Percutaneous endoscopic surgery for the lumbar spine, which was established in the last decade, requires only an 8-mm skin incision and causes minimal damage to the paravertebral muscles; thus, it is considered to be a minimally invasive technique for spinal surgery. It has been used to perform percutaneous endoscopic discectomy via two main approaches: the TF approach is a posterolateral one through the intervertebral foramen and can be done under local anesthesia; the IL approach is a more traditional one through the interlaminar space and is difficult to perform under local anesthesia. Recently, these techniques have been applied for lumbar spinal stenosis (LSS), the TF method for foraminal stenosis under local anesthesia, and the IL method for central and lateral recess stenosis under general anesthesia. In this study, using a fresh human cadaver model, we performed simultaneous decompression of the lateral recess and foraminal stenosis at L4-5 using the TF approach. Computed tomography confirmed enlargement of the lateral recess and intervertebral foramen. This technique, which can be performed under local anesthesia, should benefit elderly patients with LSS and poor general condition due to multiple comorbidities. Finally, we introduce the concept of percutaneous transforaminal ventral facetectomy using a spinal percutaneous endoscope. J. Med. Invest. 64: 1-6, February, 2017

Primary biliary cholangitis (PBC), formerly known as primary biliary cirrhosis, is an organ-specific autoimmune disease that predominantly affects middle-aged women and is characterized by the chronic progressive destruction of small intrahepatic bile ducts with portal inflammation and, ultimately, fibrosis. The serological hallmark of PBC is the presence of anti-mitochondrial autoantibodies (AMA). Several mechanisms have been proposed for immune-mediated bile duct damage in PBC, including the roles of T cells, B cells, other cell phenotypes, and AMA. A sign of fragility of biliary epithelial cells caused by apoptosis, senescence, and autophagy has also been noted. Several complex steps and mechanisms appear to be involved in the induction and progression of cholangitis and biliary degeneration in patients with PBC. J. Med. Invest. 64: 7-13, February, 2017

The adherens junction (AJ) is a cadherin-based and actin filament associated cell-to-cell junction. AJs can contribute to tissue morphogenesis and homeostasis and their association with actin filaments is crucial for the functions. There are three types of AJs in terms of the mode of actin filament/AJ association. Among many actin-binding proteins associated with AJs, α-catenin is one of the most important actin filament/AJ linkers that functions in all types of AJs. Although α-catenin in cadherin-catenin complex appears to bind to actin filaments within cells, it fails to bind to actin filaments in vitro mysteriously. Recent report revealed that α-catenin in the complex can bind to actin filaments in vitro when forces are applied to the filament. In addition to force-sensitive vinculin binding, α-catenin has another force-sensitive property of actin filament-binding. Elucidation of its significance and the molecular mechanism is indispensable for understanding AJ formation and maintenance during tissue morphogenesis, function and repair. J. Med. Invest. 64: 14-19, February, 2017

Citrus Sudachi is the special local product of Tokushima Prefecture, and over 98% of Sudachi consumed in Japan every year is produced in Tokushima Prefecture. In this study, we evaluated the function of sudachi peel extract (SPE) using an animal model of obesity. C57BL/6 mice were fed a high-fat diet containing 1% SPE powder. Treatment with SPE significantly decreased body weight compared to that of mice fed a high-fat diet. A significant difference in body weight was observed between the control and SPE groups from 7 weeks after the start of the experiment, the significant difference continued until the end of the 14-week experiment. Reduction of blood glucose levels following insulin administration in SPE-treated mice was grater than that in control mice. Determination of mRNA expression in adipose tissue showed that the expression level of TNF-α in the SPE group was significantly decreased compared to that on the control group. These results suggest that SPE potentially has the ability to attenuate body weight gain. J. Med. Invest. 64: 20-23, February, 2017

Rotational alignment of the femoral component in total knee arthroplasty (TKA) is important for patellar tracking and ligament balance. Preoperative planning based on radiography might have a potential risk for over-rotation because these X-ray based measurements can not detect asymmetric cartilage wear on posterior condyle. The purpose of this study is to evaluate the effect of the posterior condylar cartilage of varus osteoarthritic knee on rotational alignment of the femoral component in TKA. We established two different condylar twist angles (CTA) from intraoperative multiplanar reconstruction (MPR) images and intraoperative information of navigation system. The CTA measured by a navigation system that includes the cartilage (4.8±2.0°) was smaller than those measured by MPR images, which does not include the cartilage (6.6±2.1°) (p<0.05). The difference between these two angles that corresponds to the remaining posterior condylar cartilage was 1.7±1.2°. This result demonstrated that the posterior condylar cartilage might lead to over-rotational of the femoral component in varus osteoarthritic knee. Therefore, when determining rotational alignment of the femoral component, surgeons should consider the effect of the remaining posterior condylar cartilage to avoid the over-rotation of the femoral component, especially in severe varus knees. J. Med. Invest. 64: 24-29, February, 2016

Maintenance of axonal excitability relies on complex balance by multiple ion currents, but its evaluation is limited by in vitro single channel neurophysiological study on overall behavior. We sought to evaluate behaviors of multiple ion currents by pharmacological blockade. The threshold tracking technique was used to measure multiple excitability indices on tail sensory nerve of normal male mice before and after administration of either BaCl₂ or ivabradine. Mathematical modeling was used to identify the interval changes of the channel parameters. After administration of BaCl₂ and ivabradine, the following changes were present: greater threshold changes of both depolarizing and hyperpolarizing threshold electrotonus by both; additionally, reduced S2 accommodation, reduced late subexcitability and increased superexcitability by BaCl₂, increased S3 accommodation by ivabradine. Mathematical modelling implied reduction of slow K⁺ conductance, along with reduction of H conductance (Ih) by BaCl₂; and reduction of Ih while augmentation of K⁺ conductances by ivabradine. Pharmacological blockade of a selective ion channel may be compensated by other ion channels. Unintended effects by ion channel modification could be caused by secondary current alteration by multiple ion channels. J. Med. Invest. 64: 30-38, February, 2017

Purpose; To investigate the prevalence, clinical significance of high intensity zone (HIZ), and associated disc degeneration. Materials and methods; We undertook retrospective analysis of 228 patients, aged from 15 to 55 years, who had undergone magnetic resonance (MR) imaging of lumbar spine in outpatient clinic from 2013 to 2014. HIZ was defined as a presence of high intensity signal in the annulus on T2-weighted images. All HIZ positive discs were classified according to Pfirrmann grading system for presence of disc degeneration. Results; Forty-three patients (18.8%) with 53 intervertebral discs demonstrated HIZ. There was no significant predominance about age and gender for the presence of HIZ. HIZ occurred mainly at L4-5 (43.3%) and L5-S1 (30.2%) levels, infrequently at L3-4 (17%) and rarely at upper levels. The prevalence of disc degenerations with Pfirrmann grade 3, 4, and 5 were significantly higher in HIZ positive patients than in randomly selected 35 HIZ negative patients (64% vs. 46%, respectively). Conclusion; In this study we identified that the presence of HIZ was directly proportional to increased incidence of disc degeneration in remaining lumbar discs. The prevalence of significant degeneration was significantly higher in HIZ positive patient at lower three lumbar levels. J. Med. Invest. 64: 39-42, February, 2017

Objectives: To investigate the effects of human umbilical cord blood-derived mononuclear cell (hUCB-MNC) transplantation on pulmonary hypertension (PH) induced by monocrotaline (MCT) in immunodeficient mice and their distribution. Methods: MCT was administered to BALB/c Slc-nu/nu mice, and PH was induced in mice 4 weeks later. Fresh hUCB-MNCs harvested from a human donor after her delivery were injected intravenously into those PH mice. The medial thickness of pulmonary arterioles, ratio of right ventricular to septum plus left ventricular weight (RV/S+LV), and ratio of acceleration time to ejection time of pulmonary blood flow waveform (AT/ET) were determined 4 weeks after hUCB-MNC transplantation. To reveal the incorporation into the lung, CMTMR-labeled hUCB-MNCs were observed in the lung by fluorescent microscopy. DiR-labeled hUCB-MNCs were detected in the lung and other organs by bioluminescence images. Results: Medial thickness, RV/S+LV and AT/ET were significantly improved 4 weeks after hUCB-MNC transplantation compared with those in mice without hUCB-MNC transplantation. CMTMR-positive hUCB-MNCs were observed in the lung 3 hours after transplantation. Bioluminescence signals were detected more strongly in the lung than in other organs for 24 hours after transplantation. Conclusions: The results indicate that hUCB-MNCs are incorporated into the lung early after hUCB-MNC transplantation and improve MCT-induced PH. J. Med. Invest. 64: 43-49, February, 2017

The terminal elimination half-life (t1/2) of empagliflozin is 13.1 hours. Accordingly, we hypothesized that the administration of empagliflozin every other day might improve glycemic control in patients with type 2 diabetes mellitus, not being inferior to the therapy every day. We investigated the clinical effects and safety of the addition of empagliflozin every day or every other day to type 2 diabetic patients with a poor control in glycemia. Thirteen Japanese patients diagnosed as type 2 diabetes mellitus recruited to this study. Subjects were divided into two groups; one was treatment with 10 mg of empagliflozin every day (Group A), the other was 10 mg of empagliflozin every other day (Group B). The comparable study of multiple clinical indexes between the 2 groups was made before and 8, 16, and 24 weeks after the treatment. After the treatment for 24 weeks, the HbA1c level was decreased both in group A (from 7.5%±1.1% to 6.5%±0.8%) and in group B (from 7.6%±0.8% to 7.2%±0.5%). This pilot trial suggested the possibility of 10-mg every other day administration with empagliflozin for Japanese patients with type 2 diabetes mellitus. J. Med. Invest. 64: 50-57, February, 2017

Purpose: To determine whether differences in tumor volume between arterial spin labeling (ASL) and contrast-enhanced T1-weighted MR images (CE+T1WI) can help differentiate glioblastoma (GBM) from brain metastasis. Materials and methods: Patients with a diagnosis of GBM (n=25) or brain metastasis (n=13) were examined by both conventional and ASL MR imaging. Volumes of interest with high signal intensity on ASL and CE+T1WI were defined using three dimensional analysis software. Tumor volume difference (ASL-CE) and tumor volume ratio (ASL/CE) were obtained. Absolute maximal tumor blood flow (TBF) and TBF ratio (normalized to white matter) were also measured. The Mann-Whitney U test and receiver operating characteristic curve analysis were performed to compare measurements between the tumor groups. Results: Both tumor volume difference and tumor volume ratio were significantly higher in GBM than in metastasis. Both TBF and TBF ratio were higher for GBM than for metastasis, but the differences were not significant. Conclusion: The difference in tumor volume as measured by ASL high signal intensity and CE+T1WI might be useful for differentiating GBM from metastasis, whereas ASL-derived TBF is insufficient. J. Med. Invest. 64: 58-63, February, 2017

Although Lp(a) have been thought to be a cardiovascular risk factor, it is unclear whether lowering Lp(a) levels reduces the risk of cardiovascular diseases. No pharmacological agents which selectively reduce serum Lp(a) levels, and Lp(a) is present in primate but absent in common laboratory animals such as mice and pigs. In the present study we used transgenic mice of human Lp(a) and tested effect a novel Lp(a) lowering drug D-47 on neointima formation after vascular injury. D-47 successfully decreased plasma levels of Lp(a) and possibly inhibited neointima formation in Lp(a) transgenic mice. The results indicate that we can modulate plasma Lp(a) levels by pharmacologic agents and inhibit atherogenic properties of Lp(a) by reducing plasma levels of Lp(a). J. Med. Invest. 64: 64-67, February, 2017

Analyses of radiographic changes and clinical symptom of destructive spondyloarthropathy (DSA) on consecutive 42 patients managed with long-term hemodialysis were performed to elucidate radiographic changes of DSA and the factors that influence to the destructive changes. Patients underwent plain radiographs of the cervical spine with 9 years interval. Grading of radiological feature from lateral view was classified into grade 0 to grade 3. Clinical symptom was evaluated using modified Japanese Orthopaedic Association scoring system for cervical myelopathy (mJOA score). Destructive changes were observed in 3 patients at the first examination, and those were observed in 15 patients 9 years after the first examination. There is no statistically significant difference between the duration of hemodialysis and the grade. The mean age at the onset of hemodialysis, however, was significantly higher in patients of grade 2 and 3 than those of grade 1. Older patients with long-term hemodialysis had destructive changes. Destructive changes commonly observed in lower cervical spine. The average numbers of the involved disc level were 1.6 in grade 2 and 1.0 in grade 3. Clinical symptoms were varied in each grade and there was no statistically significant difference in total mJOA score among these grades. J. Med. Invest. 64: 68-73, February, 2017

Aims: This study investigated the efficacy of structured writing on reducing self-harm ideations and enhancing emotion regulation. Methods: Japanese university students (N=22) participated in the study. Participants were randomly assigned to the structured writing group (n=10; 70% female), or an assessment only control group (n=12; 67% female). For three consecutive days, participants in the intervention group performed structured writing that included psycho-education and self-reflection about emotions. The Self-Harm Ideation Scale, the Generalized Expectancy for Negative Mood Regulation Scale, and the Acceptance and Action Questionnaire-II were used to assess outcomes. Results: Structured writing had a short-term effect on expectancies for self-regulation of negative moods and acceptance of negative emotions, but had a limited effect on self-harm ideations. Conclusion: This study presents preliminary evidence that increasing awareness, learning, and reflection about emotions resulting from using a structured writing program is particularly useful for regulating emotions. J. Med. Invest. 64: 74-78, February, 2017

Introduction: Curative laparoscopic gastrectomy (LG) is associated with good outcomes when performed for early gastric cancers. The aim of this study was to identify risk factors for recurrence after LG. Methods: 212 patients with gastric cancer who underwent gastrectomy were enrolled (LG: 143, open gastrectomy, OG: 69). Univariate analysis was used to assess overall (OS) and disease-free survival (DFS) in LG and OG group. Multivariate analysis was used to assess risk factors for recurrence after LG. Results: In LG, six cases of recurrence were observed (liver: 2, peritoneum: 4). Neither lymph node nor port-site recurrences were evident after LG. The 5-year DFS after LG was 91.4%. Based on univariate analysis of 5-year DFS, three negative prognostic factors-lymph node metastasis, lymphatic invasion, and venous invasion-were identified. The independent risk factor for recurrence of LG was lymph node metastasis. LG and OG showed no significant differences in 5-year DFS among Stage IA, IB, IIA, and IIB groups. Independent risk factors for recurrence after LG or OG were tumor invasion≥muscularis mucosa and lymph node metastasis. Conclusions: DFS following LG is comparable to that following OG. Lymph node metastasis is an independent risk factor for gastric cancer recurrence after LG. J. Med. Invest. 64: 79-84, February, 2017

Purpose: The aim of this study was to clarify the changes in medication-taking behavior and related factors over time in patients with initial mild cerebral infarction up to 12 months after onset. Methods: Thirty-one patients with initial mild cerebral infarction were surveyed a total of four times: on admission to hospital, 3 months after onset, 6 months after onset, and 12 months after onset. Patients were surveyed regarding medication compliance, awareness of taking medication, perceived behavioral control, lifestyle risk factors, and subjective norms. Results: Medication compliance improved over time from the time of admission, but no changes were seen in awareness of taking medication. A cluster analysis based on changes in medication compliance over time revealed a “Persistently high compliance group” and a “Persistently low compliance group” for medication compliance. The health locus of control in the “Persistently high compliance group” was perceived as the result of chance and fate. Conclusions: Assessing the current state of medication compliance and the health locus of control during hospitalization permitted an understanding of patient characteristics, and indicated a need for recurrence prevention education and medication guidance tailored to each patient's cognitive and behavioral characteristics. J. Med. Invest. 64: 85-95, February, 2017

Purpose: We investigated the relationship between uncertainty and emotions in advanced lung cancer patients after initial therapy. Methods: Fourteen advanced lung cancer patients participated in this study. A survey was conducted using the Universal Uncertainty in Illness Scale (UUIS) and the Profile of Mood States-Brief Form (POMS-Brief Form), Japanese Version. Results: The total UUIS score of each participant ranged from 42 to 109, with a mean±SD of 70.7±20.9. The T-scores for the 6 factors of the POMS-Brief Form were 50.2±11.9 (mean±SD) for tension-anxiety (T-A); 49.6±12.2 for depression-dejection (D); 40.4±4.9 for anger-hostility (A-H); 41.8±9.3 for vigor (V); 44.2±5.8 for fatigue (F); and 52.7±15.2 for confusion (C). In terms of the correlation between the total UUIS score and the respective T-scores of the six POMS-Brief Form factors, a strong correlation was seen between total UUIS score and D (r=0.735, p=0.003). A substantial correlation was also seen between total UUIS score and T-A (r=0.694, p=0.006). Conclusions: In advanced lung cancer patients after initial therapy, uncertainty had an effect on emotions. J. Med. Invest. 64: 96-100, February, 2017

In this study, we have investigated the effects of the newly synthesized analog of Pseudomonas aeruginosa quorum-sensing autoinducer named AIA-1 (autoinducer analog) against antibiotic-resistant bacteria. In vitro susceptibility and killing assays for P. aeruginosa PAO1ΔoprD mutant and clinical isolates were performed by using antibiotics and AIA-1. In an in vivo assay, a luminescent carbapenem-resistant strain derived from PAO1ΔoprD was injected into neutropenic ICR mice and bioluminescence images were acquired after the treatment with antibiotics and AIA-1. Additionally, we investigated the effects of the combination use against carbapenem-resistant Enterobacteriaceae (CRE). Using killing assays in P. aeruginosa, the survival rates in the presence of antibiotics and AIA-1 significantly decreased in comparison with those with antibiotics alone. Furthermore, dual treatment of biapenem and AIA-1 was more effective than biapenem alone in a mouse infection model. AIA-1 did not change the MICs in P. aeruginosa, suggesting that AIA-1 acts on the mechanism of antibiotic tolerance. Conversely, the MICs of antibiotics decreased in the presence of AIA-1 in some CRE strains, indicating that AIA-1 may require additional mechanism to act on CRE. In conclusion, AIA-1 may be a potent drug for clinical treatment of infections caused by antibiotic-resistant bacteria. J. Med. Invest. 64: 101-109, February, 2017

Objective: Idiopathic interstitial pneumonias (IIPs) are a group of heterogeneous diffuse parenchymal lung disorders of unknown etiology. An acute exacerbation (AE) is an acute respiratory deterioration that occurs in IIPs. The prognosis of AE of IIPs (AE-IIPs) is extremely severe; however, no established therapies exist. We aimed to evaluate the efficacy of leukocytapheresis (LCAP) to treat patients with AE-IIPs. Patients and Methods: Six chronic IIPs patients who developed AE were enrolled in this study. We performed LCAP on days 2, 3, 9 and 10 in all six patients. All patients were also treated with high-dose corticosteroids and a continuous administration of low-molecular-weight heparin. We observed 30-day survival after the diagnosis of AE to evaluate the efficacy of LCAP. We also assessed oxygenation, high-resolution computed tomography (HRCT) findings, and certain chemical mediators in the peripheral blood. Results: Five of six patients survived more than 30 days. One patient died of progressive respiratory failure. Oxygenation and HRCT findings tended to improve in all survivors. The serum levels of lactate dehydrogenase, high mobility group box-1, and interleukin-18 were significantly decreased statistically post-LCAP. No severe adverse events occurred. Conclusion: We suggest that LCAP is a safe and effective therapy for treating patients with AE-IIPs. J. Med. Invest. 64: 110-116, February, 2017

Purpose: To investigate the utility of the Short Nutritional Assessment Questionnaire (SNAQ) in the nutritional evaluation of patients with cancer undergoing outpatient chemotherapy. Methods: We included 229 patients with cancer who were undergoing outpatient chemotherapy between October 2015 and April 2016. The SNAQ and the revised SNAQ (addition of age and body mass index) were implemented, and their relationships with Controlling Nutritional Status (CONUT), an indicator of bionutritional assessment, were examined. Results: The cutoff value of the SNAQ score corresponding to moderate-to-severe undernourishment in CONUT values was 0.5, with a sensitivity of 87.5% and a specificity of 65.9%, and the corresponding values for the revised SNAQ score were 2.5, 91.7%, and 62.9%, respectively. This cutoff value and the corresponding positive prediction value for the revised SNAQ were superior to those of SNAQ. Binary logistic regression analysis with the revised SNAQ and sex as independent variables and the CONUT value as the dependent variable revealed that the higher the SNAQ score, the more likely it was that CONUT moderate-to-severe undernourishment would be identified (odds ratio, 1.48;, 1.34-1.96). Conclusion: Nutritional evaluation with the revised SNAQ can predict moderate-to-severe undernourishment according to CONUT in patients with cancer undergoing outpatient chemotherapy. J. Med. Invest. 64: 117-121, February, 2017

Accumulating evidence supports the “glucagonocentric hypothesis”, in which antecedent α-cell failure and inhibition of glucagon secretion are responsible for diabetes progression. Protein kinase C (PKC) is involved in glucagon secretion from α-cells, although which PKC isozyme is involved and the mechanism underlying this PKC-regulated glucagon secretion remains unknown. Here, the involvement of PKCδ in the onset and progression of diabetes was elucidated. Immunofluorescence studies revealed that PKCδ was expressed and activated in α-cells of STZ-induced diabetic model mice. Phorbol 12-myristate 13-acetate (PMA) stimulation significantly augmented glucagon secretion from isolated islets. Pre-treatment with quercetin and rottlerin, PKCδ signaling inhibitors, significantly suppressed the PMA-induced elevation of glucagon secretion. While Go6976, a Ca²⁺-dependent PKC selective inhibitor did not suppress glucagon secretion. Quercetin suppressed PMA-induced phosphorylation of Tyr³¹¹ of PKCδ in isolated islets. However, quercetin itself had no effect on either glucagon secretion or glucagon mRNA expression. Our data suggest that PKCδ signaling inhibitors suppressed glucagon secretion. Elucidation of detailed signaling pathways causing PKCδ activation in the onset and progression of diabetes followed by the augmentation of glucagon secretion could lead to the identification of novel therapeutic target molecules and the development of novel therapeutic drugs for diabetes. J. Med. Invest. 64: 122-128, February, 2017

Maintenance hemodialysis outpatients must limit salt and water intake to maintain electrolyte balance and blood pressure. In Kawashima Hospital, nationally registered dietitians provide hemodialysis patients with monthly nutritional counseling. We investigated whether nutritional counseling affects interdialytic weight gain (IDWG) and blood pressure. We investigated 48 hemodialysis patients whose monthly average IDWG ratio to dry weight exceeded 5.1% and who had not had a long-term hospital admittance of > 1 month. After the 48-month nutritional counseling period, the IDWG ratio had improved in 37 of the patients (77.1%), significantly decreasing from 6.0±0.7 to 5.3±0.9%. Estimated salt and water intake decreased significantly from 13.3±2.7 to 11.8±2.4 g/day and 2528±455 to 2332±410 ml/day, respectively. During the intervention period, normalized protein catabolic rate and body mass index did not change substantially. Pre-hemodialysis systolic and diastolic blood pressures had significantly decreased from 149±19 to 134±18 mmHg, and 82±13 to 75±10 mmHg for 48 months after study initiation, respectively. The dosage of antihypertensive drugs had significantly decreased in the group that experienced improvement in the IDWG ratio. Long-term nutritional counseling by nationally registered dietitians may improve the IDWG ratio and blood pressure of hemodialysis patients by decreasing their salt and water intake. J. Med. Invest. 64: 129-135, February, 2017

Background: It was reported that hamstring muscle tightness may increase mechanical loading on the lumbar spine. Therefore, we attempt to decrease tightness in the leg muscles in pediatric patients. Methods: Forty-six pediatric patients with spondylolysis underwent rehabilitation. We applied active stretching to the hamstrings, quadriceps, and triceps surae. Tightness in each muscle was graded as good, fair, or poor. We educated each patient on how to perform active stretching at home. They were re-evaluated for muscle tightness 2 months later. Results: Tightness at baseline and after 2 months was as follows: for the hamstrings, good in 3 patients, fair in 9, and poor in 34 and significant improved after 2 months (p<0.05), with improvement by least 1 grade seen in 86% of patients with fair or poor at baseline; for the quadriceps, 7, 3, and 30 patients had good, fair and poor, with significant improvements in 72% (p<0.05). For the triceps surae, 6, 3 and 10 patients had good, fair and poor, which improved significantly (p<0.05). Conclusion: Home-based active stretching was effective for relieving muscle tightness in the leg in a pediatric population. Adolescent athletes should perform such exercise to maintain flexibility and prevent lumbar disorders. J. Med. Invest. 64: 136-139, February, 2017

Background/Aims: To determine whether the presence of a multidisciplinary rehabilitation nutrition team affects sarcopenia and cachexia evaluation and practice of rehabilitation nutrition. Methods: A cross-sectional study using online questionnaire among members of the Japanese Association of Rehabilitation Nutrition (JARN) was conducted. Questions were related to sarcopenia and cachexia evaluation and practice of rehabilitation nutrition. Results: 677 (14.7%) questionnaires were analysed. 44.5% reported that their institution employed a rehabilitation nutrition team, 20.2% conducted rehabilitation nutrition rounds and 26.1% conducted rehabilitation nutrition meetings. A total of 51.7%, 69.7%, 69.0% and 17.8% measured muscle mass, muscle strength, physical function and cachexia, respectively. For those with a rehabilitation nutrition team, 63.5%, 80.7%, 82.4% and 22.9% measured muscle mass, muscle strength, physical function and cachexia, respectively, whereas 46.7%, 78.0% and 78.1% of the respondents reported implementation of nutrition planning strategies in consideration of energy accumulation, rehabilitation training in consideration of nutritional status and use of dietary supplements, respectively. Multivariate logistic regression analysis showed that the use of a rehabilitation nutrition team independently affected sarcopenia evaluation and practice of rehabilitation nutrition but not cachexia evaluation. Conclusions: The presence of a multidisciplinary rehabilitation nutrition team increased the frequency of sarcopenia evaluation and practice of rehabilitation nutrition. J. Med. Invest. 64: 140-145, February, 2017

Background: Serum albumin concentration (SAC) is a prognostic factor that is affected by many factors such as postural change, liver function and food intake. Chronic kidney disease (CKD) patients excrete proteinuria, have low-protein diet, and receive glucocorticoid therapy. No one has evaluated the most influential factors on SAC in CKD patients. Methods: A retrospective study. Hospitalized CKD patients with less than 1 g/gCreatinine proteinuria receiving glucocorticoid therapy (n=28), with 1 or more g/gCreatinine proteinuria not receiving glucocorticoid therapy (n=36), and with 1 or more g/gCreatinine proteinuria receiving glucocorticoid therapy (n=39) were enrolled. SAC, hemoglobin, proteinuria and blood pressure at the last outpatient check-up before hospitalization, on the second day of hospitalization, at the last laboratory examination before discharge, as well as at the first outpatient follow-up after discharge were analyzed. Results: SAC decreased on the second day of hospitalization and increased at the first outpatient follow-up significantly in all groups. Unexpectedly, the change of SAC was irrelevant to the amount of proteinuria. Conclusions: SAC was affected by not only proteinuria, but also postural change, physical activity, and food in CKD patients. SAC should be analyzed by standardizing a patient's condition during phlebotomy. J. Med. Invest. 64: 146-152, February, 2017

Objective: To improve primary prevention of child maltreatment, the association between at-risk parents identified by maternity hospitals and local health centers and intervention outcomes was investigated. Methods: A screening program for primary prevention of child maltreatment has been implemented for parents with children aged<3 years in A Prefecture. At-risk parents are identified at maternity hospitals and local health centers. Public health nurses provide intervention to promote positive parenting through home visits, and referred to child protective centers when they suspect child maltreatment. Results: Between 2009 and 2014, a total of 2,252 new at-risk parents were identified, 956 from maternity hospitals and 1,296 from local health centers. Among these at-risk parents, 356 (15.8%) were referred to child protective centers for possible child maltreatment, 88 of which came from maternity hospitals and 268 from local health centers. The rate of referral from maternity hospitals was significantly lower than that from local health centers (9.2% vs. 20.7%, p<0.001). Conclusions: Identification of at-risk parents during pregnancy and early intervention resulted in a decrease in the rate of referrals to child protective centers. The specific risk factors of “perceived lack of social support”, “mental illness” and “teen pregnancy” may be mitigated by early intervention. J. Med. Invest. 64: 153-159, February, 2017

The coexistence of technology and caring is best exemplified in nursing. The theory of Technological Competency as Caring in Nursing illuminates this coexistence as the essence of technology in health care premised on machine technologies as a generic concept of objects or things that are mechanical, organic, and electronic. With its timely development these technologies are continually imbued with artificial general intelligence. As such, the ultimate expression of machine technologies in nursing turns out to be autonomous robots (ARs) with future potentials of functions comparable to human persons. While theory-based nursing practice is essential to nursing care practice, quality human care, particularly with technologies assuming indispensable practice process mechanisms is critical. Some practice-based questions informing ARs and human person engagements in nursing care practice include, “Will ARs which are imbued with artificial intelligence replace nurses in their practice?” “What contributions to quality human health care will autonomous and artificially intelligent robots provide?” While these questions may reflect far-reaching ramifications of technologies in health care, it must also be acknowledged that these technologies are fundamental to the delivery of quality human health care now, and in the future. J. Med. Invest. 64: 160-164, February, 2017

We describe a case of acute oculomotor nerve palsy caused by a ruptured middle cerebral artery (MCA) aneurysm. A 59-year-old female presenting with headache and nausea was admitted to our hospital. Her consciousness was alert, and had no other neurological deficit without left oculomotor nerve palsy. A computed tomography (CT) showed SAH extending from left sylvian cistern to basal cistern. CT angiography revealed a left MCA aneurysm which protruded toward internal carotid artery. The patient was successfully treated with surgical clipping. The oculomotor nerve palsy resolved immediately after the surgery. Perioperative radiological evaluation revealed that there were no evidence of midbrain hemorrhage or stroke, vessel anomaly of basilar, posterior cerebral or superior cerebellar artery, vasospasm, and uncal herniation. Furthermore, intraoperative findings revealed that the aneurysm was projected toward the affected carotid cistern and oculomotor nerve. From these findings and time course of oculomotor nerve palsy, it is suggested that the jet flow of bleeding from the ruptured MCA aneurysm caused oculomotor nerve palsy in the patient. J. Med. Invest. 64: 165-167, February, 2017

Presently, lumbar spondylolisthesis did not have the indication of direct repair surgery because of the difficulty to reduce the slippage. In this report, we presented a case and described a minimally invasive direct repair surgery to reduce and repair the pars interarticularis defects of lumbar spondylolisthesis. First, curettage and removal of the synovium of the pars interarticularis and decompression of nerve root are conducted. Next, cancellous bone is harvested from the iliac crest. And then the Percutaneous Pedicle Screws are inserted bilaterally. A rod is bended and placed just caudal to the spinous process. We can make reposition of slipped vertebra and stabilize the loose lamina more firmly using a reduction tool and a rod pusher. Finally, bone grafts are implanted onto the pars defects. The Smiley face rod method is very useful to reduce the slippage and repair the pars defects in the lumbar spondylolisthesis especially in adolescent athletes. J. Med. Invest. 64: 168-172, February, 2017

Fibroma of tendon sheath, which is a benign soft tissue tumor, primarily affects the finger, hand, or wrist. It rarely involves the knee and only a few cases appear in the literature. Here, we report a case of fibroma of tendon sheath on the medial side of the knee, in a previously hardly reported location, and provide detailed imaging and histological findings. A 54-year-old man presented with his right knee pain and a palpable mass that had developed 3 months earlier. Magnetic resonance imaging showed isointensity in the soft tissue tumor on T1-weighted images, variable intensity on T2-weighted images, and contrast enhancement. The specimen obtained by needle biopsy showed no histological findings of malignancy. Marginal resection was performed and the microscopic diagnosis was fibroma of tendon sheath. Since fibroma of tendon sheath is relatively rare, the radiological feature is not specific, and a rate of local recurrence following excision is high, careful diagnosis, surgical treatment and long-term follow-up are necessary. J. Med. Invest. 64: 173-176, February, 2017

Herein, we report coincident recurrences at the port site and functional end-to-end anastomosis after laparoscopic right hemicolectomy for cancer of the ascending colon. The patient was an 83-year-old man who had undergone the aforementioned procedure (Stage IIA) in the referral hospital. At the 10-month follow-up, computed tomography showed two tumours around 3 cm in diameter: one on the right-flank abdominal wall - the surgical port-site - and the other at the functional end-to-end anastomosis. Likewise, a positron emission tomography scan was positive for two tumours. Endoscopic examination showed an ulcerated tumour with a clear margin, and a biopsy confirmed moderately differentiated tubular adenocarcinoma. The patient was diagnosed with coincident recurrences at the port site and functional end-to-end anastomosis after laparoscopic right hemicolectomy for cancer of the ascending colon. We re-operated in March 2016. The tumours at the functional end-to-end anastomosisand functional end-to-end anastomosiswere resected. After 7 months, no recurrence was detected. J. Med. Invest. 64: 177-180, February, 2017

A healthy 18-year-old girl was referred to our hospital for further evaluations of cardiac angiosarcoma. Transthoracic echocardiography showed an immobile 4.6 cm×3.7 cm cardiac mass. The mass was occupying right atrial chamber and partially, invading into annulus of tricuspid valve on transesophageal echocardiography. At surgery, the mass was seen to be protruding from right atrial appendage and adhering to right side of pericardium. The histological findings were consistent with cardiac angiosarcoma and immunological staining was positive for CD34 and CD31. Afterward, although she received radiochemotherapy, she died of metastasis of cardiac angiosarcoma more than three years after surgical resection. J. Med. Invest. 64: 181-183, February, 2017

With increased interest in fitness and health care, jogging has become more popular as an exercise to promote health. However, sudden cardiac death during sports or exercise has also been reported. Some apparently healthy elderly individuals take up sports for both recreation and health improvement based only on completion of a questionnaire, without undergoing medical evaluation. We report the case of a 66-year-old Japanese man who suddenly died of acute ischemic heart disease during first-time jogging. He collapsed an hour after starting. A trainer promptly started cardiopulmonary resuscitation. An automated external defibrillator (AED) was applied, and defibrillation was attempted once by bystanders. However, he remained in cardiopulmonary arrest until he reached the emergency department, where he was pronounced dead. The autopsy found concentric hypertrophy of the left ventricular wall without fibrosis or degeneration, atherosclerotic changes in the coronary arteries, and severe lung congestion. We diagnosed death from acute myocardial ischemia. We suspect that many healthy elderly individuals have provoked a heart attack by prematurely attempting moderate or vigorous exercise, as in this case. The elderly require comprehensive medical assessment before exercise can be started. Moreover, this case shows that an AED is not always helpful. J. Med. Invest. 64: 184-186, February, 2017

The strategy for an infant with congenital mitral stenosis should be determined by three important factors: left ventricular volume, the degree of the systemic outflow tract obstruction, and the type of mitral valve dysfunction. A successful staged biventricular repair in early infancy for a patient who had congenital mitral stenosis with short chordae, hypoplastic left ventricle and coarctation of the aorta, and the long-term results are described. There were the following important hemodynamic factors that led to the successful biventricular repair in the patient. Total systemic output was barely supplied through the hypoplastic left ventricle after closure of the ductus arteriosus on admission. The neonate underwent repair of coarctation of the aorta alone as the initial stage at 9 days after birth. Also, spontaneous closure of the foramen ovale following repair of coarctation of the aorta accelerated the progressive left ventricular growth. Open mitral commissurotomy with an interatrial fenestration using the modified Brawley's approach was performed for a 40-day-old infant. Good left ventricular growth and good mitral valve function have been observed for 18 years after open mitral commissurotomy. Appropriate early augmentation of left ventricular inflow through the mitral valve might be effective for growth of a hypoplastic left ventricle. J. Med. Invest. 64: 187-191, February, 2017