The concept of vulnerable plaque (VP) has been widely accepted as the primary cause of acute coronary syndrome (ACS) and sudden cardiac death. ACS is thought to result from sudden disruption of a VP with subsequent occlusive thrombosis. VP typically consists of several components; a large necrotic core, thin fibrous cap, increase in macrophage activity, increase in vaso vasorum, and positive remodeling.
In recent years, invasive or non-invasive diagnostic imaging modalities have been developed for indentifying VP. VP has been recognized in various modalities not only by visualization of cross sectional images by high-resolution imaging modalities, such as virtual histology intravascular ultrasound (VH-IVUS) , integrated backscatter (IB) IVUS, and optical coherence tomography (OCT), but also by direct visualization by intracoronary angioscopy.
VH-IVUS uses advanced radiofrequency signal analysis of ultrasound signals and allows detailed qualitative and quantitative assessment of plaque composition, while IB-IVUS analyzes the radiofrequency signal by applying a fast Fourier transformation of the component of the backscattered signals. Different tissue components reflect the radiofrequency signaling at different power levels, which could be used to differentiate various tissue components. Angioscopy allows direct visualization of internal surface of the lumen, providing the detailed information of characteristics of plaque and thrombus. Optical coherence tomography (OCT) is an analog of IVUS, but uses light instead of sound. OCT has a 10-fold higher image resolution (10-15 μm) compared to conventional IVUS, therefore it is able to provide superior image quality. The commercially available versions of the technology used time-domain (TD) OCT (M2, M3, Lightlab, Westford, MA, USA) and fourier-domain (FD) OCT (C7XR, Lightlab, Westford, MA, USA) . OCT is the only imaging modality with high enough resolution to measure fibrous cap thickness and neovascularization. Moreover OCT has a unique ability of detecting macrophages.
In this review, we attempted to summarize the advantages and limitations of the currently available intravascular modalities.

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Chronic pancreatitis (CP) is a painful, yet benign inflammatory process of the pancreas. Surgical management should be individualized because the pain is multifactorial and its mechanisms vary from patient to patient. Two main pathogenetic theories for the mechanisms of pain in CP have been proposed: the neurogenic theory and the theory of increased intraductal/intraparenchymal pressures. The latter theory is strongly supported by the good results of drainage procedures in the surgical management of CP. Other possible contributing factors include pancreatic ischemia; a centrally sensitized pain state; and the development of complications, such as pseudocysts and stenosis of the duodenum or common bile duct. Common indications for surgery include intractable pain, suspicion of neoplasm, and complications that cannot be resolved with radiological or endoscopic treatments. Operative procedures have been historically classified into 4 categories: decompression procedures for diseased and obstructed pancreatic ducts; resection procedures for the proximal, distal, or total pancreas; denervation procedures of the pancreas; and hybrid procedures. Pancreaticoduodenectomy and pylorus-preserving pancreaticoduodenectomy, once the standard operations for patients with CP, have been replaced by hybrid procedures, such as duodenum-preserving pancreatic head resection, the Frey procedure, and their variants. These procedures are safe and effective in providing long-term pain relief and in treating CP-related complications. Hybrid procedures should be the operations of choice for patients with CP.

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Background: Bacterial meningitis is characterized by a marked predominance of polymorphonuclear leukocytes (PMNs: segmented granulocytes or neutrophils) in the cerebrospinal fluid (CSF), whereas aseptic meningitis is characterized by a predominance of mononuclear leukocytes (MNs: lymphocytes or monocytes). However, the pathophysiology of this predominance of PMNs in the CSF of patients with bacterial meningitis has never, to our knowledge, been clearly described.
Methods: To investigate the predominant cell components of CSF from pediatric patients with bacterial meningitis, we investigated cell death in association with levels of tumor necrosis factor-alpha (TNF-α) in the CSF, using the MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl-tetrazolium bromide) assay and flow cytometry.
Results: The MTT assay of the CSF revealed that the PMNs had survived, while the MNs rapidly had undergone cell death. Although PMNs survived in CSF with high levels of TNF-α, PMN apoptosis was demonstrated with flow cytometry.
Conclusions: The present study suggests that the pathophysiology of PMN predominance in the CSF of patients in the acute phase of bacterial meningitis is related to the rapid cell death of MNs and the survival of PMNs brought about by high levels of TNF-α.

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Background and Purpose: There is no consensus regarding the optimal method for diagnosing the dissection of intracranial arteries. We have developed a rapid and accurate examination method to diagnose vertebral artery dissection in the acute stage of cerebral infarction.
Methods: Twenty-two patients with severe headache and neck pain and/or symptoms of brain stem or cerebellar ischemia underwent magnetic resonance imaging (MRI) with a 1.5-T scanner. Our protocol generated 3 contrast-weighted scans (T2-weighted, diffusion-weighted, and basi-parallel anatomical scanning [BPAS] -MRI) and conventional angiographs within 3 hours of the onset of symptoms. Then, we retrospectively analyzed the findings to identify the most reliable imaging method for diagnosing vertebral artery dissection in the acute stage of cerebral infarction.
Results: Based on the symptoms and the findings of T2-weighted imaging and conventional angiography, the initial diagnosis was dissection in 17 patients, lacunar infarction in 3 patients, and atherothrombosis in 2 patients. After follow-up studies the diagnosis was changed in 7 patients. The diagnosis based on symptoms and the findings of T2-weighted MRI and BPAS-MRI was dissection in 13 patients, atherothrombosis in 6 patients, and lacunar infarction in 3 patients. In 3 patients the diagnosis was changed during the follow-up phase.
Conclusions: The diagnostic accuracy rate was higher with T2-weighted MRI and BPAS-MRI than with T2-weighted MRI and conventional angiography. We suggest that when intracranial vascular dissection is suspected, both the inner and outer contours of vessels must be inspected and that BPAS-MRI should be performed instead of conventional angiography to establish the definite diagnosis.

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Background: In patients with large tumors, securing sufficient working space to perform laparoscopic resection can be difficult. The purpose of this technical note is to describe a technique for easy performance of laparoscopic distal pancreatectomy involving large cystic pancreatic tumors.
Surgical Technique: Early in surgery, a small incision was made in the abdominal wall directly above the tumor to remove the laparoscopically resected tissues from the abdominal cavity. After the margin of the incision was secured with a wound protector, a double-balloon catheter was used to remove the contents of the tumor under direct observation, without allowing any leakage into the abdominal cavity. The volume of the tumor could, thus, be safely reduced. As a result, laparoscopic distal pancreatectomy was safely performed, even for 17-cm-diameter mucinous cystic neoplasm of the pancreas.
Conclusion: A wound protector and a double-balloon catheter are helpful for removing the contents of a cystic tumor. A small abdominal incision for removing the resected tissues can be used during the resection procedure to aspirate the tumor contents, and, as a result, laparoscopic distal pancreatectomy can be performed safely, even for large cystic pancreatic tumors.

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Mesh surgeries, such as sacrocolpopexy and transvaginal mesh surgery, are commonly used to treat pelvic organ prolapse. Although mesh surgeries have a high success rate, they are unsuitable for some patients. For a patient with pelvic organ prolapse and highly calcified multiple fibroids, we performed hybrid sacrocolpopexy combined with transvaginal mesh surgery with a method modified for the patient's condition. Three months after surgery, the results were highly satisfactory. This approach is simple, secure, and versatile for patients who are not good candidates for conventional mesh surgeries. This novel hybrid mesh surgery is an option for treating various types of pelvic organ prolapse.

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We report an unusual case of bilateral Galeazzi fractures associated with dislocation of the right elbow and fracture of the right scaphoid caused by a motorbike accident in a 32-year-old man. Bilateral radiuses were fixed with plates, and the right scaphoid was fixed with a screw after closed reduction of the right elbow. A satisfactory result was obtained with a return to work and no radiographic problems 7 years after surgery. The mechanism of the injury was thought to be a high-velocity fall on the outstretched hands combined with extreme pronation of the forearms and extension of the wrists and the elbows. This case had a favorable outcome following operative stabilization of the fracture-dislocations and early mobilization.

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Fibrolipomatous hamartoma of nerves without macrodactyly is a rare lesion characterized by fibrofatty proliferation causing epineural and perineural fibrosis with fatty infiltration around the nerve bundles. We report an unusual case of fibromatous hamartoma of the ulnar digital nerve of the thumb in a 43-year-old woman. Magnetic resonance imaging revealed a large fusiform mass along the nerve. The findings were unusual and pathognomonic and included a coaxial cable-like appearance on axial sections and a spaghettilike appearance on coronal sections on both T1- and T2-weighted images; these findings were useful for the diagnosis and preoperative evaluation of this lesion. Surgical exploration revealed a yellow, cordlike mass of the digital nerve enlarged by fat. Gross excision could not be done without extensive damage to the nerve. Therefore, a limited excision with biopsy of the fibrolipomatous tissue around the nerve bundles was performed. The histological appearance was consistent with fibrolipomatous hamartoma. There was no recurrence of the mass and no neurological deficit 3 years after surgery. Some authors have suggested that invasive excision can cause catastrophic sensory or motor deficits because of the extensive fatty infiltration of the nerve fascicles. In conclusion, the recommended treatment for this lesion is limited excision with only biopsy to confirm the diagnosis.

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On March 11, 2011, after the Great East Japan Earthquake and tsunami, the government declared a nuclear emergency following damage to the Fukushima Daiichi Nuclear Power Plant. A second hydrogen explosion occurred on March 14 at the plant's No. 3 reactor and injured 11 people. At that time the prime minister urged people living 20 to 30 km from the Daiichi plant to stay indoors. Under these circumstances, many residents of Iwaki City, which was largely outside the 30-km zone, left the city, making it difficult to get supplies to the remaining residents. The only transportation route open for supplies and medical resources was roads, and many drivers feared the rumor that the city was contaminated by radioactive materials and, so, refused to go there. Nippon Medical School (NMS) heard that medical resources were running short at Iwaki Kyoritsu Hospital, which requested water, medications, food, fuel (gasoline), medical support, and the evacuation of 300 inpatients. As a first step, NMS decided to evaluate the situation at the hospital and, on March 16, the director of the NMS Advanced Emergency Center visited the hospital and helped provide triage for about 200 patients. Critically ill patients receiving ventilatory support were given priority for evacuation because they would be most at risk of not being able to evacuate should the Japanese government order an immediate evacuation of the city. We tried to evacuate the inpatients via an official framework, such as the Disaster Medical Assistance Team (DMAT), but DMAT could not support this mission because this hospital was not within the 30-km evacuation zone. Moreover, the Iwaki City government could not support the evacuation efforts because they were fearful of the rumor that Iwaki was contaminated by radioactive material. Ultimately, we realized that we had to conduct the mission ourselves and, so, contacted our colleagues in the Tokyo metropolitan area to prepare enough hospital beds. We evacuated 15 patients to 8 hospitals over a 5-day period. As a result, we could reduce the number of patients at Iwaki Kyoritsu Hospital, and, thereby, the collapse of medical services in the city was avoided. In retrospect, someone might say the government-either central or local-should ideally have carried out this mission and created a system by which to do it. At the same time, however, to overcome any future bureaucratic issues, we should also prepare private networks, such as those used by NMS, because they can respond flexibly to unexpected large-scale disasters.

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At 14:46 on March 11, 2011, the Great East Japan Earthquake and tsunami occurred off the coast of Honshu, Japan. In the acute phase of this catastrophe, one of our teams was deployed as a Tokyo Disaster Medical Assistance Team (DMAT) to Kudan Kaikan in Tokyo, where the ceiling of a large hall had partially collapsed as the result of the earthquake, to conduct triage at the scene: 6 casualties were assigned to the red category (immediate), which included 1 case of cardiopulmonary arrest and 1 of flail chest; 8 casualties in the yellow category (delayed); and 22 casualties in the green category (minor). One severely injured person was transported to our hospital. Separately, our medical team was deployed to Miyagi 2 hours after the earthquake in our multipurpose medical vehicle as part of Japan DMAT (J-DMAT). We were the first DMAT from the metropolitan area to arrive, but we were unable to start medical relief activities because the information infrastructure had been destroyed and no specific information had yet reached the local headquarters. Early next morning, J-DMAT decided to support Sendai Medical Center and search and rescue efforts in the affected area and to establish a staging care unit at Camp Kasuminome of the Japan Self-Defense Force. Our team joined others to establish the staging care unit. Because information was still confused until day 3 of the disaster and we could not adequately grasp onsite medical needs, our J-DMAT decided to provide onsite support at Ishinomaki Red Cross Hospital, a disaster base hospital, and relay information about its needs to the local J-DMAT headquarters. Although our medical relief teams were deployed as quickly as possible, we could not begin medical relief activities immediately owing to the severely damaged information infrastructure. Only satellite mobile phones could be operated, and information on the number of casualties and the severity of shortages of lifeline services could be obtained only through a "go and see" approach. Because there was no way to transmit or receive this vital information, disaster workers in the affected areas faced many challenges. For the future, network data links need to be made more resistant to infrastructure damage, and redundant or reach-back systems involving multitiered satellite, wireless, and radio frequency data links would provide definitive solutions. Such integrated systems should be designed around seamless connectivity based on an "always best connected" principle for maintaining communication quality.

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This report describes our onsite medical rounds and fact-finding activities conducted in the acute phase and medical relief work conducted in the subacute phase in Miyagi prefecture following the Great East Japan Earthquake and subsequent tsunami that occurred off northeastern Honshu on March 11, 2011. As part of the All-Japan Hospital Association medical team deployed to the disaster area, a Nippon Medical School team conducted fact-finding and onsite medical rounds and evaluated basic life and medical needs in the affected areas of Shiogama and Tagajo. We performed triage for more than 2,000 casualties, but in our medical rounds of hospitals, clinics, and nursing homes, we found no severely injured person but did find 1 case of hyperglycemia. We conducted medical rounds at evacuation shelters in Kesennuma City during the subacute phase of the disaster, from March 17 through June 1, as part of the Tokyo Medical Association medical teams deployed. Sixty-seven staff members (17 teams), including 46 physicians, 11 nurses, 3 pharmacists, and 1 clinical psychotherapist, joined this mission. Most patients complained of a worsening of symptoms of preexisting conditions, such as hypertension, respiratory problems, and diabetes, rather than of medical problems specifically related to the tsunami. In the acute phase of the disaster, the information infrastructure was decimated and we could not obtain enough information about conditions in the affected areas, such as how many persons were severely injured, how severely lifeline services had been damaged, and what was lacking. To start obtaining this information, we conducted medical rounds. This proved to be a good decision, as we found many injured persons in evacuation shelters without medication, communication devices, or transportation. Also, basic necessities for life, such as water and food, were lacking. We were able to evaluate these basic needs and inform local disaster headquarters of them. In Kesennuma City, we found that some evacuation shelters could not contact others even after 1 week after the earthquake. We realized from our experiences that, unlike our activities following more localized earthquake disasters, the first task following such large-scale disasters is to acquire information on basic life needs, including medication needs, and the number of persons requiring assistance. We must provide medical relief according to the unique characteristics of the disaster-affected areas as well as the specific nature of the disaster, in this case, a tsunami.

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