In Graves’ disease, one of the postoperative complications of surgical treatment is symptomatic hypocalcemia, which is defined as symptoms of hypocalcemia such as tetany, paresthesia, and muscle cramps. The aim of this study was to evaluate the preoperative factors predicting the development of symptomatic hypocalcemia after thyroidectomy in Graves’ patients. One hundred nine patients with Graves’ disease underwent surgery between January 2005 and August 2010 in our department. We investigated the relationship between postoperative symptomatic hypocalcemia and the serum levels of preoperative thyroid hormones, preoperative biochemical tests, and operating states in these patients. A univariate analysis determined that the preoperative serum free triiodothyronine (T3), free thyroxin (T4), and alkaline phosphatase (ALP) levels before the administration of potassium iodide were significantly higher in the symptomatic hypocalcemia patients. A multivariate analysis shows the preoperative serum free T4 level before the administration of potassium iodide to also be significantly higher in the symptomatic hypocalcemia patients. In conclusion, the preoperative serum free T4 level before the administration of potassium iodide was thus determined to be a risk factor for developing postoperative symptomatic hypocalcemia.

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The Mental Health Gap Action Programme (mhGAP) proposed by the World Health Organization (WHO) is a planned action that aims at providing uniform medical care, especially mental health care and services, to all people worldwide, regardless of economic status. Because not only the levels of medical care, but also the political and economic situations vary among countries, it is extremely difficult for a plan to be successfully implemented in every country with standardized methodology, even if the directionality is ethically correct and ideal. Against this background, authorized personnel provide mental health care activities across the globe, and they report on activities and promote mutual understanding at the WHO mhGAP Forum, an informal meeting convened yearly in Geneva. The 5th mhGAP meeting was attended by 48 member states and 58 partner organizations. From Japan, 5 professionals attended the meeting and presented different viewpoints. Among various policies proposed at the Forum, one in particular about training and recruiting health professionals for low-income countries has gained a special consensus. In addition, the importance of training medical professionals who are not specialized in psychiatry and the importance of developing educational programs for educators were emphasized. It is important for Japan to proactively participate in mhGAP to contribute to global mental health initiative.

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Background: The similarities between Kawasaki disease (KD) and superantigen (SA) diseases indicate that a microbial SA might cause KD. Viral diseases can trigger an endogenous SA. Methods: We evaluated expression of Vß2 (responding to staphylococcal TSST-1) and Vß7 (responding to the endogenous SA induced by type-1 interferon or Epstein-Barr virus infection) on T cells from 70 KD patients along with the following control subjects: 18 non-vasculitic patients (NVs), 7 patients with anaphylactoid purpura (AP), and two with neonatal TSS-like exanthematous disease (NTED), a typical SA disease. We examined the correlation of clinical features of KD with Vß2⁺ or Vß7⁺CD4⁺T cell populations. Results: The Vß2⁺CD4⁺T cell rates were comparable between KD patients (9.9±2.9%) and NVs (9.0±1.8%), but were lower in AP patients (6.6±1.8%). However, the Vß2⁺CD4⁺T cell rate was significantly higher in KD patients with erythematic BCG inoculation site lesions (10.8±3.2%) than in those without (8.8±2.1%) and NVs (9.0±1.8%), but much lower than in NTED patients (25.2%, 16.9%). Multivariate linear regression analysis with elevation of Vß2 expression as a dependent variable revealed significant correlations with BCG. In contrast, Vß7⁺CD4⁺T cell rates were not significantly different between KD patients and other study subjects. Conclusion: While we were unable to find evidence supporting the involvement of the endogenous SA in the pathogenesis of KD in this study, modest expansion of the Vß2⁺CD4⁺T cell population in a subgroup of KD with erythematic BCG inoculation site lesions implies the involvement of a microbial agent(s) different from TSST-1 as well as immunopathological heterogeneity of KD. (249 words)

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　Blood coagulation factor VII is involved in the extrinsic clotting system, and congenital defects or deficiencies affecting blood coagulation factor VII are rare. We report the case of a patient who was diagnosed with factor VII deficiency based on a preoperative examination and then underwent factor VII replacement therapy and orthognathic surgery, together with a brief discussion of the literature. 　The patient was a 25-year-old woman. She presented to our hospital after being diagnosed with jaw deformity and underwent sagittal splitting ramus osteotomy and genioplasty under general anesthesia. Preoperative tests revealed an abnormally short prothrombin time. Blood tests detected very low coagulation factor VII activity (33%), and so the patient was diagnosed with factor VII deficiency. 　We conducted preoperative factor VII replacement therapy to inhibit bleeding, and then the abovementioned surgical procedure was performed safely. The operative time was 1 hour 30 minutes, and little intraoperative blood loss occurred. The patient’s postoperative course was good, e.g., no abnormal bleeding occurred, and she was discharged on postoperative day 7.

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A case of surgical resection of a pulmonary artery pseudoaneurysm after middle lobectomy is reported. A 76-year-old man with lung cancer, interstitial pulmonary fibrosis, and pneumoconiosis was referred for surgical resection. Right middle lobectomy with lymph node dissection was successfully performed. Postoperatively, the patient did well until a sudden high fever developed on postoperative day eight. Antibiotic therapy was started for suspected acute pneumonia, but the low-grade fever did not improve. Contrast-enhanced computed tomography showed a bronchopleural fistula that caused a pulmonary artery pseudoaneurysm. Right lower lobectomy via posterolateral thoracotomy was performed to resect the pseudoaneurysm. The pulmonary artery stump was sutured by monofilament unabsorbable stiches. The bronchus stump was sutured interruptedly with a pedicle of intercostal muscles. The patient’s postoperative course following repeat thoracotomy was complicated, including exacerbation of interstitial pneumonia and tracheostomy. He is still in hospital, and weaning off the mechanical ventilator is being attempted.

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　A 55-year-old woman had been treated for rheumatoid arthritis with tocilizumab 1 month prior to the onset of mild abdominal pain. Computed tomography revealed swelling of the appendix and ascites around the appendix. She was diagnosed with acute appendicitis and underwent emergency surgery. Although her symptoms and laboratory data indicated mild infection, surgery was conducted because of the computed tomography findings and because we believed that the physical findings and laboratory data were not dependable due to the tocilizumab. 　Upon surgery, a perforated inflamed appendix and abscess formation around the appendix were confirmed. Tocilizumab, which is relatively new, may conceal signs of infection or dull response to tests such as the Blumberg sign for peritonitis. It should be widely noted that the physical findings and laboratory data of patients with abdominal distress under tocilizumab treatment may be misleading.

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