Coronary multi-detector row computed tomography (MDCT) has rapidly progressed since 64-slice MDCT significantly improved the temporal and spatial resolution of coronary anatomy. Coronary CT has recently become a standard clinical tool that can rule out coronary artery disease (CAD) and detect coronary lesions. Many reports have described the excellent accuracy of 64-slice MDCT in detecting significant stenosis. Coronary atherosclerotic plaque can also be visualized using MDCT and the most recent types of MDCT such as 320-slice and dual-source CT have rapidly spread. Thus, coronary MDCT technology is still under development.

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Capsule endoscopy (CE) is a feasible, non-invasive and safe modern-day medical procedure for the detection and diagnosis of small-intestinal lesions that are not accessible with a conventional colonoscope or an upper gastrointestinal endoscope. CE reflects a very much desired advance in the identification and diagnosis of intestinal disorders. CE is a tiny device bearing a camera, which is swallowed by the patient. As it moves along the intestine, multiple images are taken from the inside wall of the intestine and wirelessly transmitted to a recorder, which is attached to the patient. Recently, CE has gained an unrivalled popularity for examinations of the small-bowel.

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Diffusion tensor imaging (DTI) is one of the most promising MRI techniques for characterizing microstructural changes of cerebral white matter in brain research and clinical applications. The number of DTI studies is increasing, and more than 7500 articles have been published over the last decade. DTI enables visualization and characterization of white matter tracts in vivo by providing a unique image contrast on white matter that is unavailable with routine MR techniques; this allows three-dimensional (3D) visualization of neuronal pathways and quantification of the diffusion properties of white matter. Since its introduction in 1994, DTI has been used to study the structure of white matter and changes to its integrity within normal brains and brains affected by aging, stroke, dementia, psychiatric disorder, tumor, and other conditions. In this paper, the technical aspects and clinical applications of DTI are reviewed with a focus on clinical use and in vivo studies. The strengths and weaknesses of the approach are discussed and current extensions of the technology (q-space imaging and diffusional kurtosis imaging) are summarized.

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Ultrasonography (US) using a high frequency probe has recently gained attention as a useful diagnostic imaging tool in the routine medical care of musculoskeletal diseases including rheumatoid arthritis (RA) because it allows detailed real-time observation of soft tissues in shallow layers including the synovium, tendons, muscles, blood vessels, and nerves. Using a gray scale, US plots synovial thickening and synovial fluid retention in joint capsules and tendon sheaths, and then shows blood flow signals using the Doppler method. This allows diagnosis of active synovitis, arthritis, and tenosynovitis depending on whether the observed Doppler signal appears as an accumulation of spotty signals in line with the site of synovial thickening. US is useful for the early diagnosis, determination of activity and remission, and prediction of prognosis of arthritis because of its higher sensitivity to detect inflammation in an articular site compared with that of conventional and blood examinations. Because performing routine joint US for an articular site in every patient is difficult due to temporal restriction, it is practical to perform joint US only in selected cases and when conventional examinations fail to detect inflammation around the articular sites. Therapeutic agents for RA have significantly advanced in recent years. Improvements in the diagnostic techniques for RA are also needed. Joint US is a useful diagnostic imaging tool that promises better medical care through complementation of judgment based on conventional examination.

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Background: Disaster is a serious public issue. Japan is a disaster-prone country, and historically has experienced extremely major disaster-related accidents. Juntendo hospital was established in Tokyo in 1838, and has been reconstructed completely after various disasters as a disaster-resistant hospital.
Training design and curriculum: A disaster medicine training program was started for 2nd-year medical students at Juntendo University in 2008, and it has consisted of a general introduction (Lecture, 90 minutes) together with three types of practical training including first aid, victim transport and triage (Practice, each 120 minutes). These practices are carried out in a mixed style “lecture plus problem based learning plus practice exercise”. The key competencies addressed in the general introduction are the types of disasters, the disaster medical system in Japan, DMAT (Disaster Medical Assistant Team), triage methods and crush syndrome. Furthermore, medical students watch the disaster scene video, and discuss the solutions to problems at the scene with problem-based learning. The three types of practices including first aid, victim transport and triage are guided by an emergency care doctor collaborating with non-physician teaching staff members from 13 departments of basic medical sciences.
Conclusions: The disaster medicine education and training program at Juntendo University, especially its mixed education style and faculty constitution, is exceptional and unique, and is popular among the students. In order to carry on the Juntendo spirit of ‘unbowed’ hospital, this program should continue to be developed in the future.

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To understand the role as a nurse working in an emergency primary care center during times of disaster, we performed disaster simulative desk-top training drills. During the simulative training, the Emergo Train System (ETS) was used.
ETS: Is an interactive educational simulation system developed at the Centre for Teaching and Research in Disaster Medicine and Traumatology (KMC) at the University of Linkoping, Sweden. ETS can be used for education, training, and simulations of emergencies and disasters. ETS can be used to test and evaluate incident command systems, hospital preparedness and surge capacity. www.emergotrain.com
From the training and the discussion held afterwards, we were able to recognize the need to be more aware of the crisis in disaster situations by strengthening the disaster education system and possibly initiating an action card system in the near future.

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Currently, we are most afraid of a “megaquake”, which may strike the Tokai, Nankai and East-Nankai regions simultaneously and trigger massive tsunamis. Located 3 kilometers inland and protected by two barriers, Juntendo University Shizuoka Hospital is not likely to suffer from tsunami damage. However, as a designated core hospital for rescue operations in Shizuoka Prefecture, we take disaster preparedness very seriously and engage in stockpiling supplies and training our staff. We also joined the Disaster Medical Assistance Team (DMAT). Our “Doctor Helis” were used most frequently after the Great East Japan Earthquake. Being a key player in the area, we conduct joint rescue training exercises with the fire departments in Eastern Shizuoka. This report briefly discusses the current issues and efforts being made to further prepare for future disasters.

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The Great East Japan Earthquake caused unprecedented damage and led to a massive loss of life. Damage spread beyond Tohoku, and Juntendo University Urayasu Hospital, which adjoins Tokyo along Tokyo Bay, suffered from ground subsidence, liquefaction, and disruption of lifeline systems [systems for electric power, natural gas, water and wastewater, and transportation]. Starting in the very early stages of the disaster, Urayasu Hospital dispatched a disaster medical assistance team (DMAT) and medical aid team. The hospital’s water supply and sewerage systems were damaged and water supply was disrupted, hampering its ability to continue providing care. Based on this experience, a disaster task force member centrally involved in formulating the hospital’s emergency response to the water supply disruption, submitted a business analysis report on which large parts of this article are based. We prioritized water uses and he cited the need to prepare for disasters. A disaster response hospital, Urayasu Hospital has established committees to prepare for disasters and it continues to conduct drills. The hospital also began operating a Rapid Response Car. Urayasu Hospital seeks to be ready for disasters by drawing on lessons from the Great East Japan Earthquake. Urayasu Hospital seeks to improve patient survival and enhance the local emergency response system by dispatching DMATs and by operating a Rapid Response Car.

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Our hospital is the only hospital in Nerima where emergency doctors are available to provide medical care 24 hours a day, and is in the position to accept patients in the event of disaster as a disaster base hospital. Even though Nerima-ward is a commuter town in Tokyo with a population of 700,000, the number of beds per capita is the lowest among the 23 wards. That being said, we have been working to build a regional collaboration among local hospitals, medical associations, and administrative bodies since our establishment as our contribution toward disaster control. For our in-hospital measures, we provide triage training and BCP (Business Continuity Plan) simulations, and have upgraded our facilities and increased our on-hand supplies for potential disasters. Moreover, we managed to send 13 staff to the site of the Great East Japan Earthquake in March 2011 for medical support. Other measures include our participation in and management of MIMMS (Major Incident Medical Management and Support), which is a course for disaster simulation training and DMAT (Disaster Medical Assistance Team) activity.

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The arterial distribution to the rotator cuff muscles was studied in 14 upper extremities of Japanese cadavers and its diversity was correlated with the variable arterial origin.
The supraspinatus was supplied with arterial branches from the suprascapular artery (SPS), the infraspinatus with those from SPS and from the circumflex scapular artery (CS), and the teres minor with those from the posterior circumflex humeral artery and from CS, and the dorsal aspect of the subscapularis with those from SPS and from CS, whereas the ventral aspect of the subscapularis was supplied with branches from several variable origins. On the basis of origin and course, SPS was classified into proximal and distal types (pSPS and dSPS) and the subscapular artery was classified into superficial and deep types (sSBS and dSBS). The boundary between the distribution areas of SPS and CS in the infraspinatus and the dorsal aspect of subscapularis were variable and influenced primarily by the types of SPS with larger distribution areas of SPS in the cases of dSPS, and secondarily by the types of SBS with larger distribution areas of CS in the cases of dSBS. The kinds of branches and their distribution areas to the ventral aspect of the subscapularis were influenced by both the types of SPS and SBS.
The present study revealed the main distribution areas of arteries in the rotator cuff muscles and their variation, and predicted the weakly vascularized areas in these muscles, which corresponded well to the localization of trigger points that elicit referred pain.

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Purpose: Delirium is one of the most common postoperative complications among elderly patients undergoing major surgery. However, biomarkers for delirium have not yet been elucidated. We therefore investigated the relationship between postoperative delirium and the serum anticholinergic activity (SAA).
Materials: Patients undergoing elective esophagectomy or gastrectomy under combined thoracic epidural and general anesthesia were prospectively studied.
Methods: The levels of SAA were measured inside the operating room after the induction of anesthesia before the surgery began, and immediately after the surgery had finished, but before the patient awoke from anesthesia. The occurrence of postoperative delirium was determined using the Confusion Assessment Method (CAM).
Results: Postoperative delirium was identified in 41.2% of the 34 patients enrolled in this study. Compared with the non-delirious group, the delirious group had a significantly higher number of preoperatively SAA (+) patients whose elevated SAA levels were still detectable after surgery (p < 0.05).
Conclusions: Patients who had incomplete or no ability to compensate for the elevated anticholinergic activity were more likely to develop postoperative delirium.

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The podocyte possesses a unique morphology characterized by a large cell body and numerous foot processes, which enwrap the glomerular capillary. The intercellular space between foot processes is kept wide open to pass through the glomerular filtrate and connected with the slit diaphragms. It has been believed that the slit diaphragm plays an important role in permeability barrier function, because the lack of the components of slit diaphragm causes massive proteinuria. The podocyte is derived from the polarized epithelial cell mass converted from the undifferentiated metanephric mesenchyme at the first stage of glomerular development. The dramatic structural and functional transformation of the podocyte is occurred during differentiation of the kidney. The morphological changes of podocytes seen under the pathological condition are tightly associated with the pathogenesis of proteinuria. The organization and maintenance of the unique cell shape is achieved by the novel cytoskeletal elements. Especially, regulation of actin filaments in foot processes is important for maintaining integrity of the cytoskeleton and organization of the slit diaphragm. Recently, we have focused on two myosins which are actin-binding motor proteins and expressed in podocyte. In addition, we have investigated a new cell signaling system at the slit diaphragm. In this lecture, I review our recent progress in the function of those molecules in health and disease.

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Bone marrow (BM) microenvironment plays a critical role in the process of leukemogenesis with the dynamic interactions between leukemic cells and cells of the bone marrow microenvironment. In the BM microenvironment, two kind of BM specific niches, “osteoblastic (endosteal)” and “vascular” niches, provide a sanctuary for subpopulations of leukemic cells to evade chemotherapy-induced death and allow acquisition of a drug-resistant phenotype. The key components and regulatory mechanisms (via cytokines, chemokines, adhesion molecules, and hypoxic conditions) of these niches contribute to the process of leukemogenesis. The understanding of the molecular pathways critical for microenvironment/leukemia interactions and the contribution of the BM niches to the leukemogenesis may provide a rationale for appropriately tailored molecular therapies targeting not only leukemic cells but also their microenvironment to ensure improved outcomes in leukemia. At the same time, the better understanding of the nature of hematopoietic stem cells, leukemia stem cells and their niches is expected to provide an alternative approach to the treatment of various serious diseases, including leukemia, in clinical practice.

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The case is a 76-year-old woman, who consulted our hospital due to back pain and bilateral costalgia. She was diagnosed with multiple bone metastases of the right breast cancer upon close examinations. The result of a needle biopsy indicated a human epidermal growth factor receptor-2 (HER2) enriched type papillotubular carcinoma. Treatment due to trastuzumab was not suitable because of poor cardiac function, leading to the selection of a denosumab-administration regimen against systemic bone metastases in addition to capecitabine. Denosumab was subcutaneously injected in 120 mg doses every 4 weeks, and oral administration of capecitabine at 1,200 mg/day (administration for 3 weeks and 1 week drug withdrawal) was initiated from the second denosumab administration onwards. After initiation of the combination therapy of denosumab and capecitabine, the levels of tumor markers were gradually decreased, accordingly, the tumor size in the right breast was regressed. The patient’s general condition was also significantly improved. Few adverse events were recognized in combined therapy using denosumab and capecitabine, and it was believed to have high efficacy and tolerability in cases with poor performance status.

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Two pediatric patients for whom local anesthetic infiltration of the wound was used for postoperative pain management are reported. Case 1 was an 11-year-old male undergoing pyeloplasty. Surgery was performed by a lumbodorsal approach. During wound closure, an 18-gauge multi-hole catheter was placed on the layer above the transversus abdominis muscle. Postoperatively, 20 ml of ropivacaine 0.375% were administered through the catheter, and continuous infusion of ropivacaine 0.2% at 3 ml/h was performed. As additional analgesia, fentanyl 0.2 μg/kg/h was infused intravenously. Pain scores on the Numerical Rating Scale (NRS) and the Prince Henry Pain Scale (PHPS) were low (NRS: 0-2, PHPS: 1) until the catheter was removed. No side effects were observed. Case 2 was a 2-year-old female with congenital biliary dilatation. Surgery was performed through a right upper quadrant transverse incision. As in case 1, during wound closure, a catheter was placed on the layer under the rectus abdominis muscle. Postoperatively, 5 ml of ropivacaine 0.375% were administered through the catheter, and continuous infusion of ropivacaine 0.2% at 2 ml/h was performed. Fentanyl 0.2 μg/kg/h was infused intravenously. Until the catheter was removed, pain scores were 1 on the FACES Pain Rating Scale. These cases show that this approach can provide pain relief for postoperative pediatric cases.

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