There are no guidelines regarding whether to perform either a radical transurethral resection of the bladder tumor (TUR-BT) or a total cystectomy after TUR biopsy for huge bladder cancer, and this decision is entrusted to each institution. Of 439 patients in whom TUR-BT was performed from 2005 through 2009, the weight of the total resected volume was > 50 g in 6 patients, and among these 6 patients the following variables were compared: operating time, weight of resected volume, transfusion volume, presence or absence of hydronephrosis, preoperative urinary cytology, serum cytokeratin 19 fragment (CYFRA) level, intraoperative bladder compliance, and histopathological findings. The median age, operating time, weight of resected volume, transfusion volume, and length of follow-up were 72 years, 300 minutes, 88 g, 202 mL, 16 months, respectively. The serum CYFRA level in patients with muscle-invasive cancer (11.8 ng/mL) was higher than that in patients with non-muscle-invasive cancer (5.06 ng/mL). All patients with non-muscle-invasive bladder cancer survived without recurrence. Although the mean length of follow-up was only 16 months (5-59 months), the 1 patient who was followed up for 59 months had no recurrence. In cases of muscle-invasive bladder cancer, all patients, except for a relatively recent patient, have died. In cases without muscle invasion, lymph node metastasis, distal metastasis, or preoperative renal dysfunction accompanied by hydronephrosis, with favorable bladder compliance, we believe that radical TUR-BT should be actively performed to preserve the bladder. A second TUR-BT should be performed in cases of non-muscle-invasive cancer without G3 components to treat the huge bladder cancer.

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The efficacy of total colonoscopy following a positive result of the fecal occult blood test (FOBT) for the early detection of colorectal cancer and polyps was evaluated. A total of 1,491 patients with positive FOBT results underwent total colonoscopy at the Institute of Gastroenterology, Nippon Medical School, Musashi Kosugi Hospital, from April 2002 through July 2009. Abnormalities were found in 1,312 of the 1,491 patients (88.0%). Ninety-six of the 1,491 patients (6.4%) were found to have early cancer, but 59 patients (4.0%) were found to have advanced cancer. The early cancers were treated with endoscopic mucosal resection or endoscopic submucosal dissection in 81 patients, with laparoscopy-assisted colectomy in 10 patients, and with open surgery in 5 patients. Fifty-one of the 59 patients with advanced colorectal cancer underwent conventional open surgery, and 8 patients underwent laparoscopic surgery. The cancers detected were more likely to be early cancers than advanced cancers. In addition to malignancies, other abnormalities found included inner or external hemorrhoids, diverticula of the colon, ulcerative colitis, ischemic colitis, infectious colitis, and colorectal polyps. Our results show that a high percentage of lesions detected with total colonoscopy following a positive FOBT result are early colorectal cancers and polyps.

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The aim of this study was to determine the perinatal outcomes of placental abruption associated with the presence of histological chorioamnionitis. We reviewed the obstetric records of 96 singleton deliveries complicated by placental abruption after 22 weeks' gestation. Of these 96 cases, 37 cases (39%) were diagnosed as having histological chorioamnionitis in the placenta. The incidence of premature delivery, preterm rupture of the membranes and low birth weight in the cases of placental abruption with chorioamnionitis were higher than in cases without chorioamnionitis. However, there were no significant differences in the incidence of other outcomes, such as fetal demise, low Apgar score, or low umbilical artery pH, between the cases of placental abruption with and without histological chorioamnionitis. Although the incidence of prematurity in the cases of placental abruption with chorioamnionitis was higher than that in cases without chorioamnionitis, there were no significant differences in fetal and neonatal conditions between the abruption cases with and without chorioamnionitis.

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In organized orientation programs for newly recruited medical interns of the Nippon Medical School Hospital, the working committee of the clinical simulation laboratory introduced a laboratory training session that was designed to improve the clinical skills of the medical interns. The session consisted of 6 training courses, comprising internal examination, tracheal intubation, auscultation of heart sounds, bandaging and the collection of samples of venous and arterial blood. Medical interns rotated to a new course every 30 minutes and did practical trainings in each of the 6 skills. A total of 36 newly recruited medical interns participated in the training session. The majority of medical interns took part in the practical training actively and positively. The session was efficiently carried out from the standpoints of human resources and the teaching hours involved. A post training questionnaire survey, completed by the medical interns, revealed that many of them valued the sessions for comprehensibility of the instructions, the descriptions in the manual and the content of the training; however, only 21% thought that they had successfully acquired the clinical skills. Medical interns must continually engage in self-training to steadily acquire basic clinical skills. The convenience of a clinical simulation laboratory, together with the reinforcement of the education of clinical skills during internship, is necessary to strengthen the educational benefits of the training session.

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Merkel cell carcinoma (MCC) is a rare skin tumor that usually occurs on the head, neck, or extremities of elderly patients; it has a high incidence of local recurrence, regional lymph node metastasis, and subsequent distant metastasis. We report a MCC that developed rapidly on the left corner of the upper lip of a 100-year-old woman. An incisional skin biopsy was performed to confirm MCC. Computed tomography showed no metastasis. The tumor was widely excised with a margin of 1 cm. Immediate reconstruction with a reverse Estlander flap from the lower lip was performed under general anesthesia. Additional surgery was also performed under general anesthesia 2 weeks later to widen the patient's lips. The surgical results were satisfactory. The patient died of senile deterioration a year after hospitalization for long-term medical treatment, without any recurrence or metastasis of MCC. Despite the patient's age, we considered it necessary to resect the tumor widely because of its rapid growth. The tumor margin was 1 cm. No radiotherapy was performed, but we believe that surgery alone was effective in allowing this patient to live an additional year without recurrence or metastasis. To the best of our knowledge, this patient is the oldest person with MCC yet described.

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We report a rare case of commotio cordis caused by traffic injury. The patient was a 60-year-old female driver who suffered severe steering wheel impact to the chest during a head-on collision in which her car overturned. She had no history of cardiac disease. Emergency medical services arrived at the scene within 12 minutes of the accident. Evidence of ventricular fibrillation led the paramedics to carry out immediate defibrillation with an automated external defibrillator. Restoration of spontaneous circulation was confirmed within 2 minutes, along with establishment of sinus rhythm and normal wave form on electrocardiography. The patient was transported to our hospital in an emergency helicopter. General examination revealed chest bruising, and computed tomography of the chest showed pulmonary contusions; there was no other evidence of critical injury. We performed endotracheal intubation, as the patient had consciousness disturbance, and then initiated hypothermic therapy in the intensive care unit. Meanwhile, the hemodynamics remained stable, and there was no recurrence of arrhythmia. On day 15, the patient's consciousness improved, and she was able to communicate. Two months later, she was transported to another hospital for rehabilitation.

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A 31-year-old woman presented with worsening numbness and pain in the arms and chest. Neurological findings at admission were decreased pain sensation and temperature sensation in the arms and chest. Magnetic resonance demonstrated a large cervical syrinx from the level of C4 to Th4 associated with Chiari I malformation. Occipital craniectomy and C1 laminectomy were performed for foramen magnum decompression. Intraoperative ultrasonography, performed after removal of the outer membrane of the dura mater at the level of the foramen magnum, revealed insufficient decompression. Therefore, the dura mater was completely opened and duraplasty was performed with a polyglycolic acid patch and fibrin glue. Sufficient decompression was thus achieved. The neurological symptoms and signs improved within the first postoperative month, and magnetic resonance showed a decrease in the size of the syrinx and no cerebrospinal fluid leakage. In patients undergoing foramen magnum decompression with duraplasty, the use of a polyglycolic acid patch and fibrin glue renders suturing unnecessary and avoids the common complications associated with suture duraplasty.

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Peripartum cardiomyopathy (PPCM) is a form of heart failure that occurs in women within 1 month before delivery and 5 months after delivery. The outcome of PPCM is variable but improves significantly when appropriate medication is administered in the acute phase; furthermore, the outcome does not worsen even after discontinuation of therapy in the chronic phase. The symptoms and signs of PPCM are similar to those of idiopathic dilated cardiomyopathy. The medical management of patients with PPCM is similar to that for other other forms of heart failure. Recent experimental data implicate a casual role of prolactin in the development of PPCM. Prolactin secretion can be reduced with bromocriptine which had benefitical effects in a small study. We present a Japanese woman with acute PPCM treated with bromocriptine as a therapeutic option. Following treatment, the serum prolactin levels dropped swiftly. Concurrently, LV function improved, and heart failure symptoms decreased, accompanied by a decrease in the BNP level.

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