This study aimed to identify industries with the highest frequency of people with metabolic syndrome (MetS) in order to prioritize the industries that insurers should target for health guidance programs. We analyzed insurance claims data provided by the Fukuoka Branch of the National Health Insurance Association. Data were analyzed from 115,839 insured individuals aged 40-75 years who underwent medical examinations during fiscal year 2015 (April 1, 2015–March 31, 2016). The analyzed items included body mass index, waist circumference, systolic blood pressure, diastolic blood pressure, triglyceride level, high-density lipoprotein cholesterol, and fasting plasma glucose (or, if not measured, glycated hemoglobin) measured at the medical checkup, and drug treatment status from the medical questionnaire. MetS was defined according to the criteria of the joint committee of eight Japanese medical societies. A patient was diagnosed with MetS if defined values were met for two or more of the following: blood pressure, lipids, and blood glucose plus waist circumference. The prevalence of MetS risk and the relative risk were calculated by type of industry. Finally, logistic regression analysis was performed to examine the relationship between MetS risk and type of occupation, adjusting for sex, age, and income. MetS risk was significantly associated with the transportation industry and postal work (odds ratio [OR], 1.30; 95% confidence interval [CI], [1.21-1.38]) and the construction industry (OR, 1.07; 95% CI, [1.01-1.15]). Men aged 50 years or older and patients with higher income showed a tendency for higher risk. The results of the study suggest that insurers could put priority of health guidance projects for the insured in the transportation, postal, and construction industries to focus on approaches to both the workplace environment and lifestyle improvement.

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　　At Anjo Kosei Hospital, patients receive injectable medication for diabetes treatment and devices for self-monitoring of blood glucose as in-hospital prescriptions. Pharmacists manage prescriptions according to established protocols when there is over- or under-prescribing. In this study, we retrospectively examined outpatient prescriptions for patients attending endocrinology and diabetology from January 2014 to June 2015 (before protocol implementation) and from July 2015 to December 2020 (after protocol implementation) to evaluate the usefulness of protocol-based supporting prescription by pharmacists. Changing prescriptions based on the protocol simplified prescription queries in 661 of 721 cases (91.7%), and significantly decreased the rate of unplanned doctor visits after the introduction of the protocol (p<0.05). Optimization of prescriptions through protocol-based assistance in prescribing is expected to reduce the burden on physicians, patients, and pharmacists by reducing the number of formal inquiries for questionable prescriptions and the number of unplanned doctor visits.

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　We use transumbilical laparoscopic-assisted appendectomy (TULAA) with a lifting retractor as the surgical technique of first choice for acute appendicitis. Although this technique provides excellent cosmetic results and contributes to reducing medical costs, it is less advantageous in difficult-to-complete cases that require conversion to pneumoperitoneum or additional ports. We retrospectively reviewed the records of 76 patients who underwent laparoscopic appendectomy between June 2020 and March 2023 (43 in a TULAA group and 33 in a pneumoperitoneal conversion group) to identify preoperative factors associated with pneumoperitoneal conversion. Univariate analysis showed significant differences for preoperative C-reactive protein (CRP) level, age, and body mass index. Logistic regression analysis identified preoperative CRP level and age as significant risk factors for pneumoperitoneal conversion. The pneumoperitoneal conversion rate was 12.5%, 48.2%, and 68% for patients with 0, 1, and 2 preoperative risk factors, respectively, indicating patients with 2 risk factors were more likely to undergo pneumoperitoneal conversion. These data may inform the selection of the surgical technique and the decision to convert to pneumoperitoneum.

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　Deep neck abscess can cause upper airway stenosis and obstruction, and sometimes emergency airway management is required. Here we present a case of deep neck abscess in which awake intubation with a video laryngoscope (McGRATH™ MAC) was more useful than with flexible bronchoscope. A man in his 80s was transported to our hospital with throat and chest pain. Contrast-enhanced computed tomography revealed a deep neck abscess (right peritonsillar abscess). The otolaryngologist attempted drainage by puncture, but this was ineffective. There was a risk of upper airway obstruction, and emergency airway management was required. First, we attempted endotracheal intubation with a flexible bronchoscope but could not secure the field of view because of the upper airway edema and stenosis. Next, we attempted tracheal intubation using a video laryngoscope, which ultimately was successful. The blade of the video laryngoscope compressed and lifted the soft tissue and then it secured the space of the upper airway.

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　A woman in her 50s underwent abdominal total hysterectomy for uterine myoma. She was discharged from the hospital on postoperative day (POD) 6 following an uneventful postoperative course but returned to the outpatient clinic on POD 11 with chief complaints of fever and abdominal pain. Blood tests at presentation showed a C-reactive protein level of 22.95 mg/dL and a white blood cell count of 21300/μL, indicating an increased inflammatory response. Transvaginal ultrasonography and contrast-enhanced computed tomography (CT) revealed a small amount of ascites and a thickened pelvic peritoneum. Based on these findings, pelvic peritonitis was diagnosed and the patient was readmitted to the hospital. After admission, antimicrobial treatment with cefmetazole 3 g/day was started, but transvaginal ultrasonography on POD 13 (3 days after readmission) revealed an intra-pelvic abscess. The abscess was punctured under transvaginal ultrasonographic guidance and the puncture fluid was submitted for microbiological examination, followed by CT-guided drainage. At the same time, the antimicrobial regimen was changed to sulbactam/ampicillin 9 g/day and doxycycline (DOXY) 200 mg/day (100 mg/day from the following day). On POD 18 (8 days after readmission), Mycoplasma hominis was detected in the abscess culture, leading to the decision to increase the dose of DOXY to 200 mg. Subsequently, with improvement of subjective and objective symptoms and reduction of the abscess cavity, the patient was discharged from the hospital on POD 21 (11 days after readmission). Although M. hominis is a common urogenital commensal, it can be a potential pathogen in a patient with a pelvic abscess that occurs as a late postoperative complication and does not respond to beta-lactam antibiotics, so treatment decisions should be made with this organism kept in mind.

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　A man in his 70s was transported to our hospital for acute exacerbation of chronic kidney disease. After arrival, he began having visual hallucinations, which were attributed to cognitive decline. We subsequently found that he had been taking amantadine 100 mg/day prescribed by another hospital. We thought that the visual hallucinations were caused by overdose of amantadine and discontinued the drug. Since abrupt discontinuation of antiparkinsonian drugs has a risk of neuroleptic malignant syndrome, tapering the dosage is desirable in most cases. However, the half-life of amantadine in patients with severe renal dysfunction is estimated to be 7-10 days, and thus the blood concentration of amantadine can be inferred to decrease slowly. Therefore, we chose to discontinue amantadine without tapering in the expectation of rapid improvement of the visual hallucinations, considering that the risk of neuroleptic malignant syndrome would be lower than that in patients with normal renal function who discontinued amantadine immediately. After the discontinuation of amantadine, no increase in creatine kinase level or muscle rigidity was observed, and the visual hallucinations improved on day 7 after discontinuation.

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　Recently, with the increase of laparoscopic surgery, there has also been an increase in the number of surgeries that require the head-down position for a long duration and left-right rotation. We have encountered 3 cases of brachial plexus neuropathy that was thought to be caused by such surgical positions in our institute. Currently, we have improved the fixation method and fixtures and created a neuropathy checklist, and we are conducting standardized observation and decompression programs within the team. We examined whether our current programs are effective using a body pressure measuring device for 20 patients undergoing headdown lithotripsy surgery under general anesthesia. The correlation between the mean body pressure on the right shoulder after 30 min and body tilt angle was studied. We also observed changes in body pressure before and after manual decompression every 30 min while the patient was in the head-down position. Before that study, we conducted an experience questionnaire survey of 10 operating room nurses. The results indicated that there was no increase in body pressure in proportion to the body tilt angle (15-20 deg). The body pressure after decompression decreased significantly at 30, 60, and 120 min after placing the patient in the head-down lithotripsy position. There was no significant correlation between body pressure and the headdown positioning time. There was a significant correlation between body mass index (BMI) and body pressure at 30 min (r=0.474, p=0.035). Complaints of trunk displacement, shoulder pain and pressure, and head and neck traction were often noted in the nurse questionnaire. These complaints were more frequently seen in cases with a larger right-down rotation angle and higher BMI. From these results, it was concluded that decompression of the body with the current fixtures and our regular observation and decompression program using the neuropathy checklist is effective for preventing brachial plexus injury in patients undergoing lithotripsy laparoscopic surgery in the head-down position and with left-right rotation.

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