Minimally invasive percutaneous endoscopic discectomy (PED) with a transforaminal approach under local anesthesia was started in the late 20th century. As the procedure requires a skin incision of only 8 mm, it is the least invasive disc surgery procedure at present, and owing to advances in instruments and optics, the use of this technique has gradually spread. In Japan, Dr. Dezawa from Teikyo University Mizonokuchi Hospital introduced this technique in 2003. Thanks to his efforts, the number of surgeons who can perform PED has increased, although the number of active PED surgeons is still only around 20. The first author (K.S.) started PED in 2010. In this review article, we explain the state-of-the-art PED transforaminal technique for minimally invasive disc surgery and present three successful cases. J. Med. Invest. 61: 217-225, August, 2014

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Hip arthroscopy is among the most rapidly evolving arthroscopic techniques in the last decade and offers the benefits of being both a minimally invasive procedure and an excellent diagnostic tool. Improvements in instrumentation and surgical skills have advanced our ability to accurately diagnose and treat various conditions of the hip joint, and hip arthroscopy has elucidated several pathologies that cause disabling symptoms. Many of these conditions were previously unrecognized and left untreated. The indications for hip arthroscopy include the management of early osteoarthritis, synovial disorders (e. g., synovial osteochondromatosis), labral tears, chondral lesions, and femoroacetabular impingement (FAI), which is increasingly recognized as a disorder that can lead to the development of early cartilage and labral injury. A better understanding of hip arthroscopy, including the anatomy, improved surgical techniques, indications, and complications of the procedure, is essential for its success. This review article discusses the state of the art of arthroscopic hip surgery. J. Med. Invest. 61: 226-232, August, 2014

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Elbow arthroscopy has become a safe and effective treatment option for a number of elbow disorders. The most rewarding and successful indication is the removal of loose bodies. Loose bodies are often a result of osteochondritis dissecans (OCD) of the capitellum, and arthroscopy in this case is useful for performing debridement, thereby eliminating the need for a more extensive open procedure associated with complications. In this review, we describe our arthroscopic technique for OCD of the capitellum. We usually conduct arthroscopy in the supine position, and use 2.9-mm arthroscopes of 30° and 70°. The 70° arthroscope provides a greater operative field than the 30° arthroscope. Arthroscopic treatment for OCD may require 2 anterior and 2 posterior portals. Loose bodies are commonly found in the radial fossa, coronoid fossa, and in the olecranon fossa. Once the loose bodies are removed, all unstable cartilage of the capitellum lesion is removed to create a stable bed. If any sclerotic changes to the lesion bed are observed, we create microfractures in the lesion bed. The most significant complication in arthroplasty is neurovascular injury. However, we have never experienced this devastating complication, which can be avoided by paying careful attention to detail. J. Med. Invest. 61: 233-240, August, 2014

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Brain metastases occur in 20-40% of patients with advanced malignancies and lung cancer is one of the most common causes of brain metastases. The occurrence of brain metastases is associated with poor prognosis and high morbidity in patients with advanced lung cancer, even after intensive multimodal therapy. Progress in treating brain metastases has been hampered by a lack of model systems, a lack of human tissue samples, and the exclusion of brain metastatic patients from many clinical trials. While the biology of brain metastasis is still poorly understood, it is encouraging to see more efforts are beginning to be directed toward the study of brain metastasis. During the multi-step process of metastasis, functional significance of gene expressions, changes in brain vasculature, abnormal secretion of soluble factors and activation of autocrine/paracrine signaling are considered to contribute to the brain metastasis development. A better understanding of the mechanism of this disease will help us to identify the appropriate therapeutic strategies, which leads to circumvent brain metastases. Recent findings on the biology of lung cancer brain metastases and translational leads identified by molecular studies are discussed in this review. J. Med. Invest. 61: 241-253, August, 2014

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The purpose of this study was to evaluate the clinical outcome of boron neutron capture therapy (BNCT) and conventional treatment in patients with newly diagnosed glioblastoma. Since 1998 we treated 23 newly-diagosed GBM patients with BNCT without any additional chemotherapy. Their median survival time was 19.5 months; the 2-, 3-, and 5-year survival rates were 31.8%, 22.7%, and 9.1%, respectively. The clinical results of BNCT in patients with GBM are similar to those of recent conventional treatments based on radiotherapy with concomitant and adjuvant temozolomide. J. Med. Invest. 61: 254-263, August, 2014

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The minimally invasive percutaneous endoscopic discectomy (PED) as the postero-lateral approach with the local anesthesia was started in the late 20th century. The procedure only requires 8 mm of skin incision; thus, it is the least invasive disc surgery presently. The surgery related complications were reviewed in the initial 100 cases from the single surgeon (K. S., first author). Two cases showed exiting nerve irritation, and complained of leg paresthetic pain for 6 to 12 weeks after the surgery (2.0%). The symptoms got better with medicines. One showed post-surgical epidural hematoma, and required surgical removal of the mass (1.0%). Two cases complained neck pain during surgery (2.0%). Surgeons would be aware of the specific complications for the postero-lateral approach of PED procedure. J. Med. Invest. 61: 264-269, August, 2014

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Macrophages in hyperlipidemic conditions accumulate cholesterol esters and develop into foamy transformed macrophages. During this transformation, macrophages demonstrate endoplasmic reticulum fragmentation and consequently produce acyl coenzyme A: cholesterol acyltransferase 1 (ACAT1)-positive late endosomes (ACAT1-LE). ACAT1-LE-positive macrophages effectively esterify modified or native low-density lipoprotein-derived free cholesterol, which results in efficient cholesterol esterification as well as atherosclerotic plaque formation. These macrophages show significant cholesterol ester formation even when free cholesterol egress from late endosomes is impaired, which indicates that free cholesterol is esterified at ACAT1-LE. Genetic blockade of cholesterol egress from late endosomes causes Niemann-Pick disease type C (NPC), an inherited lysosomal storage disease with progressive neurodegeneration. Induction of ACAT1-LE in macrophages with the NPC phenotype led to significant recovery of cholesterol esterification. In addition, in vivo ACAT1-LE induction significantly extended the lifespan of mice with the NPC phenotype. Thus, ACAT1-LE not only regulates intracellular cholesterol metabolism but also ameliorates NPC pathophysiology. J. Med. Invest. 61: 270-277, August, 2014

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Background: Propofol causes vasodilation via endothelium-dependent and -independent mechanisms. Because endothelial function is impaired with aging, the effects of propofol on endothelium-dependent vasodilation might be altered by aging. The aim of this study was thus to determine the effects of aging on vascular responses to propofol. Methods: Young (4-6 weeks old) or adult (16-25 weeks old) rats were anesthetized with sevoflurane. The thoracic aorta was dissected and cut into pieces 3-4 mm in length. In some rings, the endothelium was deliberately removed. The ring segment of the aorta was mounted for isometric force recording at a resting tension of 0.5-1.0 g in a 2 ml organ bath, containing Krebs-Ringer bicarbonate buffer. Arteries were precontracted with phenylephrine, and the function of endothelium was confirmed with acetylcholine. Then, we studied the concentration-dependent effects of propofol in endothelium-intact (control group) and -denuded aortic rings (denuded group), as well as those treated with N^ω-nitro-L-arginine methylester (L-NAME group). Results: Relaxation due to propofol was observed in the control groups of both young and adult rats in a concentration-dependent manner, but the magnitude of relaxation was significantly greater in young rats. In addition, in young rats, relaxation due to propofol was significantly and equally reduced in both L-NAME and denuded groups at all propofol concentrations that we studied (10^-6-10^-3 M). In adult rats, relaxation due to propofol was quite similar between control and L-NAME groups at all propofol concentrations, whereas it was significantly reduced in the denuded group. Conclusion: These results suggest that endothelium-derived nitric oxide plays an important role in propofol-induced vasodilation in young rats, but not in adult rats. J. Med. Invest. 61: 278-284, August, 2014

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Surface sterilization of fresh produce has been needed in the food manufacturing/processing industry. Here we report a UVA-LED (Ultra Violet A-Light Emitting Diode) system for surface sterilization that is safe, efficacious, low cost, and apparently harmless to fresh produce. To test the system, Escherichia coli strain DH5α was spot-inoculated onto vegetable tissues, and treated under UVA-LED. Tissues were homogenized and bacteria quantified by colony-forming assay. Possible effects of UVA-LED on vegetable quality were evaluated by HPLC. Tissue weight changes were checked after treatment at 4℃, 15℃, and 30℃. Bacterial inactivation by UVA-LED radiation was observed after a 10 min treatment and increased with increasing time of irradiation. The log survival ratio reached -3.23 after a 90 min treatment. Bacterial cells surviving treatment grew slowly compared to non-irradiated control cells. Cabbage tissue lost weight over time after treatment, and weight loss increased with increasing incubation temperature, but there was no difference between losses by UVA-LED treated and control tissues at any temperature tested. In addition, no differences of Vitamin C content in cabbage tissue were detected by HPLC after UVA-LED treatment. These results suggest that UVA-LED treatment has great potential for vegetable surface sterilization in the food manufacturing/processing industry. J. Med. Invest. 61: 285-290, August, 2014

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Long-term suppression of postprandial glucose concentration is an important dietary strategy for the prevention and treatment of type 2 diabetes. Because previous reports have suggested that seaweed may exert anti-diabetic effects in animals, the effects of Wakame or Mekabu intake with 200 g white rice, 50 g boiled soybeans, 60 g potatoes, and 40 g broccoli on postprandial glucose, insulin and free fatty acid levels were investigated in healthy subjects. Plasma glucose levels at 30 min and glucose area under the curve (AUC) at 0-30 min after the Mekabu meal were significantly lower than that after the control meal. Plasma glucose and glucose AUC were not different between the Wakame and control meals. Postprandial serum insulin and its AUC and free fatty acid concentration were not different among the three meals. In addition, fullness, satisfaction, and wellness scores were not different among the three meals. Thus, consumption of 70 g Mekabu with a white rice-based breakfast reduces postprandial glucose concentration. J. Med. Invest. 61: 291-297, August, 2014

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Human chymase converts big endothelin (ET)-1 to 31-amino acid length ET-1 {ET-1(1-31)} that also possesses a potent vasoconstrictive action. In addition, ET-1(1-31) is an intermediate peptide, which is then readily transformed to mature ET-1 by the neutral endopeptidase 24-11. To investigate the relevance of pathophysiology of ET-1(1-31) in vivo, we have developed specific sandwich-type, enzyme-linked immunosorbent assay to measure the plasma concentration of ET-1(1-31) in healthy volunteers and patients with myocardial infarction. The plasma concentrations of ET-1(1-31) in healthy volunteers were 24.8 ± 5.2 pg/ml (n=11). ET-1(1-31) concentration in plasma was elevated in patients with acute myocardial infarction, and its elevation was several times higher and lasted longer than that of ET-1. In addition, tissue concentration of ET-1(1-31) in the myocardium from a patient with acute myocardial infarction was extremely high (12729.8 ± 2617.7 pg/mg protein). These results suggest that ET-1(1-31) may play some pathological roles in the remodeling, especially in sites where inflammatory cells produced a large amount of proteases, such as myocardial infarction. J. Med. Invest. 61: 298-305, August, 2014

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Sp6 is a transcription factor of the SP/KLF family and an indispensable regulator of the morphological dynamics of ameloblast differentiation during tooth development. However, the underlying molecular mechanisms remain unclear. We have previously identified one of the Sp6 downstream genes, Rock1, which is involved in ameloblast polarization. In this study, we investigated the transcriptional regulatory mechanisms of Rock1 by Sp6. First, we identified the transcription start sites (TSS) and cloned the 5'-flanking region of Rock1. Serial deletion analyses identified a critical region for Rock1 promoter activity within the 249-bp upstream region of TSS, and chromatin immunoprecipitation assays revealed Sp6-binding to this region. Subsequent transient transfection experiments showed that Rock1 promoter activity is enhanced by Sp6, but reduced by Sp1. Treatment of dental epithelial cells with the GC-selective DNA binding inhibitor, mithramycin A, affected Rock1 promoter activity in loss of enhancement by Sp6, but not repression by Sp1. Further site-directed mutagenesis indicated that the region from -206 to -150 contains responsive elements for Sp6. Taken together, we conclude that Sp6 positively regulates Rock1 transcription by direct binding to the Rock1 promoter region from -206 to -150, which functionally distinct from Sp1. J. Med. Invest. 61: 306-317, August, 2014

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Background: Mandibular reconstruction using a fibular graft is a difficult procedure that requires technical expertise to enable adequate occlusal function and restore an aesthetic appearance. Here we used three-dimensional (3D) sodium chloride (NaCl) models for simulated mandibular reconstruction surgery. This study aimed to reveal the accuracy of mandibular reconstruction with fibular grafts using this model. Methods: Mandibular reconstructions using 3D NaCl models were performed in 5 cases. The maxilla, mandible, and fibular models were developed using computed tomography (CT) data. We performed preoperative cutting and simulation surgery using this model. Angles between the body of the corpus and symphysis were measured from the axial view (n = 4). Angles between the ramus and the body of the corpus were measured from the lateral and axial views (n = 6). These angles were measured on simulated models and postoperative CT images were compared. Results: Differences between the angles measured on the simulated models and postoperative CT images were 0-5° (mean, 1.9°). Conclusions: We were able to reproduce the neomandibles with precise osteotomies using the 3D NaCl models. We believe that simulated mandibular reconstruction surgery using this model might help reduce the number of intraoperative neomandibular segment adjustments. J. Med. Invest. 61: 318-324, August, 2014

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Background: Neuropathic diabetic foot ulcers are generally deep and infectious wounds extending to the bone or joint. We performed microsurgical free flap transfer for limb salvage and vascular augmentation of feet with diabetic neuropathy. Methods: Angiography was performed to identify any significant arterial disease. The free flaps were transplanted after resection of the damaged skin and infected bone. Flow-through or end-to-side anastomosis to the dorsalis pedis artery was performed to preserve the arterial blood flow to the residual foot. Results: An anterolateral thigh flap and free flaps based on the subscapular artery system were transplanted in 1 and 10 patients, respectively. All flaps survived. Arterial flow on the distal side of the anastomosis was postoperatively confirmed in all patients. During a mean follow-up period of 52 months, the long-term complications observed were recurrent ulcers in 4 patients. The limb salvage rate was 100%, and 82% of patients achieved functional ambulation. Conclusions: Microsurgical flap transplantation is a safe and useful technique for minimal amputation of a diabetic neuropathic foot. Postoperative protection of the feet is important in order to avoid recurrence of foot ulceration. The use of protective footwear custom-tailored for each patient is strongly recommended. J. Med. Invest. 61: 325-332, August, 2014

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The associations of dietary patterns with metabolic syndrome (MetS) and insulin resistance have not been fully investigated in the Japanese population. A cross-sectional study was performed on 513 subjects without treatment for diabetes who had participated in the baseline survey of a cohort study in Tokushima Prefecture, Japan. Frequencies of consumption of 46 foods and beverages were assessed using a questionnaire. MetS was diagnosed using the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criteria. Logistic and linear regression analyses were used to examine the associations of the dietary patterns with the prevalence of MetS, its components, and the Homeostasis Model of Assessment-Insulin Resistance (HOMA-IR). Using principal component analysis, four dietary patterns were extracted: prudent diet (high intake of vegetables and fruits); high fat/Western (high intake of fried foods, fried dishes and meat); bread and dairy products; and seafood patterns. After adjustment for sex, age, and other potential confounders, prudent diet pattern scores were inversely correlated with the prevalence of reduced serum high-density lipoprotein cholesterol (P=0.04) and high blood pressure (P=0.05), and bread and dairy products pattern scores were correlated with a lower prevalence of abdominal obesity (P=0.04) and high plasma glucose (P=0.04). The high fat/Western pattern was positively correlated with HOMA-IR (P=0.04). Prudent dietary pattern and bread and dairy products pattern may be correlated with a lower prevalence of some components of MetS. A high fat/Western dietary pattern may be positively associated with insulin resistance in the Japanese population. J. Med. Invest. 61: 333-344, August, 2014

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Buckwheat powder or protein has been shown to decrease the total serum cholesterol level in non-diabetic mice or rats. However, the lipid-lowering effect of buckwheat bran extract (BBE) in diabetic mice has not been fully elucidated. KK-A^y mice that received six-week treatment with BBE showed decreased body weight and liver weight compared to those of control (vehicle) mice. However, there was no significant difference in food intake. BBE treatments prevented liver triglyceride accumulation and decreased the serum level of triglycerides. In addition, mRNA expression levels lipogenic enzyme genes, fatty acid synthase, acetyl-coenzyme a oxidase and stearyl-coenzyme a desaturase 1, but not those of β-oxidized enzyme genes, were decreased in BBE-treated mice. Level of transcription factors ChREBP and SREBP1c, transcripts of lipogenic genes, were also decreased in BBE-treated mice. These results suggest that chronic treatment with BBE derivatives could have beneficial effects on hypertriglycemia in patients with type 2 diabetes mellitus. J. Med. Invest. 61: 345-352, August, 2014

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Dysphagia is associated with nutritional deficits and increased risk of aspiration pneumonia. The aim of the present study was to evaluate the impact of nutrition therapy for the patients with dysphagia at an acute care hospital. We also tried to clarify the factors which improve swallowing function in these patients. Seventy patients with dysphagia were included in the present study. Multidisciplinary nutrition support team evaluated swallowing function and nutrition status. Most patients were fed by parenteral or enteral nutrition at the time of the first round. Of these 70 patients, 36 became able to eat orally. The improvement of swallowing function was associated with higher BMI in both genders and higher AMC in men. Mortality was high in the patients with lower BMI and %AMC, suggesting importance of maintaining muscle mass. Thirteen (38.2%) of 34 patients who did not show any improvement in swallowing function died, but no patients who showed improvement died (p<0.001). In addition, the patients with nutrition intake about<22 kcal/kg/day during follow-up period, showed significantly poorer recovery from dysphagia and poor outcome, compared to those with about>22 kcal/kg/day. These results suggest that it is important to maintain nutritional status to promote rehabilitation in patients with dysphagia even in an acute care hospital. J. Med. Invest. 61: 353-360, August, 2014

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The aim of this retrospective study was to examine whether serum albumin levels offer a good marker of nutritional status in patients with burns. Serum albumin levels have been used to evaluate nutritional status in burns patients, even though these levels are affected by various factors and are not specific to malnutrition. To clarify whether provision of nutrition or presence of inflammation affects serum albumin levels, we studied serum albumin levels, C-reactive protein (CRP) levels and caloric intake over time in 30 patients with burns. Serum albumin levels did not respond to provision of nutrition, but correlated negatively with CRP levels, suggesting that serum albumin levels are more closely associated with inflammation than nutrition. This study also suggests that hypoalbuminemia is a good indicator of the severity of burns or associated complications. We conclude that serum albumin levels do not offer a good nutritional marker in burns patients. J. Med. Invest. 61: 361-368, August, 2014

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Objective: To investigate the prevalence of osteochondrosis in children and adolescent soccer players. Materials and Methods: A questionnaire was distributed to players of all 113 junior soccer teams participating in a regional summer championship in August 2012 inquiring about pain in the body during or after training or a match. Physical examination of the lumbar spine or legs was recommended to players who complained of pain on the questionnaire, and for those who had positive findings on the physical examination, radiographic or ultrasonic examination at our hospital was recommended. Results: Questionnaires were collected from 1162 players of 97 teams, and 547 players (47.1%) complained of pain in the lumbar spine or legs. Physical examination was performed on 494 players, 394 of whom were referred for physical examination (79.8%). Of these 494 players, 20 (4.0%) had positive lumbar spine findings, 26 (5.3%) had hip findings, 198 (40.1%) had knee findings, 117 (23.7%) had ankle findings, 226 (45.7%) had heel findings, and 90 had findings in other parts of foot (18.2%). Radiographic or ultrasonic examination was performed in 106 (26.9%) players at our hospital and 80 (75.5%) players were diagnosed with osteochondrosis. Sever's disease was diagnosed in 49 players, Osgood-Schlatter disease in 13, bipartite patella was in 12, Sinding-Larsen-Johansson disease in 10, osteochondritis dissecans of the distal femur in 1, and spondylolysis in 3. Conclusions: The majority of players who had experienced pain and were found to have osteochondrosis had severe injuries such as osteochondritis dissecans or lumbar spondylolysis. We suggest many of the players involved in this study receive further radiographic or ultrasonic examination. J. Med. Invest. 61: 369-373, August, 2014

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We have previously generated a macaque-tropic human immunodeficiency virus type 1 (HIV-1mt) clone designated MN4/LSDQgtu by genetic manipulation from a parental virus that replicates poorly in rhesus macaque cells. In rhesus cell line M1.3S and peripheral blood mononuclear cells (PBMCs), MN4/LSDQgtu grows comparably to a standard simian immunodeficiency virus clone derived from the rhesus macaque (SIVmac239) that can induce the acquired immunodeficiency syndrome (AIDS) in the animals. In this study, we further modified the Vpr-coding region of MN4/LSDQgtu genome by introducing vpr gene of an SIV clone from the greater spot-nosed monkey (SIVgsn166) or vpx gene of SIVmac239 to generate four new clones for determining functional importance of the central genomic area. Furthermore, two clones with an additional Gag-p6 mutation were made to ensure the virion-packaging of Vpx. In addition, accessory gene mutant clones of MN4/LSDQgtu with a frame-shift mutation, including a vpr mutant, were constructed and their growth properties were examined. Infection experiments showed that newly constructed viruses all grew poorly to various degrees in M1.3S cells, relative to MN4/LSDQgtu. Together with the previous data, our results here show that vpr/vpx gene in the appropriate context of HIV-1 genome is critical for viral growth ability. J. Med. Invest. 61: 374-379, August, 2014

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The goal of this study was to investigate the electrocardiographic and chronobio-logical features of paroxysmal atrioventricular (AV) block (PAVB) using data from ambulatory electrocardiography (AECG). The study population consisted of five men and six women aged from 47 to 82 years of age. Main presenting symptoms were pre-syncope in five patients (45.5%) and syncope in three patients (27.3%). Organic cardiovascular diseases were seen in eight patients (72.7%), and AV conduction disturbances were seen in six patients (54.5%), such as right bundle branch block, first to second degree AV block on standard 12-lead electrocardiography. Incidence of PAVB events were 1-329 (37.9 ± 98.0) episodes/patient/day, and the maximum pause during Holter recordings was 3.3-12.4 (6.39 ± 3.09) seconds. This maximum pause caused by intrinsic AV block was longer than that of vagally mediated AV block (8.4 ± 3.2 sec vs 4.7 ± 1.0 sec, p<0.05). In chronobiological analysis, episodes of PAVB exhibited a circadian rhythm characterized by a peak between 2:00 am and 4:00 am and a trough between 0:00 pm and 2:00 pm. AECG is a useful tool to detect the maximum pause occurring during sleep and provides critical data necessary to prevent the sudden cardiac death caused by PAVB. J. Med. Invest. 61: 380-387, August, 2014

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The pedicle screw (PS) system is widely used for spinal reconstruction. Recently, screw insertion using the cortical bone trajectory (CBT) technique has been reported to provide increased holding strength of the vertebra, even in an osteoporotic spine. CBT is also beneficial due to its low invasiveness. We have been performing hybrid reconstruction with CBT at the cranial level and PS at the caudal level based on the concept of minimal invasiveness. We applied this hybrid technique to 6 cases of degenerative spondylolisthesis. Surgery was completed with a small skin incision of around 5-6 cm, which is shorter than that of the conventional PS procedure. The mean percent slippage before surgery was 19.8%, and this was reduced to 3.9% after surgery and almost maintained 3 months after surgery. Furthermore, no major surgical complications were observed. Here, we introduce the minimally invasive hybrid technique of CBT-PS. Surgeons should be aware of the procedure as an option for minimally invasive lumbar spine reconstructive surgery. J. Med. Invest. 61: 388-392, August, 2014

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Study Design: Multicenter intraoperative biomechanical analysis. Purpose: This study aimed to assess the maximal insertional torque (MIT) of lateral mass screw (LMS) and pedicle screw (PS) in the cervical or thoracic vertebrae during surgery. Methods: During posterior spinal fusion, cervical or thoracic multi-axial screws were placed at different cervical or thoracic levels and the MIT was recorded for each screw revolution using an analogue torque wrench. Screw number was as follows: 11 PS at C7, 134 LMS (C3-6) (Magerl technique, 70; Roy-Camille technique, 64), and 33 PS in the thoracic region. Results: Average MIT values (cNm) were as follows: for PS (diameter: 3.5 mm) at C7, 45.3 ± 21.9 in men and 60.0 ± 20.1 in women (p=0.28); for Magerl screws, 69.0 ± 20.5 in men and 58.6 ± 15.7 in women (p=0.13); and for Roy-Camille screws, 51.0 ± 17.9 in men and 42.4 ± 15.9 in women (p=0.52). The average MIT for Magerl screws was significantly higher than that for Roy-Camille screws in men and women (both p<0.01). Conclusions: Intraoperative insertional torque could be a good indicator to evaluate the purchase and help guide decisions on screw type and insertion technique. Further postoperative assessments with sequential X-rays are needed to reveal the significance of MIT during posterior spinal fusion. J. Med. Invest. 61: 393-398, August, 2014

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Clinical research is important to improve medical quality, and ethics review is essential to conduct clinical research. Since the establishment of the first Japanese ethics committee at the University of Tokushima in 1982, Japanese ethics committees have increased. In this study, we surveyed the status of clinical studies and ethics committees in one Japanese region. The survey was conducted in collaboration with the Tokushima Medical Association. A questionnaire was established and mailed to all medical institutions (n=737) registered to the Tokushima Medical Association in 2012. Among 737, 223 (30.3%) questionnaires were returned and 221 were completed and are included in this analysis (respondents). Among respondents, 51 (23.1%) had performed clinical research, and of these, 17 had established ethics committees (though one was omitted from the following analysis due to an unsatisfactory response). Among 16 ethics committees, review of protocol amendments, review of serious adverse events, annual follow-up of approved protocols, and education for committee members were active in 10 (62.5%), 9 (56.3%), 6 (37.5%) and 4 (25.0%), respectively. Research ethics education was active in 4 (25.0%). Based on the results, we attempt to establish an appropriate system for ethical conduct of health-related research in Tokushima Prefecture. J. Med. Invest. 61: 399-403, August, 2014

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A 70-year-old woman with dyspnea on exertion was admitted to our hospital. She had a history of apical hypertrophic cardiomyopathy (HCM) and repeated hospitalization for heart failure. Results of physical examination were normal except for leg edema. Echocardiography showed apical HCM with preserved LV systolic function (LVEF=70%). Although dyspnea on exertion and leg edema improved rapidly with the use of diuretics, her symptoms soon worsened when daily activity was started again. In order to examine the effect of preload on hemodynamics, we performed a lower limb positive pressure test by compressing both legs using a household air leg massager. Echocardiography showed increases in mitral E velocity, E/A ratio and pulmonary venous D flow as well as decrease in stroke volume during the lower limb positive pressure test. Simultaneously-recorded pressure study also showed elevated LVEDP and increased v wave of pulmonary capillary wedge pressure. These results suggested that even a small increase in preload led to elevation of LVEDP and symptomatic worsening due to severe diastolic heart failure in the present case. The lower limb positive pressure test may be useful for assessing the effect of preload on hemodynamics in patients with diastolic heart failure. J. Med. Invest. 61: 404-408, August, 2014

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Patellar dislocation is a well-recognized major complication after total knee arthroplasty (TKA). Treatment of this injury is determined according to the cause of the dislocation. In particular, proximal realignment, distal realignment, and lateral retinaculum release are options if patellar instability is not caused by prosthetic malposition. Here we report a case of patellar dislocation following TKA due to rupture of the medial structures that was treated by medial patellofemoral ligament reconstruction and lateral retinacular release. In addition, we provide a brief review of the related literature. J. Med. Invest. 61: 409-412, August, 2014

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We report the case of a 29-year-old male professional soccer player who presented with symptoms of plantar fasciitis. His symptoms occurred with no remarkable triggers and gradually worsened despite conservative treatments including taping, use of insoles, and physical therapy. Local corticosteroid injection was given twice as a further intervention, but his plantar fascia partially ruptured 49 days after the second injection. He was treated conservatively with platelet-rich plasma, and magnetic resonance imaging showed regenerative change of the ruptured fascia. Five months after the rupture, he returned to his original level of training. If professional athletes find it difficult to refrain from athletic activity, as in the present case, the risk of rupture due to corticosteroid injection should not be overlooked. J. Med. Invest. 61: 413-416, August, 2014

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Achilles tendon rupture is a common trauma requiring surgical management. For chronic Achilles tendon rupture in particular, reconstructive surgery is desirable and several methods have been described. Here we present a case of chronic Achilles tendon rupture reconstructed using the semitendinosus tendon because of the difficulty in pulling down the proximal stump to reach the distal stump and due to an insufficient margin for hooking a suture to the distal stump. Postoperatively, the patient had a fully functional tendon and resumed his normal activities of daily living. Using this surgical technique, we expect favorable outcomes in cases of Achilles tendon rupture. J. Med. Invest. 61: 417-420, August, 2014

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A 71-year-old woman had an episode of syncope due to hypoglycemia of 27 mg/dl. She was diagnosed with insulinoma and scheduled for laparoscopic enucleation along with the use of an artificial endocrine pancreas (STG-22, Nikkiso Co., Ltd., Tokyo, Japan). Anesthesia was maintained with sevoflurane and remifentanil. Her blood glucose level was controlled using the artificial endocrine pancreas, which enabled continuous blood glucose monitoring and computer-operated glucose and insulin infusion to maintain the blood glucose level at a steady state. The target concentration of blood glucose was set at 80-120 mg/dl during surgery. Until removal of the tumor, the blood glucose level was kept at around 80-100 mg/dl. After removal of the tumor, the blood glucose level gradually increased, but it was kept in the normal range by the artificial endocrine pancreas. The artificial endocrine pancreas was useful to monitor and maintain blood glucose levels during and after the removal of insulinoma, without any hyper- or hypoglycemia. J. Med. Invest. 61: 421-425, August, 2014

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Acute acalculous cholecystitis (AAC) is a rare complication of infectious mononucleosis (IM). An immunocompetent 6-year-old Japanese girl complained of epigastralgia during the course of IM. Ultrasonography (US) revealed a markedly thickened and sonolucent gallbladder wall. No gallstones were apparent. Antibodies against Epstein-Barr virus (EBV) confirmed primary EBV infection. Cytomegalovirus immunoglobulin M showed a false-positive result in the acute phase, probably due to cross-reaction to EBV nuclear antigen. We diagnosed her as AAC related with primary EBV infection. She recovered completely by conservative treatment. US should be performed in consideration of the possibility of AAC when a patient with IM complains of epigastralgia. J. Med. Invest. 61: 426-429, August, 2014

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We present a rare case of acute onset cauda equina syndrome caused by a ruptured myxopapillary ependymoma with accompanying hemorrhage. A 26-year-old healthy woman developed muscle weakness and sensory disturbances in her bilateral lower extremities. Magnetic resonance imaging showed a huge mass from the L1 body to the L2-3 disc level. She was able to ambulate with crutches after the tumor was successfully removed. To prevent recurrence, she received whole brain and spinal cord radiation. No sing of recurrence were detected at the 8 month follow up. J. Med. Invest. 61: 430-435, August, 2014

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Here we report a rare case of synovial osteochondromatosis of the hip and provide a brief review of the literature. A 37-year-old woman was referred to our department with a 3-year history of right hip pain. At initial consultation, she complained of pain upon standing and when sitting down, occasional pain at rest and nocturnal pain in the right hip, and worsening of the pain at premenstruum. The range of motion of the affected hip was totally limited by pain. Plain radiography revealed a slightly calcified (or ossified) lesion at the acetabular fossa of the right hip. Computed tomography showed clusters of loose bodies filling the acetabular fossa. Synovial osteochondromatosis was suspected and she underwent hip arthroscopic surgery. Complete resection was performed using the lateral and anterior portals. Postoperatively, her symptoms disappeared entirely and she was discharged 4 days after surgery. The patient regained full range of motion of the right hip and follow-up CT revealed no remaining loose bodies in the right hip. Hip arthroscopy is considered to be effective for the diagnosis and treatment of synovial osteochondromatosis of the hip and is minimally invasive. J. Med. Invest. 61: 436-441, August, 2014

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Tension pneumothorax is a rare but potentially life-threating complication of laparoscopic fundoplication. Electrocardiogram (ECG) changes may be used in the diagnosis of intraoperative tension pneumothorax. This case study examines a pediatric patient who underwent laparoscopic fundoplication. Sudden decreases in oxygen saturation were observed during dissection, although the patient's decrease in blood pressure was less marked. Manual ventilation with high inspiratory pressure and inspiratory pause improved oxygenation. The amplitude of the R-wave decreased from 0.8 mV to 0.3 mV in 5 seconds. Twenty minutes later, oxygen saturation decreased again, the R-wave amplitude decreased from 0.3 mV to 0.1 mV in 1 second, and the decrease in blood pressure was marked. Manual ventilation with high inspiratory pressure improved oxygenation, blood pressure, and R-wave amplitude within two minutes. After conversion to open surgery, the cardiorespiratory condition gradually improved, but the R-wave amplitude did not fully recover, even at the end of surgery. Right-side pneumothorax was subsequently confirmed by postoperative chest X-ray. Chest drains were inserted after surgery. This case suggests that trends in R-wave amplitude are potential indicators of intraoperative tension pneumothorax. J. Med. Invest. 61: 442-445, August, 2014

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Apophyseal ring fracture is a unique disease in children and adolescents. Its clinical features include low back pain, sciatica, paravertebral muscle spasm and tenderness, restricted back motion, neurological symptoms, and tight hamstrings. For all athletes, body flexibility is one of the most important factors for better performance. Therefore, persistent tight hamstrings has a negative influence on athletic performance. In this report, we present two adolescent athletes with apophyseal ring fracture treated successfully by conservative treatment for severe low back pain (LBP) and leg pain, despite having persistent tight hamstrings for more than one year. Unlike herniated nucleus pulposus, bony fragments in the spinal canal never disappear. Although conservative treatment can alleviate LBP and leg pain, surgical removal of fragments is considered when symptoms such as tight hamstrings and restricted lumbar motion due to canal stenosis are found, particularly in athletes. J. Med. Invest. 61: 446-451, August, 2014

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