VOLUME 75 NUMBER 3,4 August 2013

Current Issue

ISSN 2186-3326
(Online ISSN)
ISSN 0027-7622
(Print ISSN--v.72no.3/4)

Impact Factor(2019)
 0.762

Invited Review Articles

Surgical Management of Infected Thoracic Aneurysms

AKIHIKO USUI
pg(s) 161 - 167

<Abstract> - < PDF >

Infected thoracic aortic aneurysm (ITAA) is a relatively rare disease. The diagnosis of ITAA is generally made comprehensively based on symptoms, laboratory data and CT findings. Several series of blood cultures are mandatory to first detect the infecting organism. ITAA is usually suspected as a result of the CT findings. A short-interval CT re-examination is essential to confirm the correct diagnosis. A CT scan commonly demonstrates a rapid enlargement of the aneurismal lumen and soft tissue mass surrounding the aorta. One of the characteristics of ITAA is the presence of several nodular or saccular aneurysms localized in different aortic portions. Patients with ITAA are associated with high incidences of aneurismal rupture due to the aneurysm’s abrupt growth. Therefore, ITAAs are associated with both high morbidities and mortalities. The major concerns regarding surgical treatment for ITAA are the control of infection, the resection of whole infected tissue, grafting via an aseptic route and the prevention of recrudescent infection. Therefore, effectual antibiotic therapy is mandatory as the first choice of therapy. Ideally surgical intervention is indicated in patients with a controlled infection. It is essential to excise the whole infected aneurysm and to reconstruct in-situ grafting via an aseptic route. However, urgent surgery is often required in patients with an uncontrolled infection because they have an impending aneurismal rupture. In such cases, an extra-anatomical bypass without cardiopulmonary bypass is applicable. Surgical strategies should therefore be determined on a case-by-case basis because these patients present various clinical courses.
Epstein-Barr Virus-Associated Lymphoid Malignancies: The Expanding Spectrum of Hematopoietic Neoplasms

HIROSHI KIMURA, JUN-ICHI KAWADA and YOSHINORI ITO
pg(s) 169 - 179

<Abstract> - < PDF >

Ubiquitous Epstein-Barr virus (EBV) infects not only B cells but also T and NK cells, and is associated with various lymphoid malignancies. The spectrum of EBV-associated lymphoid malignancies is expanding from Burkitt lymphoma to the newly defined systemic EBV+ T cell lymphoproliferative disease of childhood and hydroa vacciniforme-like lymphoma. However, some EBV-associated malignancies are not defined well and overlap other diseases. Furthermore, the role of EBV in tumorigenesis of lymphoid malignancies is still not clear. Further studies are necessary to clarify the pathogenesis of EBV-associated lymphoid malignancies for a better classification of each disease and for the establishment of effective treatment.

Original Papers

Mechanical Advantages of a Truss-Structure-Based Fracture Fixation System – A Novel Fracture Fixation Device “PinFix” –

TETSUYA ARAI, MICHIRO YAMAMOTO, KATSUYUKI IWATSUKI, TADAHIRO NATSUME, TAKAAKI SHINOHARA, MASAHIRO TATEBE, SHIGERU KURIMOTO, HIDEYUKI OTA, SHUICHI KATO and HITOSHI HIRATA
pg(s) 181 - 192

<Abstract> - < PDF >

A small, light, ball-joint device called PinFix, which can instantly convert a simple percutaneous cross pin fracture fixation system into a rigid external fracture fixation system based on truss structure, was developed. The purpose of this study was to compare the mechanical load and breaking strength of this truss-structure-based fixation system to that of the conventionally used external cantilever structure-based fixation system. Three types of mechanical loading tests, axial, bending, and torsion, were performed on an artificial fractured bone treated with either three-dimensional PinFix fixation, two-dimensional PinFix fixation, or conventional external fixation. The three- and two-dimensional PinFix fixations showed significantly more stiffness than conventional fixation on all three loading tests. Finite element analysis was next performed to calculate the stress distribution of the parts in PinFix and in the conventional fixator. The applied stress to the rod and connectors of PinFix was much less than that of the conventional external fixator. These results reflected the physical characteristic of truss structure in which applied load is converted to pure tension or compression forces along the members of the PinFix. In conclusion, PinFix is a simple fracture fixation system that has a truss-structure with a high rigidity.
Therapeutic Strategy for Granulomatous Lobular Mastitis: A Clinicopathological Study of 12 Patients

KAZUHISA AKAHANE, NOBUYUKI TSUNODA, MASAMICHI KATO, SUMIYO NODA, YOSHIE SHIMOYAMA, SATOKO ISHIGAKI, HIROKO SATAKE, SHIGEO NAKAMURA and MASATO NAGINO
pg(s) 193 - 200

<Abstract> - < PDF >

Granulomatous lobular mastitis (GLM) is a rare inflammatory pseudotumor. No therapeutic modality for this disease has been established because of its rarity. The purpose of this study is to evaluate the treatment strategies of GLM. Twelve women who met the histological criteria for GLM were retrospectively studied. The clinical data and the presentation, histopathology, and management of the disease were analyzed by reviewing the patients’ medical records. The diagnosis of GLM was confirmed histologically by core needle biopsy in 9 cases, by vacuum-assisted biopsy in 2 cases, and by excisional biopsy in 1 case. Ten patients received corticosteroid treatment and another two patients were treated with local excision or incision and drainage. The median initial dosage of corticosteroid (Prednisolone) was 30 mg/day (range: 15–60 mg/day), and the dosages were tapered according to improvement. The median duration of corticosteroid treatment was 5 months (range: 1–12 months). The median follow-up period was 22 months (range: 6–104 months), and no patient treated with corticosteroid demonstrated recurrence. However, patients treated with excision or incision and drainage had recurrences. These results suggest that steroid treatment may be the first choice in treatment strategies for GLM.
Knowledge, Attitudes and Barriers of Physicians, Policy Makers/Regulators Regarding Use of Opioids for Cancer Pain Management in Thailand

PORNSUREE SRISAWANG, MD. HARUN-OR-RASHID, TOMOYA HIROSAWA and JUNICHI SAKAMOTO
pg(s) 201 - 212

<Abstract> - < PDF >

The efficacy of opioids for cancer pain has been proven and the World Health Organization (WHO) three-step ladder has been recommended for cancer pain relief. However, undertreatment of cancer pain has still been reported in Thailand. Identification of barriers to opioid use by the physicians and policy makers/regulators, and their level of knowledge and attitudes concerning its use are influential factors for cancer pain management (CPM). This study was performed to assess the knowledge and attitudes physicians and policy makers/regulators have regarding use of opioids for CPM. Barriers to opioid availability were also studied. A self-administered questionnaire was mailed to 300 physicians and distributed to 58 policy makers/regulators from September to October 2011. A total of 219 physicians and 47 policy makers/ regulators completed the questionnaire. Of the physicians 62.1% had inadequate knowledge and 33.8% had negative attitudes. Physicians who did not know the WHO three-step ladder were more likely to have less knowledge than those having used the WHO three-step ladder (OR = 13.0, p < 0.001). Policy makers/regulators also had inadequate knowledge (74.5%) and negative attitudes (66.0%). Policy makers/ regulators who never had CPM training were likely to have more negative attitudes than those having had training within less than one year (OR = 35.0, p = 0.005). Lack of training opportunities and periodic shortages of opioids were the greatest barriers to opioid availability for physicians and policy makers/ regulators, respectively. The strengthening of ongoing educational programs regarding opioid use for CPM, and cooperation among key groups are needed.
Increasing and Decreasing Phases of Ferritin and Hemosiderin Iron Determined by Serum Ferritin Kinetics

HIROSHI SAITO, HISAO HAYASHI, AKIHIRO TOMITA, HARUHIKO OHASHI, HIDEAKI MAEDA and TOMOKI NAOE
pg(s) 213 - 223

<Abstract> - < PDF >

We attempted to clarify the mechanism of the storage iron metabolism. A new program of serum ferritin kinetics was applied for studying the increasing and decreasing phases of ferritin and hemosiderin iron in iron addition and removal in patients with a normal level of iron stores or iron overload. The change of ferritin iron in response to iron addition and removal was rapid in the initial stage, but it was slow later. In contrast, the change of hemosiderin iron was slow in the initial stage, but it became rapid later. These changes of ferritin and hemosiderin iron suggest that the turnover of ferritin iron is preferential to that of hemosiderin iron, and that the initially existed ferritin iron is gradually replaced by the ferritin iron recovered by taking iron from hemosiderin in iron mobilization. The crossing of the increasing curves of ferritin and hemosiderin iron in iron addition indicates a switching of the principal storage iron from ferritin to hemosiderin. The crossing point shifted toward a higher storage iron level in the increase of iron deposition. Iron storing capacity can be increased not only by the transformation of ferritin into hemosiderin, but also by the expansion of cell space as seen by hepatomegaly in hereditary hemochromatosis. The amounts of hemosiderin iron exceeded ferritin iron in all 10 patients with chronic hepatitis C even though they had normal storage iron levels. This suggests it is difficult to store iron in the form of ferritin in chronic hepatitis C.
Barriers to the Use of Basic Health Services among Women in Rural Southern Egypt (Upper Egypt)

CHIFA CHIANG, SHOKRIA ADLY LABEEB, MICHIYO HIGUCHI, ASMAA GHAREEB MOHAMED and ATSUKO AOYAMA
pg(s) 225 - 231

<Abstract> - < PDF >

This cross-sectional study examined potential demand-side barriers to women’s use of basic health services in rural southern Egypt (Upper Egypt). Face-to-face interviews with a structured questionnaire were carried out on 205 currently-married women, inquiring about their use of health facilities: regular antenatal care (ANC) during the last pregnancy and medical treatment services when they suffered from common illness. Questions about their perceptions of barriers to the use of health services were categorized into three primary dimensions: structural, financial, and personal/cultural barriers. Distance and transportation to health facilities (structural barriers) prevented about 30 % of the women from seeing a doctor. Forty-two percent of them felt the difficulty paying for health services (financial barriers). Approximately a quarter of women answered that gaining family permission, allocating time to go to health facilities, or concern about lack of female physicians (personal/cultural barriers) was a big problem for them. After controlling for potential confounding factors, structural barriers showed an inverse association with the use of health services. Financial barriers indicated a strong association (OR=0.18, P<0.001) with the use of curative services (medical treatment), but not with the use of preventive services (regular ANC). Contrary to our expectation, personal/cultural barriers had no statistical significance with women’s use of health services. Although the Egyptian government had successfully extended basic health service delivery networks throughout the country, women in rural Upper Egypt were still facing various barriers to the use of the services, especially structural and financial barriers.
Job Satisfaction of Health-Care Workers at Health Centers in Vientiane Capital and Bolikhamsai Province, Lao PDR

SENBOUNSOU KHAMLUB, MD. HARUN-OR-RASHID, MOHAMMAD ABUL BASHAR SARKER, TOMOYA HIROSAWA, PHAT HAMMAVONG OUTAVONG and JUNICHI SAKAMOTO
pg(s) 233 - 241

<Abstract> - < PDF >

The aim of this study was to assess job satisfaction levels among health-care workers and factors correlated with their overall job satisfaction. This cross-sectional study was conducted from July to September 2011 with 164 health-care workers using self-administered questionnaires on a six-point Likert scale. Categorical variables were reported using frequencies and median (interquartile range), while continuous data were using means and standard deviations. Spearman rho coefficients were computed to correlate the overall job satisfaction for each factor, Kruskal–Wallis and Mann–Whitney U tests were used to evaluate the differences between demographic characteristics on overall job satisfaction. Of the 164 respondents, the majority were females (65.85%). Other dominant variables were married (76.83%), age ≥41 years old (44.51%), certified heath professional level (96.30%), nurse profession (59.10%), and working experience ≤5 years (55.49%). Participants were satisfied with 17 factors, but dissatisfied with salary levels at a mean score of (3.25). The highest satisfaction reported was for the freedom to choose the method of working with a mean score of 4.99, followed by the amount of variety on the job (4.96), amount of responsibility (4.90), and relationships with co-workers (4.90). The correlation coefficient between overall job satisfaction and main factors for job satisfaction-conflict resolution at work, relationships with co-workers, and organizational structure were (0.79), (0.76), and (0.71), respectively. There were statistically significant differences in age group, working experience and position (P<0.05). In conclusion, health-care workers at health centers in Lao PDR were generally satisfied with their job except for their salary. The main factors that correlate with their overall job satisfaction were conflict resolutions at work, relationships with other co-workers, and organizational structure.
Accessibility of Health Care Service in Thasongyang, TAK Province, Thailand

TAWATCHAI YINGTAWEESAK, YOSHITOKU YOSHIDA, PAJJUBAN HEMHONGSA, NOBUYUKI HAMAJIMA and SONNGAN CHAIYAKAE
pg(s) 243 - 250

<Abstract> - < PDF >

Accessibility to health care services in Thailand is generally good, but a few areas in the country are difficult to reach. The purpose of this study was to investigate the accessibility of health care services in rural and remote areas of Thailand. It was conducted in 16 remote villages within a catchment area with a primary health care post. The health care post staff interviewed 394 respondents (197 males and 197 females) using a structured questionnaire. Most respondents utilized primary health care posts (98.5%) and medical institutes. Most of the respondents were Karen, had low incomes, and were illiterate. However, they had health insurance. Most of them took more than 30 minutes to travel from home to their primary health care post (60.9%), and took more time in the rainy season than in the dry season. Moreover, it took more than 2 hours for them to travel to the nearest hospital from their residences (64.5% in the dry season and 84.5% in the rainy season). They also paid more for medical services, travelling and food on the way to the hospital. Not only primary health care posts, but also many other medical institutes provided health care services in the villages. In conclusion, based on the results of this study, primary health care posts in remote areas are necessary to ensure the residents’ healthy lives. Therefore, improvement of the quality and accessibility of primary health care posts should be considered as the top priority.

Short Communication

Congenic Strain Differences of Renal Malformations in ACI/Mna Rats by Introgression of the Chromosomal Region of BUF/Mna Rats Containing PUR1

MUTSUSHI MATSUYAMA, CHIEMI HANEDA and KAZUO KATO
pg(s) 251 - 254

<Abstract> - < PDF >

The ACI rats developed hereditary renal malformations including agenesis and hydronephrosis at moderate penetrance. During construction of a variety of congenic strains based on ACI/Mna (ACI), BUF/Mna (BUF), and WKY/NCrj (WKY) rats, we found that the renal malformations were significantly suppressed by introgression of a segment of chromosome 13 of BUF rats containing Pur1 locus. It is plausible that this region contain a modifier locus influencing development of renal malformations.

Note

Simple and Rapid Assay Method for Simultaneous Quantification of Urinary Nicotine and Cotinine using Micro-Extraction by Packed Sorbent and Gas Chromatography-Mass Spectrometry

MASAE IWAI, TADASHI OGAWA, HIDEKI HATTORI, KEI ZAITSU, AKIRA ISHII, OSAMU SUZUKI and HIROSHI SENO
pg(s) 255 - 261

<Abstract> - < PDF >

A simple and rapid method for determination of nicotine and cotinine levels in urine was developed using samples prepared by micro-extraction by packed sorbent (MEPS) and subjected to gas chromatography- mass spectrometry (GC-MS) analysis. This method provided good reproducibility, as well as good linearity of calibration curves in the range of 1–100 and 50–1000 ng/mL for quality control samples spiked with nicotine and cotinine, respectively. The detection limit of nicotine and cotinine was as low as 0.25 and 20 ng/mL, respectively. An evaporation procedure is not suitable for nicotine determination, thus an advantage of the present MEPS assay method is direct testing with GC-MS without the need for evaporation to a dry solvent. Our findings show that it may be useful for determining nicotine levels in various types of research studies.

Case Reports

Stereotactic Radiotherapy for Spinal Intradural Metastases Developing within or Adjacent to the Previous Irradiation Field – Report of Three Cases –

YOSHIMASA MORI, CHISA HASHIZUME, YUTA SHIBAMOTO, TATSUYA KOBAYASHI, HISATO NAKAZAWA, MASAHIRO HAGIWARA and TAKAHIKO TSUGAWA
pg(s) 263 - 271

<Abstract> - < PDF >

Results of stereotactic radiotherapy (SRT ) for spinal intradural metastases developing inside or adjacent to the previous external-beam radiation therapy (EBRT ) field are shown in 3 cases. One case of spinal intramedullary metastasis and two cases of intradural extramedullary metastases were treated using a Novalis shaped-beam SRT . Case 1 developed an intramedullary metastatic tumor in the C1 spinal medulla inside the previous whole brain EBRT field and another lesion adjacent to the field in the C2 spinal medulla. Case 2 developed intradural extramedullary metastasis around C6-8 inside the previous EBRT field for the primary lung adenocarcinoma. Case 3 developed multiple spinal intradural extramedullary metastatic deposits after surgical resection and following whole brain EBRT for brain metastasis. We delivered 24 to 36 Gy in 5 to 12 fractions. The treated tumors were stable or decreased in size until the patients’ death from the primary cancer (10, 22, and 5 months). Neurological symptoms were stable or improved in all 3 patients. Palliative SRT using Novalis is expected to be safe and effective eve
Hepatic Portal Venous Gas Following Colonoscopy in a Patient with Crohn's Disease

MASAKI UJIHARA, TAKAFUMI ANDO, KAZUHIRO ISHIGURO, OSAMU MAEDA, OSAMU WATANABE, YUTA KA HIRAYAMA, KEIKO MAEDA, KAZUHIRO MORISE, MASANOBU MATSUSHITA, KOHEI FUNASAKA, MASANAO NAKAMURA, RYOJI MIYAHARA, NAOKI OHMIYA and HIDEMI GOTO
pg(s) 273 - 278

<Abstract> - < PDF >

Hepatic portal venous gas is a rare condition that occurs when intraluminal gas or gas produced by intestinal bacteria enters the portal venous circulation. It has recently been recognized as a rare complication of colon procedures by endoscopy or barium enema. Given the frequency of these procedures in patients with inflammatory bowel disease, hepatic portal venous gas may occur more frequently in these patients than previously reported. Here, we report a woman with Crohn’s disease who developed hepatic portal venous gas following colonoscopy who was treated with conservative therapy.
Surgical Treatment for Kyphoscoliosis in Cohen Syndrome

SHIRO IMAGAMA, TAICHI TSUJI, TETSUYA OHARA, YOSHITO KATAYAMA, MANABU GOTO, NAOKI ISHIGURO and NORIAKI KAWAKAMI
pg(s) 279 - 286

<Abstract> - < PDF >

Cohen syndrome is a very rare disease. Complication by spinal deformity has been reported, but management and surgery for spinal deformity in Cohen syndrome has not been previously described. The objective of this study was to examine the outcome of surgical treatment for kyphoscoliosis of Cohen syndrome with a literature review. The patient was a 14-year-old male with the characteristics of Cohen syndrome: truncal obesity, mental retardation, arachnodactyly, microcephalia, and a facial malformation. Scoliosis was conservatively treated with a brace at 13 years of age, but the spinal deformity rapidly progressed within a year. Plain radiographs before surgery showed scoliosis of 47° (T5-T11) and 79° (T11-L3), and kyphosis of 86° (T7-L1). One-stage anteroposterior corrective fusion of T4-L3 was scheduled after 2-week Halo traction. Postoperative respiratory management was carefully performed because of Cohen syndrome-associated facial malformation, obesity, and reduced muscle tonus. Respiration was managed with intubation until the following day and no respiratory problems occurred. After surgery, thoracolumbar scoliosis was 28° (correction rate: 65%). Kyphosis was markedly improved from 86° to 20°, achieving a favorable balance of the trunk. The outcome is favorable at 6.5 years after surgery. In conclusion, Cohen syndrome is often complicated by spinal deformity, particularly kyphosis, that is likely to progress even in adulthood. In our patient, spinal deformity progressed within a short period, even with brace treatment. Surgery should be required before progression to the severe spinal deformity with careful attention to general anesthesia.
Complete Bone Remodeling after Calcar Reconstruction with Metal Wire Mesh and Impaction Bone Grafting: A Case Report

TOSHIKI IWASE, ATSUSHI KOUYAMA and NAOYA MATSUSHITA
pg(s) 287 - 293

<Abstract> - < PDF >

We report the histological findings of a reconstructed calcar region four years after femoral impaction bone grafting using metal wire mesh for a case with massive defect of the proximal part of the femur. Thin cortical bone was formed just beneath the metal wire mesh and viable trabecular bone containing a small amount of granulation tissue was observed even at the bone-cement interface. Almost no necrotic bone was seen throughout the remodeled bony layer. Histological findings of the present case suggest that calcar reconstruction with impaction bone grafting using a metal wire mesh is a biologically and mechanically favorable reconstruction method for femoral revision cases combined with proximal medial segmental cortex defect.