Purpose: To clarify the association between the coronavirus disease 2019 pandemic curve and Google Trends search volumes for the disease during the three major epidemic waves in Japan.
Method: Correlation between the number of cases of coronavirus disease 2019 in Japan and the internet search volume for "corona" in the period 12th January 2020 to 19th February 2021 was evaluated using the open database provided by the Japan Broadcasting Corporation and Google Trends index data.
Results: The peak search volume for "corona" was highest during the first wave and lowest during the third wave. In contrast, the peak number of new cases per week was lowest during the first wave and highest during the third wave. The search volume and number of new cases per week showed strong correlations in each wave; however, the search volume in each wave decreased remarkably from the first to the third wave.
Conclusion: This study identified evidence of so-called "pandemic fatigue", a habituation reaction against COVID-19, in Japan. Prolonged and repeated waves of the epidemic have made people less sensitive for preventing spread of coronavirus disease 2019. Sustained, clear communication will be required to elicit the cooperation of the population in controlling the pandemic.

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Initial distribution volume of glucose (IDVG) has been demonstrated to reflect central extracellular fluid (ECF) volume and can be used as an indicator of cardiac preload. However, it is unknown whether IDVG reflects the cardiac preload in septic patients. This study aimed to investigate the changes in IDVG in endotoxin (ET)-induced septic pig models.
METHODS: We anesthetized 13pigs and sepsis was induced with intravenous ET. Five pigs were used to investigate changes in IDVG, 3pigs were used as controls and 5pigs underwent fluid resuscitation with Ringer's lactate solutions after ET. IDVG was measured with 2g glucose and calculated with one compartment model. IDVG, CO, intrathoracic blood volume (ITBV), and other parameters were measured after ET. The statistical analysis was performed with RM-ANOVA, followed by Dunnett's test or the Newman-Keuls test. P<0.05 was considered significant.
RESULTS: CO and systolic BP significantly decreased and lactate levels significantly increased 4h after ET. IDVG and ITBV significantly decreased but central venous pressure did not change 4h after ET. IDVG and CO were significantly increased with volume loading, but the effects disappeared after 1h.
CONCLUSIONS: IDVG reflected the changes in the central ECF volumes and can be an indicator of cardiac preload in septic states.

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Objective: This study aimed to investigate the physical performance and cognitive function related to the second fall in older adults who have suffered previous falls and fractures.
Method: This prospective cohort study included older adults who were admitted to hospital with an orthopedic fall-related injury and who completed 12 months of follow-up investigations. We evaluated the Berg Balance Scale (BBS), Timed Up and Go Test, Four-Square Step Test, walking speed, 30-Second Chair-Stand Test, 6-Minute Walk Test, Falls Efficacy Scale, Functional Independence Measure, and Mini Mental State Examination. Telephone interviews were used to investigate the fall status of the subjects monthly for 12 months. Principal component analysis was used to derive orthogonal factor loading. Logistic regression analysis was used to determine which factors were associated with a second fall.
Results: The first three principal components (PC1, PC2, PC3) accounted for 77.2% of the variance in the data at hospital discharge. The principal components biplot, showed that the BBS an independent comprehensive indicator. The logistic regression analysis results showed the BBS score to be a risk factor for falls (odds ratio=0.81, 95% confidence interval=0.64-0.95).
Conclusion: The BBS score was associated with the risk of second falling in older adults with a history of fractures.

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Objective: Icing is the most common care method for Japanese baseball players to prevent secondary tissue damage. However, because of reports that icing causes decrease in muscle strength and reduction in training effect, currently there is no standard post-pitching care. The purpose of this study was to longitudinally investigate whether different post-pitching care methods are associated with different effects on shoulder joint function.
Method: Aerobic exercise, stretch training, and icing were administered, at intervals of more than a week, to nine high school baseball pitchers after each of them pitched 100 throws. A comparative study was performed by measuring shoulder joint function after pitching, after care completion, and at 24 hours, 48 hours, and 72 hours post pitching.
Results: Significant differences were observed in shoulder rotation range of motion and external rotation muscle strength due to differences in care. Icing was the most selected care method in the questionnaire survey as well.
Conclusion: Depending on differences in post-pitching care, the shoulder joint function changes. Awareness about changes in shoulder joint function due to different care methods will help prevent pitching disorders through the selection of appropriate care depending on circumstances such as pitching day intervals.

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Background & Aims: The aim of the present study was to elucidate the possible factors responsible for the difference in the COVID-19 case fatality rate by country.
Methods: In reference to the reported studies, 14 factors possibly related to COVID-19 case fatality rate were identified. Of the 191 countries and regions listed on the global map of the COVID-19 dashboard by the Center for Systems Science and Engineering at Johns Hopkins University, 79 countries were selected taking into account the amount of data and its reliability. Correlations of the COVID-19 case fatality rate with 13 possible factors were investigated. Epidemiological data such as food consumption, and meteorological data were obtained from public online databases.
Results: Only fish and seafood consumption had a negative correlation with the case fatality rate by country. Seafood consumption decades ago correlated better than that in 2017. The correlation coefficient between sea food consumption and the COVID-19 case fatality rate decreased from -0.51 in 1970 to -0.29 in 2017.
Conclusion: Fish and seafood eating habit during childhood and young adulthood may be associated with decreased death by COVID-19 in their later years.

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Background: Implantable cardiac monitor (ICM) is an effective tool to detect atrial fibrillation (AF) in patients with embolic stroke undetermined sources (ESUS). We investigated predictive factors for AF detection in ESUS patients with ICM implantation.
Methods: A total of 29 ESUS patients who underwent ICM implantation (median 71 [66-84] years and 18 males) were followed-up for a median of 253 [44-570] days.
Results: AF was detected in 10 patients (34.5%). The median time from ICM implantation to AF detection was 41.5 [33.25-59.25] days and that from stroke onset to AF detection was 62.5 [52.25-71.75] days. AF was detected within 90 days after ICM implantation in 90% (9/10) of the study patients. Plasma brain natriuretic peptide level was significantly higher in patients with AF detection than in those without it (125 [49.8-550.8] versus 18.2 [14.1-60.0] pg/mL, p=0.007). More frequent supraventricular premature contraction (SVPC) on Holter electrocardiogram (ECG) was observed in patients with AF detection than in those without it (1.81 [0.40-4.80] versus 0.04 [0.02-0.13] %/day, p<0.001). Cox proportional hazards model showed that the frequent SVPCs was a significant factor for AF detection.
Conclusions: The frequent SVPCs on Holter ECG is an independent predictor for covert AF in ESUS patients.

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Background: Women often experience medically unexplained symptoms as they age, and their possible causes include changes in autonomic activity. Heart rate variability is a relevant marker for autonomic function.
Methods: The autonomic activities of patients who underwent gynecologic surgery were prospectively measured and evaluated by menopausal status. Parameters included the standard deviation of the mean R-to-R intervals (SDNN) and index of the sympathetic nervous system (SNS) function. Patients also evaluated the severity of their headache, hot flashes, anxiety, irritability, fatigue and shoulder stiffness using the visual analog scale (VAS-P, VAS-H, VAS-A, VAS-I, VAS-F and VAS-S, respectively). Measurements were conducted shortly before, immediately after, and 1 week after surgery.
Results: The study cohort (N = 101) consisted of 14 premenopausal, 39 surgically menopausal, and 48 naturally menopausal patients. At 1 week after surgery, surgically menopausal patients had significantly smaller mean SDNN than premenopausal patients. Surgically menopausal patients also showed significant correlation between the SNS index and VAS-I and VAS-F.
Conclusions: The SNS index in surgically menopausal patients can be a promising tool for evaluating the severity of menopausal symptoms. Parasympathetic nerve activity decreased immediately after the operation in the surgical menopausal group. Therefore, early hormone replacement therapy may be necessary in surgical menopause group.

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    The purpose of this paper is to report the usefulness of continuous intra-arterial infusion of antibiotics for the treatment of intractable skin infection, using a tunneled catheter technique without a port.
    An elderly woman presented with pain in the left leg with a chronically infected intractable giant skin ulcer, for which amputation was recommended by former doctors to avoid the occurrence of skin cancer, because she had multiple (five times in 14 years) skin grafts and the skin ulcer continuing for so many years. The patient requested an alternative and interventional radiological treatment was selected.
    The pus in the ulcer yielded numerous Pseudomonas aeruginosa and Proteus vulgaris. She was treated by continuous intra-arterial infusion of an antibiotic, Sulbenicillin, using a tunneled catheter technique without a port for 18 days. The organisms in the ulcer were completely eradicated, and the ulcer gradually healed with decreased size. When the size of the ulcer became minimal a skin graft completed the treatment, avoiding amputation. No local or subcutaneous infection relating to the procedure was noted during or after the treatment.
    In a follow-up two years after the treatment, she was found to be living well without any complications.

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A large proportion of well-defined breast masses are generally benign. In this study, we report two cases of male breast cancer that showed well-defined masses. Case 1 is a male in his 50s. US revealed a well-defined mass of approximately 16.6 mm in the E region of the right mammary gland. Breast cancer was diagnosed by needle biopsy. Breast muscle-sparing mastectomy and senti-nel lymph node biopsy (SN) were performed. Histopathology showed invasive ductal carcinoma of the breast, classified as pT1cN0M0, stage I. Case 2 is a male in his 60s. Ultrasonography (US) revealed a well-defined mass approximately 18 mm, in the E region of the left mammary gland. Breast cancer was diagnosed by aspiration biopsy and cytology. The patient underwent pectoral muscle-sparing mastectomy and axillary lymph node dissection (Ax). Histopathology showed invasive micropapillary carcinoma, and all samples for lymph node biopsy were negative. Pathologic staging was pT1cN0M0, stage I. In male breast cancer, tumors with well-defined mass images are frequently reported. In men, even a well-defined mass is suspected to be breast cancer and should be scrutinized.

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Although arachnoid cysts are generally asymptomatic and are often detected incidentally by imaging studies, they have been reported to cause obstructive hydrocephalus, endocrine disorders, and visual dysfunction in rare cases. In this study, we report a case of obstructive hydrocephalus caused by an arachnoid cyst, which responded well to endoscopic third ventriculostomy. The patient was a 3-year-old boy who was referred to our department with the chief complaint of vomiting, gait disturbance, and abnormal eye position. An MRI scan showed hydrocephalus and a cystic mass close to the cerebral aqueduct. Cystectomy and endoscopic third ventriculostomy were performed. After the surgery, the symptoms gradually improved, and the hydrocephalus tended to improve on imaging examinations. Based on the intraoperative findings and the results of the pathological examination, the cystic mass was diagnosed as an arachnoid cyst originating from the third ventricle, and it was considered that the arachnoid cyst caused the obstructive hydrocephalus. Most arachnoid cysts are asymptomatic; however, if they are found incidentally on imaging studies, the younger the patient, the more likely they are to spontaneously enlarge and cause obstructive hydrocephalus. Thus, arachnoid cysts in children should be followed up carefully.

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Erythromelalgia is a rare clinical entity that manifests as redness, heat, and burning pain in the extremities. The causative gene for erythromelalgia, SCN9A, encodes a voltage-gated sodium channel, subtype Nav1.7. We report a case of a 26-year-old woman with erythromelalgia. She had 15-year history of recurrent purpura and swelling in the lower extremities. At 16 years of age, she was diagnosed with skin biopsy-proven leukocytoclastic vasculitis associated with unexpected hypogammaglobulinemia (IgG 320 mg/dL, IgA 12 mg/dL, IgM 35 mg/dL). Under the tentative diagnosis of refractory IgA vasculitis, she was treated with prednisolone and intravenous immunoglobulin administration. However, the therapeutic intervention was only partially effective. Because of an atypical clinical course of IgA vasculitis, a genetic analysis for erythromelalgia was conducted when at 25 years of age, which revealed a pathogenetic mutation in the SCN9A gene. Her mother also had the same mutation. After the diagnosis of erythromelalgia, carbamazepine administration was initiated and the treatment was successful. Unusual clinical manifestations of refractory purpura and hypogammaglobulinemia sometimes occur in selected patients with erythromelalgia. This case may contribute to the expansion of phenotypic presentation of erythromelalgia.

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