As a current topic of interest, we report the utility of robot-assisted surgical navigation, using da Vinci, which is currently in operation in our department. In Japan, the Pharmaceutical Affairs Law regarding robot-assisted surgery was approved in 2009, which enabled us to perform robot-assisted prostatectomy for prostate cancer with coverage under the health insurance system from April 2012. As many as 180 units of robotic surgical systems are in operation in Japan this year, making Japan a robotic surgery Mecca, second only to the United States. Japan is by far the number one robotic-surgery-operating country in Asia. At the time of robot-assisted partial nephrectomy, in order to perform selective renal artery shut-off precisely, we conduct functional analysis of a medical image preoperatively, which provides us with a great deal of anatomical information during the operation. More specifically, a life-sized kidney model made by a 3D printer is very useful for this purpose. This model is based on the CT volume rendering image, and the 3D printer adopts a color-coded system in which tumor, kidney, and blood vessels are displayed with different colors. Surgical navigation and the 3D printer model in the case of partial nephrectomy enhanced our surgical performance and improved surgical safety.

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Robotic surgery has spread rapidly throughout the United States, Europe, South Korea, and elsewhere in recent years. Gynecological robotic surgery started in 2005, and is currently performed more often than urological robotic surgery. This type of surgery is optimal for delicate surgical operations in a relatively narrow surgical field: gynecological pelvic surgery is an appropriate example. The benefits of robotic surgery include an increased range of motion with instruments, three-dimensional stereoscopic vision, and improved ergonomics for the operating surgeon. The greatest advantage is that mastery at a high technical level can be achieved in a short period. Furthermore, robotic surgery is advantageous for laparoscopic surgery as the laparotomy expert can shift to it directly. Given the current state of robotic surgery in the United States and Europe, it will eventually spread to the gynecologic cancer surgery methods in Japan. There have been improvements to the cost, but it is necessary to establish a set of standards for robotic surgery that focuses on safety.

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Telemicrosurgery applications have expanded quickly since the 1990s. The development of robotics has allowed a glimpse into new perspectives in nerve microsurgery. Minimally invasive surgery has quickly become the first therapeutic option in many operative indications, reducing postoperative complications and increasing patient comfort. Surgical robotics already proved useful, leading to numerous enhancements of the technique. We will introduce you how to make telemicrosurgery of the brachial plexus surgery with da Vinci robot in this review.
In Oberlin technique, our results demonstrate the feasibility of the robot-assisted surgery. The absence of sensory feedback was not a problem. The development of specific retractors should improve the mini-invasive technique.
In brachial plexus surgery, mini-invasive robot-assisted brachial plexus surgery has the double advantage of better cosmesis and improved functional outcome by decreased scarring. It was difficult to confirm with absolute certainty without electrical stimulation that the nerve identified and biopsied was the superior trunk of the brachial plexus. We had no other difficulties with this procedure. The workspace was perfectly maintained by low-pressure insufflations of CO2.
In telemicrosurgery, we think that there are many requiring ingenuity. More animal research and clinical study will be needed to develop the field of telemicrosurgery. We believe that Juntendo University will be able to do it and have to do it!!

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Transoral robotic surgery (TORS) has gained importance in the resection of head and neck tumors worldwide. Oropharyngeal cancer, especially T1 and T2 tumors of the tongue base and lateral wall, could be easily visualized using the da Vinci system. The benefits of TORS over traditional open surgery include hand tremor reduction, better visualization, and the minimization of surgical trauma. Furthermore, TORS could preserve better swallowing function compared with primary chemoradiation or conventional open surgery. Our department will prepare for the introduction of TORS in advance of its approval by the Ministry of Health, Labour and Welfare.

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Robotic surgery is a promising new field in pediatric surgery expected to develop markedly. It involves the application of technology that minimizes stresses related to therapeutic intervention, which will greatly benefit the treatment of children requiring surgery. While it is only a matter of time before robotic surgery is adopted routinely, there are technical issues related to instruments and equipment required to perform the wide range of surgical procedures in patients of various sizes covered by pediatric surgery; in other words, equipment must also be adaptable enough to use from neonates to teenagers. Unfortunately, current robotic instruments are just scaled down adult instruments, for example, instruments used with 2D/3D telescopes scaled down from 8 mm to 5 mm. We anticipate that, as the number of complex pediatric laparoscopic/thoracoscopic procedures performed with robotic enhancement increases, there will be improvement in the hardware with associated measurable benefits in patient outcomes.

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Objective: To determine whether or not there is a correlation between the severity of hand osteoarthritis (OA) and low bone mineral density (BMD).
Materials: In 30 patients with hand OA who attended our department with chief complaint of arthralgia in the fingers, data on BMD and the radiographic severity of hand OA were statistically analyzed. Of the 30 subjects studied, 24 were females and 6 males. All subjects aged between 49 and 85 years (mean: 70.0 years). They consisted of 18 subjects with Heberden’s nodes, 8 with Bouchard’s nodes, and 9 with rhizarthrosis.
Methods: Radiographic severity of hand OA was scored with the Kellgren/Lawrence scale (grade 0-4). BMD of vertebral bodies was measured by dual-energy X-ray absorptiometry.
Results: A statistically significant correlation was found between the radiographic severity of Heberden’s nodes and low BMD, whereas neither rhizarthrosis nor Bouchard’s nodes showed any correlation between radiographic severity and BMD.
Conclusions: A statistically significant correlation between the radiographic severity of hand OA and BMD was established solely for Heberden’s nodes. Although low BMD may influence the progression of hand OA, there may also be other influencing factors.

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Objective: Podocytes play an important role in maintaining the structural integrity and function of the glomerular filtration barrier. Adriamycin (ADR) -induced podocyte injury has been extensively studied, however, its mechanism remains unclear. In the present study, we aimed to explore novel genes associated with podocyte injury induced by ADR.
Methods: A microarray assay was carried out on isolated podocytes with and without ADR treatment and analyzed using Genespring GX software. Two genes, Fos-like antigen 1 (FOSL1) and Regulator of G-protein signaling 2 (RGS2) were selected as candidate genes because their levels showed the most significant changes after ADR-induced podocyte injury. To confirm the changes in mRNA levels and their protein expression, ADR was added to cultured mouse podocytes and analyzed at 1, 2, 6, and 24 hours using real-time PCR and immunofluorescence. Finally, we also confirmed the expression of both proteins in vivo, by staining mouse kidney tissue at 0, 3, and 15 days after ADR injection.
Results: Microarray data showed that after ADR treatment, FOSL1 was up-regulated, while RGS2 was down-regulated. Real-time PCR analysis confirmed that ADR induced a significant increase of FOSL1 at 24 hours (p < 0.001, 24 h vs. control), and a marked down-regulation of RGS2 (p < 0.001, at each time point vs. control). Immunofluorescence analysis of podocytes treated with ADR for 24 hours showed an up-regulation tendency for FOSL1 protein and a down-regulation tendency for RGS2. On ADR-induced injury mice specimens, the expression of FOSL1 was increased in a time dependent manner after the injection; on the other hand, RGS2 was down-regulated, especially 15 days after injection.
Conclusion: FOSL1 and RGS2 were both expressed in podocytes, and were significantly regulated after ADR treatment, revealing a possible role in podocyte injury induced by ADR. These results could help guide research further to finally elucidate the underlying mechanisms in podocyte injury.

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Background: Mesangioproliferative glomerulonephritis is the most common type of chronic glomerulonephritis (CGN). However, the clinical characteristics and prognosis are not fully understood in patients without Immunoglobulin A (IgA) deposition. To explore the clinical and pathological characteristics of patients with mesangioproliferative glomerulonephritis without IgA deposition (N-IgAN), we performed dual retrospective analyses.
Methods: A single-center study was performed in 60 patients with biopsy-proven N-IgAN. 98 age- and sex-matched IgA nephropathy (IgAN) patients were randomly selected as a control group. The clinical and histopathological data at the time of renal biopsy were compared between N-IgAN and IgAN. In a second study, the data for 477 patients who had undergone maintenance renal replacement therapy (RRT) was collected and examined for the causal primary diseases.
Results: Duration from onset of renal symptoms to renal biopsy in patients with N-IgAN (71.2±123.3 months) was significantly longer than that in patients with IgAN (65.9±74.9 months) (p=0.0328). Urinary protein excretion in N-IgAN patients (0.6±1.1g/gCr) was significantly lower than that in IgAN (1.0 ± 1.3 g/gCr) (p < 0.0001). Ratio of global sclerosis, segmental sclerosis, crescents, interstitial mononuclear cell infiltration, interstitial fibrosis, and tubular atrophy were significantly lower in N-IgAN patients. Of the 477 patients who had undergone maintenance RRT, 95 patients had CGN (19.9%). Among them, 37 patients had received a renal biopsy, only one patient was N-IgAN (1%).
Conclusion: It appears that N-IgAN can be recognized as a benign disease entity in comparison with IgAN.

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Unfortunately, high maternal mortality (MM) was a “neglected” public health issue for a long time, due to women’s lower political and social priority within our society. Assessment of MM was a controversial issue, and evidence-based interventions to decrease MM remained disputed.
In September 2000, however, reducing MM was selected as one of the world’s top eight priority targets in the Millennium Development Goals (MDGs). The study aimed to analyze why MM reduction was selected in the MDGs, from historical and social perspectives. Analysis using the related documents and information identified that three dimensions might have led to including MM reduction in the MDGs.
First, in a policy dimension, a reproductive health strategy that merged women’s health with the world population issue penetrated the field of health in 2000. Second, in a technical dimension, scientific intervention through safe motherhood initiatives promoted substantial MM reduction. Lastly, as a social dimension, improvement of women’s rights and status reinforced the adoption of policies aiming to reduce MM.
Entering upon the year 2015, the targeted year of the MDGs, we refocus on the meaning of the MM reduction and hope that our recommitment contributes to accelerating MDGs progress beyond 2015.

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While target training goal achievement levels have remained unchanged, clinical training systems have been revised to enable residents in their second training year to participate in training programs they select in consideration of their career paths since 2010. This study examined the influences of revision on residents’ career choice process, based on the results of a questionnaire survey.
The majority of the residents began to consider their careers < during the first half of their second training year > , similarly to before the revision. On the other hand, the rate of those making decisions on their careers < during the second half of their second training year > decreased by 10%, suggesting that the career decision-making period may have been brought slightly forward. The influences of initial residency may be marked even after the revision of clinical training systems, as approximately 90% of the respondents answered < Influenced > . In this respect, in more than 40% of those who answered < Influenced > , they changed their career choices within a short period of time. In the present study, < clinical training experience > , < job satisfaction > , and < intellectual curiosity > were the 3 most frequent reasons for career choices, confirming that the residents selected medical departments based on their clinical training experience.

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Providing universal health insurance to the 1.2 billion people of India is a daunting task, complicated by high poverty rates and a large unorganized labor sector. Health centers are concentrated in urban areas, despite the majority of the population being rural. Emergency medicine takes on added significance in view of inaccessibility of healthcare. Government and private partnerships in community health insurance schemes have played a significant role in making affordable healthcare accessible to rural communities and families below the poverty line.
In this paper we have looked at the current situation in India, as well as the specific example of a community health insurance scheme provided by the Manipal group in coastal Karnataka to the rural fishing and agricultural community. Health indicators in this region are generally more positive than the rest of the country. Enrollment in this program has increased every year since its initiation.
We then look at emergency medicine, which as a distinct field is still in its infancy in India. At present only 24 teaching hospitals across the country have post graduate programs in this field. Current emergency health management in most centers is cumbersome and involves significant delay in delivering care.

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