectomy. Results: Among 23 cases, the mean blood loss during the operation and the length of hospitalization after the operation, with or without internal iliac artery ligation (IIAL) were not significantly different. There was no significant difference between the mean blood loss and the pathological findings of cases managed with IIAL. Conclusion: In cases of placenta previa accreta, ligation of the internal iliac artery did not significantly contribute to hemostasis during cesarean hysterectomy.

A rare case of breast cancer associated with von Recklinghausen's neurofibromatosis is reported. This case and review of the literature illustrate the problems of clinical diagnosis.A 66-year-old woman who had undergone sigmoidectomy for sigmoid colon cancer two years previously, was admitted to the hospital because of a left breast skin retraction in October, 1998. The patient had von Recklinghausen's disease (neurofibromatosis type 1). The TNM clinical staging was TlcNOMO. Modified radical mastectomy was performed. The histopathological diagnosis of the breast tumor was invasive ductal carcinoma and the skin tumor was neurofibroma. The pTNM pathological staging was pTlcNlaMO.Among patients similar to our case, almost all were staged higher than T2. This may be because multiple neurofibromas obscure breast mass at palpation, leading to delayed detection of the cancer. Systemic and careful exploration is essential for patients with von Recklinghausen's neurofibromatosis to detect breast cancer at an early stage.

New highly sensitive phosphors of LiF-TLD were prepared for use in a low dose measurement. The phosphor was doped with three kinds of impurities which are Cu, Mg, and P, Si or B ion. Sensitivity of these phosphors doped with the third dopant was higher than that of TLD-600 LiF and, especially, the sensitivity of LiF(Mg, Cu, P) phosphor was about 23 times that of TLD-600 LiF, and nearly equal to Mg2SiO4(Tb) and CaSO4(Tm) phosphors. The thermoluminescence response to the dose increases sublinearly in the dose range of 1000 rad and more, but increases linearly in the dose range of 1000 rad and less. Tribothermoluminescence intensity increases with the vibrating period, and the maximum intensity is equivalent to about 300 mrad, but when the irradiated phosphor was heated up to about 270°C or less for evaluating the dose, the dose evaluation was scarcely affected. Application of this new phosphor to environmental radiation dosimeter and medical radiation dosimeter is discussed.

Self-luminous compound emits a light by the excitation of the radiation. As a radiation source for self-luminous compound promethium-147 or tritium is used recently.In Nemoto Tokushu Kagaku Takaido Factory the radioactive luminous compound has been produced and applied to dails and hands of watch and clock from 1960 to the present time.In this paper the working methods and the radiation monitoring such as personal control, air dust monitoring, surface contamination and wastes control in this factory are discribed.

The majority of radioactive self-luminous paint produced in Japan uses 147Pm. The characteristics of the radiation from a 147Pm-activated self-luminous plate which had a luminous area of 12×8 cm2 and radioactivity of 12.5 mCi were examined. Bremsstrahlung was produced from the luminous plate absorbing the 220 keV β-particles of 147Pm. The energy of the bremsstrahlung was analyzed with use of both NaI scintillation and Ge solid state detectors: the spectrum obtained showed a peak at around 50 keV and also a small peak due to γ-rays emitted from the 147Pm at 121 keV. Measurements of the bremsstrahlung made with Lauritsen electroscope, film badges, fluoroglass dosimeters and thermoluminescent dosimeters gave estimated exposure rates of at most only 0.5 and 0.3 mR/hr respectively at distances from the plate of 3 and 7 cm.