VOLUME 83 NUMBER 3 August 2021

Current Issue

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

Impact Factor(2020)
 1.131

ORIGINAL PAPERS

Assessment of medical malpractice cost at a Japanese national university hospital

Tsuyoshi Hoshi, Yoshimasa Nagao, Naoko Sawai, Mineko Terai, Tomomi Umemura, Tatsuya Fukami, Toshihide Ito and Fumimasa Kitano
pg(s) 397 - 405

<Abstract> - < PDF >

Medical safety management has an economic dimension that has received little attention. Medical expenses associated with medical malpractice in Japan should be investigated in relation to patient safety measures and their consequences. We analyzed medical accidents that occurred within the past seven years at a university hospital. We determined that 197 accidents involved negligence by the hospital in the years from 2011 to 2017, for which the institution bore the costs of the resulting treatment; those expenses totaled JPY 30.547 million. Most incidents occurred in the hospital ward (82, 41.6%); those in the operating room were the most expensive (JPY 19.493 million, 63.8%). The greatest number of cases involved drug administration (63, 32.0%). Materials inadvertently left in surgical sites (“remnants”) cost the hospital the most per incident (JPY 9.767 million, 32.0%). Of these, medical treatment costs for remnants associated with vascular invasion were the highest. Although the total number of malpractice incidents increased over time, the annual cost to the hospital decreased, especially in cases in which costs exceeded JPY 100,000, and those associated with the operating room. Our results suggested that adverse events must be addressed to foster patient safety, decrease medical expenses, and improve hospital administrative capacity.
The prevalence of Factor V Leiden (Arg506Gln) mutation in King Khalid University Hospital patients, 2017–2019

Maram Al-Otaiby, Rahaf Althnayan, Alanoud Binmethem, Reema Bader AlEnezy, Munira Abdulrahman Alhadlg, Arjuwana Alaqeel, Sara H AlQahtani, Noman Ghufran, Abdulaziz A. Alotaibi, Nada Alayed and Imran Ali Khan
pg(s) 407 - 417

<Abstract> - < PDF >

Arg506Gln mutation is responsible for one of the procoagulant factors and most common inherited thrombophilia in the Factor V Leiden (FVL) family. The replacement of the missense mutation for Arg506Gln / R506Q is at 1691st position from Guanine to Adenine with the modification of the amino acid from arginine to glutamine. The aim of this study was to investigate the current prevalence of the G1691A mutation in the FVL gene in the capital city’s King Khalid University Hospitals (KKUH). Since 2017–2019 we have recruited 482 patients in these cross-sectional studies to test the G1691A mutation in KKUH’s FVL gene. DNA was extracted using 2mL of the EDTA blood and genotyping was performed with polymerase chain reaction and the data was analyzed using Sanger sequencing. In this study, 4.4% of the G1691A mutation was found to be positive (combined heterozygous-GA and homozygous-AA variants) and 95.6% of them with negative, i.e., homozygous normal-GG genotypes. Our study concludes that with the advances in genetic testing and their recent availability, early mutation detection could approve the genotype risks for many patients and this mutation is not as rare as previously believed in the Saudi region as our study has established with a 4.4 percent prevalence.
Feasibility of patency capsule and colon capsule endoscopy in patients with suspected gastrointestinal stenosis: a prospective study

Hiroyuki Otsuka, Masanao Nakamura, Takeshi Yamamura, Keiko Maeda, Tsunaki Sawada, Yasuyuki Mizutani, Eri Ishikawa, Takuya Ishikawa, Naomi Kakushima, Kazuhiro Furukawa, Eizaburo Ohno, Hiroki Kawashima, Takashi Honda, Masatoshi Ishigami and Mitsuhiro Fujishiro
pg(s) 419 - 430

<Abstract> - < PDF >

Patency capsule (PC) can evaluate the patency of gastrointestinal (GI) tract. We hypothesized preceding patient selection using PC would improve the successful rate of colon capsule endoscopy (CCE). Therefore, a prospective single-arm study using PC followed by CCE was conducted with a control group of CCE alone. Patients with suspected or known GI stenosis scheduled for CCE were enrolled. CCE was performed only when the PC was excreted out of the body within 33 hours of ingestion. Primary endpoint was the rate of observation of the entire GI tract within the duration of examination. The secondary endpoints were complications and CCE findings. Twenty-three patients (17 men) were enrolled. The mean age was 50.5±19.8 years. Suspected stenotic sites were 8, 5, and 10 in the small, large, and small and large bowel, respectively. Sixteen, 12, and 10 patients had abdominal pain, active inflammatory bowel disease, and history of surgery for suspected stenosis, respectively. Patency of GI tract was confirmed in 96% (22/23) of the patients by administered PC. Of the 22 patients who underwent CCE, the entire GI tract was observed in 86% (19/22). No complications were observed. The median transit times in the small bowel and colon were 99 (21–682) and 160 (5–328) minutes, respectively. CCE findings revealed ulcers, erosions, and diverticula in 5, 9, and 4 patients, respectively. In conclusion, CCE with PC might be a safer and useful modality to observe the large colon for patients with suspected GI stenosis.
Initiation and long-term use of tolvaptan for patients with worsening heart failure through hospital and clinic cooperation

Yusuke Uemura, Rei Shibata, Shinji Ishikawa, Kenji Takemoto, Toyoaki Murohara and Masato Watarai
pg(s) 431 - 441

<Abstract> - < PDF >

Worsening heart failure (WHF) has a negative impact on the prognosis of patients with heart failure. Adequate management of non-hospitalized episodes of WHF, regarded as “outpatient WHF”, may reduce the frequency of emergent/urgent hospitalization for acute heart failure; thus, the patients’ cardiac parameters return to their clinical baseline. This study aimed to investigate the efficacy of tolvaptan initiation during planned hospitalization of patients with “outpatient WHF” through hospital and clinic cooperation. The data from 28 patients with outpatient WHF referred by general practitioners to hospital were assessed. Tolvaptan administration was initiated during planned hospitalization and continued in the clinics. Patients were followed-up for 12 months. None of the patients required withdrawal of tolvaptan due to adverse effects. During the follow-up period, the loop diuretic dosage significantly decreased. There were signifi- cant favorable changes in the levels of serum creatinine, estimated glomerular filtration rate, natriuretic peptide and body weight. Kaplan-Meier survival analysis revealed that the cardiac death- and HF-related hospitalization-free survival rates were significantly higher among the patients who were administered tolvaptan for the outpatient WHF than the propensity score-matched patients who were administered tolvaptan for acute heart failure requiring emergent/urgent hospitalization. In conclusion, tolvaptan may be safe and effective for the long-term management of outpatient WHF through hospital and clinic cooperation.
Changes in barriers to implementing early mobilization in the intensive care unit: a single center retrospective cohort study

Shinichi Watanabe, Keibun Liu, Yasunari Morita, Takahiro Kanaya, Yuji Naito, Ritsuro Arakawa, Shuichi Suzuki, Hajime Katsukawa, Alan Kawarai Lefor, Yoshinori Hasegawa and Toru Kotani
pg(s) 443 - 464

<Abstract> - < PDF >

This study was undertaken to investigate the rate of mobilization, defined as a rehabilitation level of sitting on the edge of a bed or higher, and its association with changes in barriers in the intensive care unit (ICU). Consecutive patients from January 2016 to March 2019 admitted to the ICU, 18 years old or older, who did not meet exclusion criteria, were eligible. The primary outcome was the rate of mobilization. Barriers, their changes on a daily basis, and clinical outcomes, such as walking independence at hospital discharge, were also investigated. The association between the barriers and mobilization, and walking independence were analyzed by multivariate logistic regression analysis. During the study period, 177 patients were enrolled. Mobilization was achieved by 116 patients (66%) by the 7th ICU day. The barrier to mobilization was circulatory status on days 1 and 2, consciousness level on days 3 to 5, and medical staff factors on days 6 and 7. Multivariate analysis showed that consciousness level (OR: 0.38, p=0.01), and medical staff factors (OR: 0.49, p=0.01) were significantly associated with mobilization. By hospital discharge 125 patients (71%) could walk independently. Consciousness level was associated (OR: 0.52, p=0.04) with walking independence. In this study, over half of patients could achieve mobilization within the first 7 days. Barriers to mobilization in the ICU change over time. Consciousness level is significantly associated with both mobilization and independent walking at discharge.
Treatment with adipose-derived regenerative cells enhances ischemia-induced angiogenesis via exosomal microRNA delivery in mice

Tomohiro Kato, Katsuhiro Kato, Yuuki Shimizu, Mikito Takefuji and Toyoaki Murohara
pg(s) 465 - 476

<Abstract> - < PDF >

Adipose-derived regenerative cells (ADRCs), mesenchymal stem/progenitor cells from subcutaneous adipose tissue, have been shown to stimulate angiogenesis in hind limb ischemia, an effect attributed to paracrine action on endothelial cells (ECs) in mice. Despite promising therapeutic effects, the relevant molecules promoting neovascularization in this setting have not been fully elucidated. Extracellular vesicles, crucial mediators of intercellular communication, are recognized as a new therapeutic modal- ity for regenerative medicine. Here, we found that GW4869, an exosome biogenesis inhibitor targeting neutral sphingomyelinase, impaired ADRCs-mediated angiogenesis and improvement of blood perfusion in a murine hind limb ischemia model. In addition, while the supernatant of ADRCs induced murine EC migration, this effect was attenuated by pre-treatment with GW4869. RNA analysis revealed that treatment of ADRCs with GW4869 reduced the expression of microRNA-21 (miR-21), miR-27b, miR-322, and let-7i in ADRCs-derived exosomes. Furthermore, the exosomes derived from GW4869-treated ADRCs induced the expression of the miR-21 targets Smad7 and Pten, and the miR-322 target Cul2, in ECs. These findings suggest that several miRNAs in ADRCs-derived exosomes contribute to angiogenesis and improvement of blood perfusion in a murine hind limb ischemia model.
Development of a questionnaire to measure the moral sensitivity of nursing students

Miyoshi Takizawa, Katsumasa Ota and Jukai Maeda
pg(s) 477 - 493

<Abstract> - < PDF >

Moral sensitivity is important for both, qualified nurses and nursing students. Currently, however, the instruments to measure moral sensitivity exist for qualified nurses only. The objective of this study is to develop a valid and reliable instrument to assess moral sensitivity of nursing students and to examine the development and differentiation of this sensitivity by school year, clinical training, and other educational variables. The study comprised semi-structured focus group interviews and a survey using a self-administered questionnaire. The questionnaire was developed using data obtained from the focus groups and distributed to 1,995 nursing students in three Bachelor of Science in Nursing programs (BScN) and eight Nursing Diploma programs. Completed questionnaires were obtained from 473 nursing students. An exploratory factor analysis indicated that 11 items and 3 factors were extracted: “Moral Strength,” “Sense of Moral Burden,” and “Moral Responsibility.” The factors each demonstrated acceptable content- and criterion-related validity with the Resilience Measurement Scale for University Students. This three-factor structure was consistent with that of the Japanese version of the revised Moral Sensitivity Questionnaire. The mean score of each item ranged from 2.75 to 4.74 (SD = 1.04 – 1.34). A comparison of inter-year scores showed that third-year students had significantly higher Moral Strength scores in both the BScN and Nursing Diploma programs. The 11-item questionnaire developed for this study was consistent with a three-factor structure of registered nurses’ moral sensitivity and successfully identified differences in moral sensitivity among nursing students. Using this type of questionnaire will allow nursing programs to improve the moral sensitivity of nursing students by allowing lecturers to develop tailored moral sensitivity programs.
Screening of novel Midkine binding protein by BioID2-based proximity labeling

Yosuke Komata, Shoma Tsubota, Kazuma Sakamoto, Shinya Ikematsu and Kenji Kadomatsu
pg(s) 495 - 508

<Abstract> - < PDF >

Midkine (MK), a heparin-binding growth factor, is associated with the poor prognosis of the pediatric tumor, neuroblastoma. MK would be a druggable target as many studies showed inhibition of its function in various cancers suppressed tumor developments. To establish the therapy targeting MK, identification of its binding partners, and elucidation of its intracellular signaling are needed. It was reported that exogenous MK induced phosphorylation of ribosomal protein S6 (RPS6) downstream of mTOR signaling. Using RPS6 phosphorylation as a marker of MK response, we searched for MK reactive cell lines. We found that MK cell lines expressing less MK tended to respond better to MK. Next, using an MK reactive neuroblastoma cell line, MK-knocked down SH-SY5Y cells, we employed a proximity-dependent biotin identification method, which was invented to evaluate protein-protein interactions by biotinylation. We confirmed that secreted MK fused to the biotin ligase BioID2 (MK-BioID2) was able to biotinylate proteins from the cells. Biotinylated proteins were identified by liquid chromatography-mass spectrometry analyses. Twenty five proteins were found to be overlapped after three independent experiments, among which insulin-like growth binding protein 2 (IGFBP2) was further analyzed. IGFBP2 was indeed detected with immunoblotting after streptavidin pull down of MK-BioID2 labeled cell extract of MK-knocked down SH-SY5Y cells. Our study suggests that the BioID2 method is useful to identify binding partners of growth factors.
Editors' Choice
Effects of high-flow nasal cannula oxygen therapy on oral intake of do-not-intubate patients with respiratory diseases

Hirofumi Shibata, Naoya Takeda, Yoshihiro Suzuki, Toshiyuki Katoh, Norio Yoshida, Yoshinori Hasegawa, Etsuro Yamaguchi, Naozumi Hashimoto and Satoru Ito
pg(s) 509 - 522

<Abstract> - < PDF >

High-flow nasal cannula (HFNC) oxygen therapy is used widely for hypoxemic respiratory failure. However, it is unknown whether the use of HFNC is compatible with retaining the ability to eat and drink of patients with end-stage respiratory diseases as a part of palliative care. A retrospective study was conducted on subjects with hypoxic respiratory failure due to end-stage respiratory diseases, including interstitial pneumonia and malignant respiratory diseases, who were treated with HFNC or reservoir mask oxygen therapy and died with do-not-resuscitate (DNR) and do-not-intubate (DNI) status. We compared the duration of eating solids and drinking liquids and clinical variables in the HFNC group with those in the reservoir mask group. The data from a total 43 subjects including 20 with HFNC and 23 with a reservoir mask were analyzed. Fitting HFNC to subjects temporarily improved oxygenation. Durations of survival, eating solids, and drinking liquids in the HFNC group were significantly longer than those in the reservoir mask group. No significant adverse effects were observed in either group. In conclusion, the use of HFNC led to prolonged survival while preserving the ability of oral intake in patients with DNR and DNI status.
Editors' Choice
Indocyanine green emission timing of the recipient artery in revascularization surgery for moyamoya disease

Fumiaki Kanamori, Yoshio Araki, Kinya Yokoyama, Kenji Uda, Takashi Mamiya, Masahiro Nishihori, Takashi Izumi, Sho Okamoto and Atsushi Natsume
pg(s) 523 - 534

<Abstract> - < PDF >

In superficial temporal artery to middle cerebral artery anastomosis with indirect revascularization for patients with moyamoya disease, the optimal method for selecting the most appropriate cortical artery for the recipient in anastomosis has not been established. We investigated the relationship between the fluo- rescence emission timing of the recipient artery in the preanastomosis indocyanine green videoangiography and operative outcomes. This retrospective study included 51 surgical revascularization procedures for 39 moyamoya disease patients. The enrolled surgical procedures were classified into three groups based on the fluorescence emission timing of the recipient artery in preanastomosis indocyanine green videoangiography: the EARLIEST, the INTERMEDIATE, and the LATEST. Clinical characteristics and operative outcomes were also collected. The occurrence of white thrombus at the anastomosis site and symptomatic hyperperfu- sion showed significant differences between the groups classified by the fluorescence emission timing of the recipient artery in preanastomosis indocyanine green videoangiography (white thrombus, p = 0.001; symptomatic hyperperfusion, p = 0.026). The development of white thrombi was significantly higher in the LATEST group, and all symptomatic hyperperfusion was observed in the EARLIEST group. These results indicated that the LATEST group had a significantly higher risk for developing white thrombus, and the EARLIEST group was prone to occur symptomatic hyperperfusion. Selecting the recipient artery based on evaluating the fluorescence emission timing in preanastomosis indocyanine green videoangiography may be useful in reducing perioperative complications.
St8sia1-deficiency in mice alters tumor environments of gliomas, leading to reduced disease severity

Pu Zhang, Yuki Ohkawa, Satoko Yamamoto, Hiroyuki Momota, Akira Kato, Kei Kaneko, Atsushi Natsume, Yesmin Farhana, Yuhsuke Ohmi, Tetsuya Okajima, Robiul H. Bhuiyan, Toshihiko Wakabayashi, Keiko Furukawa and Koichi Furukawa
pg(s) 535 - 549

<Abstract> - < PDF >

Ganglioside GD3/GD2 are over-expressed in various neuroectoderm-derived tumors. Previous studies indicated that GD3 is involved in the enhancement of cancer properties such as rapid growth and increased invasiveness. However, little is known about the functions of GD3/GD2 in glioma cells and glioma micro- environments. To clarify the functions of GD3/GD2 in gliomas, we used a mouse glioma model based on the RCAS/Gtv-a system. At first, we compared the gliomas size between wild-type (WT) and GD3 synthase (GD3S) knockout (KO) mice, showing a less malignant histology and slower tumor growth in GD3S-KO mice than in WT mice. Immunohistochemistry of glioma sections from WT and GD3S-KO mice revealed that reactive microglia/macrophages showed different localization patterns between the two genetic types of mice. CD68+ cells were more frequently stained inside glioma tissues of GD3S-KO mice, while they were stained mainly around glioma tissues in WT mice. The number of CD68+ cells markedly increased in tumor tissues of GD3S-KO mice at 2 weeks after injection of transfectant DF-1 cells. Furthermore, CD68+ cells in GD3S(-/-) glioma tissues expressed higher levels of inducible nitric oxide synthase. We observed higher expression levels of pro-inflammatory cytokine genes in primary-cultured glioma cells of WT mice than in GD3S-KO mice. DNA microarray data also revealed differential expression levels of various cytokines and chemokines in glioma tissues between WT and GD3S-KO mice. These results suggest that expression of GD3S allows glioma cells to promote polarization of microglia/macrophages towards M2-like phenotypes by modulating the expression levels of chemokines and cytokines.
Associations between social support and access to healthcare among Filipino women living in Japan

Asako Yoshino, Reginald B Salonga and Michiyo Higuchi
pg(s) 551 - 565

<Abstract> - < PDF >

This study investigated associations between social support and access to healthcare among Filipino women living in Aichi Prefecture, Japan. A cross-sectional design was used. Self-administered questionnaires were distributed to Filipino women and collected 342 valid responses. Each participant was asked about her access to healthcare for her own health and for her youngest child’s health, and social support, as well as her socio-demographic characteristics. Of these respondents, 114 women (33%) did not have a usual source of care for themselves. Participants in our study had higher Medical Outcome Study Social Support Survey scores than people living in other Southeast Asian countries. However, distribution of the score showed that there were outliers with low scores which were very different from the others. Women with the highest emotional/informational and tangible support score showed better access to healthcare (adjusted odds ratio=0.22, 95% confidence interval 0.10–0.50, and adjusted odds ratio=0.38, 95% confidence interval 0.17–0.85 respectively). Women with a Japanese husband also showed lower odds of no usual source of care (adjusted odds ratio=0.44, 95% confidence interval 0.20–0.95). On the other hand, there was no factors significantly associated with access to healthcare for their youngest child including social support. Emotional/informational and tangible support were crucial factors associated with access to healthcare among Filipino women in Aichi Prefecture.
A simple method for the determination of glyphosate, glufosinate and their metabolites in biological specimen by liquid chromatography/tandem mass spectrometry: an application for forensic toxicology

Tomomi Ohara, Takashi Yoshimoto, Yujin Natori and Akira Ishii
pg(s) 567 - 587

<Abstract> - < PDF >

Glyphosate (GLYP) and glufosinate (GLUF) are phosphorus-containing amino acid type herbicides that are used worldwide. With their rising consumptions, fatal intoxication cases due to these herbicides, whether accidental or intentional, cannot be ignored. Both compounds are difficult to detect, and their pretreatment for instrumental analysis are complicated and time-consuming. Our aim was to develop a simple and rapid quantification method for the two herbicides and their metabolites with liquid chromatography/tandem mass spectrometry (LC/MS/MS). We also compared 2-amino-4-phosphonobutyric acid and DL-2-amino- 5-phosphonopentanoic acid as alternative internal standards (IS) to GLYP13C215N. Herbicide-containing specimens were highly diluted, evaporated to dryness, and derivatized with acetate/acetic anhydride and trimethyl orthoacetate for 30 min. at 120°C. Our optimized LC conditions successfully separated the target analytes, with acceptable linearities (R2>0.98) and matrix effects (65%–140%). Accuracy and precision ranged from 80.2 % to 111 %, and from 1.3 % to 13 % at the higher concentration, respectively. The concentration of the herbicides and their metabolites were investigated in a postmortem case of suspected herbicide poisoning cases, in which we detected GLYP and its metabolites. Using one of the three ISs, the GLYP concentrations ranged from 3.1 to 3.5 mg/mL, and 3.3 to 4.5 mg/mL in plasma and urine, respectively; GLYP metabolite concentrations in plasma and urine were 18 to 20 μg/mL and 44 to 54 μg/ mL. We thus succeeded in developing a rapid method without extraction for measuring GLYP and GLUF along with their metabolites, and demonstrated its practical applicability.
Dietary salt intake and its correlates among adults in a slum area in Dhaka, Bangladesh: a cross-sectional study

Fahmida Afroz Khan, Md. Khalequzzaman, Md. Hasan, Sohel Reza Choudhury, Chifa Chiang, Atsuko Aoyama, and Syed Shariful Islam
pg(s) 589 - 599

<Abstract> - < PDF >

High dietary salt intake increases the risk of noncommunicable diseases (NCDs). NCDs are increasing among the urban poor in Bangladesh, but the data of their dietary salt intake are yet scarce. This study aimed to explore the amount of dietary salt intake among adults in an urban slum area in Dhaka, Ban- gladesh. A cross-sectional community-based study was conducted. We randomly selected 100 residents (39 men and 61 women) aged 20–59 years without history of NCDs. A modified World Health Organization standard instrument was used for behavioral risk factor assessment and physical measurements. Dietary salt intake was estimated from the measurement of sodium (Na) excretion in spot urine samples.The estimated mean dietary salt intake was 7.8 ± 2.5 g/day, and the mean Na/potassium (K) ratio in urine was 4.9 ± 3.4. More than half (54%) of them always took additional salt in their meals, but only 6% of them consumed 5 or more servings of fruits and vegetables per day. A quarter of them perceived salt reduction not at all important. Increased mean salt intakes were marginally associated with lower waist circumference and lower waist-hip ratio. Dietary salt intake among urban slum residents was higher than the recommended level of 5 g/day; however, its association with NCD risk factors was not significant. Further studies are required to identify the urban poor specific factors.

SHORT COMMUNICATION

Is dislocation following total hip arthroplasty caused while suffering from delirium?

Takaomi Kobayashi, Tadatsugu Morimoto, Motoki Sonohata and Masaaki Mawatari
pg(s) 601 - 607

<Abstract> - < PDF >

The mechanisms and pathologies of dislocation following total hip arthroplasty (THA) in patients with postoperative delirium remain unclear. Therefore, we conducted a retrospective study of 738 patients (738 hips) who underwent unilateral THA for the treatment of hip osteoarthritis. The patients were divided into two groups; with (n = 8) and without postoperative delirium (n = 730). Patients with postoperative delirium had a higher rate of dislocation following THA due to falling from a standing position on hospitalization than those without postoperative delirium (1/8 [12.5%] patients vs. 0/730 [0%] patients, p = 0.011). A power of 80.2% was provided for the rate of dislocation following THA due to falling from a standing position on hospitalization. Postoperative delirium after THA could be a cause of falling from standing position, leading to dislocation following THA during hospitalization. Therefore, postoperative delirium and its associated falls and injuries during hospitalization should be avoided by the elimination of patient’s preventable conditions and adjustment of the hospital environments, particularly in patients with the risk factors for postoperative delirium (eg, older age, general anesthesia, medications given [intraoperative opioids and ketamine and postoperative ketamine and benzodiazepines], higher comorbidity burden [diabetes mellitus, renal diseases, depression, anxiety, and psychoses], and blood transfusions). Further investigations with a larger cohort are needed to clarify this issue.

NOTE

Certified registered nurse anesthetist and anesthesiologist assistant education programs in the United States

Takahiro Tamura, Tetsuro Sakai, Richard Henker and John M. O’Donnell
pg(s) 609 - 626

<Abstract> - < PDF >

In Japan, a relative shortage of practicing anesthesiologists continues to be a national issue. To address this issue, some Japanese medical institutions have started developing curriculums to train non-physician perioperative anesthesia personnel, including nurse practitioners and perianesthesia nurses. We urgently need to establish a national standard for the education programs that train these extended non-physician anesthesia care providers. A certified registered nurse anesthetist educational program at a large academic medical center in the United States is described in detail as a reference. Highly systematic educational programs using simulation, didactics, and full clinical subspecialty rotations are ideal if not easily achievable in many current training institutions in Japan. Anesthesia assistant education programs in the United States can be used as an additional reference to create a national educational program in Japan.

CASE REPORTS

Surgical strategy for symptomatic pineal cyst: is endoscopit third ventriculostomy necessary in addition to cyst fenestration?

Kelechi Ndukuba, Toshihiro Ogiwara, Takuya Nakamura, Keisuke Kamiya, Yoshiki Hanaoka, Tetsuyoshi Horiuchi, Samuel Ohaegbulam and Kazuhiro Hongo
pg(s) 627 - 633

<Abstract> - < PDF >

Symptomatic large pineal cyst (PC) remains a rare entity. The stable natural course of asymptomatic PCs is well established. However, large cysts may cause pressure-related symptoms necessitating surgical intervention. The surgical strategy for symptomatic PCs is still controversial. Regardless of the approach, total resection of the cyst is not mandatory. The endoscopic approach allows cyst fenestration in patients with associated obstructive hydrocephalus. On the other hand, the necessity of simultaneous endoscopic third ventriculostomy (ETV) is still debatable. Here, we report a case of a woman who underwent endoscopic cyst fenestration, biopsy, and third ventriculostomy for a large symptomatic PC and discuss the surgical strategy. A 30-year-old woman presented with headache and diplopia, MRI showed a large PC and ac- companying obstructive hydrocephalus. Simultaneous cyst fenestration, biopsy and ETV with endoscopy was successfully completed. She had an uneventful recovery period with immediate relief of symptoms. Although, the aqueduct was communicated due to cyst shrinkage, the patency of the third ventricular stoma was demonstrated in long-term follow-up scans. Based on clinical course of the present case, we concluded that ETV in addition to cyst fenestration should be considered necessary and beneficial in cases of large symptomatic PC with associated hydrocephalus whenever an endoscopic intraventricular approach is considered.
An intraoperative small distractor for non-open reduction and intramedullary fixation of pediatric displaced diaphyseal forearm fractures

Shinsuke Takeda, So Mitsuya, Katsuyuki Iwatsuki, Miku Mitsuya, Ken-ichi Yamauchi and Hitoshi Hirata
pg(s) 635 - 640

<Abstract> - < PDF >

This report describes technical tools for the treatment of pediatric displaced and unstable diaphyseal forearm fractures, which are difficult to treat by manual closed reduction. During intramedullary fixation with Kirchner wires, we propose our original small distractor as an intraoperative distraction apparatus without open reduction. This apparatus is made using parts of the Ilizarov external fixator. Apart from general external fixation devices, our apparatus is adequate for the effective shortening and lateral disloca- tion of the fracture site. This adequacy is not only because of the three-dimensional control by ball joints but also owing to the gradual adjustment structure of the Quick adjust strut (Orthofix, Verona, Italy), which allows tight and fine stretching, thus making the distractor an effective reduction tool. Our findings show the feasibility and usefulness of our reduction technique and small distractor. Our small distractor is a useful intraoperative distraction apparatus without open reduction for pediatric displaced and unstable diaphyseal forearm fractures that cannot be treated by manual closed reduction. In this report, we describe the distractor, the closed reduction technique, and the clinical results of four representative cases.
A case of sporadic late-onset nemaline myopathy with monoclonal gammopathy of undetermined significance: long-term observation of neurological symptoms after autologous stem-cell transplantation

Takashi Ando, Takahiko Sato, Shingo Kurahashi, Yuka Kawaguchi, Yusuke Kagaya, Yukiyasu Ozawa, Satoko Hirano, Yoji Goto, Kazuo Mano, Satoshi Yokoi, Tomohiko Nakamura, Ayuka Murakami, Seiya Noda, Seigo Kimura, Jun Sone, Satoshi Kuru, Gen Sobue and Masahisa Katsuno
pg(s) 641 - 647

<Abstract> - < PDF >

A 47-year-old woman presented with progressive limb weakness. A neurological examination revealed proximal dominant symmetrical muscle weakness in her limbs, and electromyography revealed complex repetitive discharges and short motor unit potentials with positive sharp waves in the biceps. We observed early recruitment in the quadriceps, and laboratory tests revealed normal creatine kinase. Serum protein electrophoresis showed monoclonal IgG-lambda, but the bone marrow aspiration specimen was normal. A muscle biopsy revealed nemaline rod accumulations in the muscle fibers; based on the results, we diagnosed the patient with sporadic late-onset nemaline myopathy with monoclonal gammopathy of undetermined significance (SLONM-MGUS). We administered repeated intravenous immunoglobulin, but her limb weakness continued, and she developed a restrictive ventilatory defect. The patient received melphalan, followed by autologous stem-cell transplantation (ASCT). Her upper extremity strength and respiratory capability improved within one year after ASCT; however, it was not until six years after ASCT that her atrophied lower extremities strengthened. A discrepancy in the timeline of treatment response between the upper or respiratory muscles and the atrophied lower limb was characteristic in the patient, suggesting that the efficacy of ASCT on SLONM-MGUS should be evaluated in the long term, especially in severely atrophied muscles. In addition, this case showed that ASCT for SLOMN-MGUS is an effective treatment option in Asian populations.
Two cases of IgG4-related disease accompanied by many cerebral microbleeds and a review of the literature: can IgG4-related disease cause cerebral small vessel vasculitis/vasculopathy?

Katsuyuki Ukai
pg(s) 649 - 654

<Abstract> - < PDF >

IgG4-related disease (IgG4-RD) is a condition of unknown cause, which involves marked tissue infiltration by IgG4-positive plasma cells into various organs throughout the body. Histopathological examinations based on biopsy examinations are essential for obtaining a definitive clinical diagnosis of IgG4-RD. However, there are only a limited number of organs from which biopsy samples can be easily obtained. Furthermore, it is impossible even for recently developed imaging techniques to directly detect abnormalities affecting small organs, such as the cerebral small vessel system. Due to these limitations, the clinical diagnosis of so-called “IgG4-related cerebral small vessel vasculitis/vasculopathy” is very difficult. In this report, two cases of IgG4-RD involving elderly patients are presented, together with their cranial magnetic resonance imaging features, especially those seen on T2* imaging. Both patients exhibited many cerebral microbleeds (CMB) on T2* imaging. I consider that it is possible to indirectly detect abnormali- ties of the small cerebral vessels by searching for CMB because they are caused by the failure of small cerebral vessels. Of course, the fact that many CMB were seen in both cases might be considered to be a coincidence. However, the chances of this are low because a rapid increase in the number of CMB, as was seen in case 1, and the occurrence of so many CMB, as was seen in case 2, are rare. Based on my clinical experiences and the detailed findings of the IgG4-RD cases described in this report, I present the hypothesis that “IgG4-related cerebral small vessel vasculitis/vasculopathy” exists.
Double common bile duct associated with pancreaticobiliary maljunction

Kenta Yamada, Takuya Ishikawa, Eizaburo Ohno, Tadashi Iida, Hirotaka Suzuki, Kota Uetsuki, Jun Yashika, Masakatsu Yoshikawa, Hideki Takami, Yoshikuni Inokawa, Hiroo Uchida, Hiroki Kawashima and Mitsuhiro Fujishiro
pg(s) 655 - 661

<Abstract> - < PDF >

A 45-year-old female was admitted to the hospital with a diagnosis of acute pancreatitis. A computed tomography scan showed two extrahepatic bile ducts. Magnetic resonance cholangiopancreatography sug- gested a stone in one of the bile ducts. Endoscopic retrograde cholangiopancreatography revealed two extrahepatic bile ducts joining at the hilum of the liver accompanied with pancreaticobiliary maljunction. Sphincterotomy was performed and a protein plug was drained from the bile duct. Several treatment options were discussed, and the patient was treated with laparoscopic cholecystectomy without extrahepatic bile duct resection and planned to be followed up considering the risk of carcinogenesis in the bile ducts.