Background: Anterior cervical discectomy and fusion (ACDF) has become a common procedure for cervical spine surgeries, since it is safe and effective in most patients. However, some patients develop life-threatening problems such as respiratory obstruction arising from rare postoperative hematoma and edema, although intraoperative bleeding caused by the connective tissue splitting procedure or bleeding caused by postoperative insertion of a suction tube has rarely been reported. Investigation of the requirement for indwelling drains in patients who undergo cervical spine surgery is necessary because of the pain, anxiety, and discomfort caused despite the use of high-quality materials. Methods: Enrolled in the study were 43 patients who underwent one-level anterior cervical fixation surgery, including 23 (randomly selected) who received an indwelling drain (group A, mean age: 57.78±14.46 years, range: 39-82 years, male/female: 13/10), and 20 who received no indwelling drain (group B, mean age: 57.00±13.99 years, range: 29-81 years, male/female: 12/8). Intraoperative bleeding amounts, lateral views of plain cervical spine radiographs, prevertebral space (PVS) changes on plain radiographs and computed tomography (CT) images, wound inspections, and pain assessments on the Numeric Rating Scale (NRS) were compared between groups. In addition, a history of risk factors for bleeding, such as hypertension, diabetes, and cerebrovascular diseases which require antiplatelet therapy, was determined. Hepatic failure was observed in none of the patients. Results: Postoperative CT images obtained the day following surgery showed no densities indicating the presence of postoperative hematoma in any of the 43 patients. The maximum amount of intraoperative bleeding was 10 mL, with no significant difference between groups. No patients reported an obvious pain level on NRS, but the pain was significantly milder in group B (A: 1.326±0.911, B: 0.555±0.556, p=0.0037). The postoperative PVS increment on plain radiographs was comparable between groups (A: 1.778±0.992, B: 1.730±0.966, p=0.8728). Discussion: Given the negligible intraoperative and postoperative bleeding observed in both groups, and the lack of difference in PVS increments between the groups, our results suggested that indwelling drains are not required for patients undergoing typical anterior cervical fixation surgery. However, it is important to take care of major vessels such as the superior and inferior thyroid arteries and the external jugular vein as well as the prevertebral venous plexus during surgery.

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Purpose: The purpose of this study was to describe and evaluate the detailed anatomic locations and areas of ligamentous attachments and paths of the transverse carpal ligament (TCL) on a three-dimensional (3-D) surface model. Methods: Ten fresh-frozen cadaver wrists were used to dissect and identify the TCL. Their ligament attachments and whole bone surfaces were digitized three-dimensionally and their areas evaluated. The attachments of each ligament were represented in a model combining CT surfaces overlaid by a digitized 3-D surface, and were also visually depicted with a different color for each on 3-D images of the bones. Results: The TCL was found to be composed of two or three discrete ligaments. Both the trapezium-hook of hamate ligament and the trapezium-pisiform ligament were identified in all ten specimens. The scaphoid-pisiform ligament was found in only two of the ten specimens. The average areas of the attachments of the TCL were 42.7 mm² on the trapezium, 30.0 mm² on the hook of hamate, 21.6 mm² on the pisiform, and 12.7 mm² on the scaphoid. Conclusions: The anatomic 3-D attachment sites of the TCL were visually shown qualitatively, and their areas quantified. This 3-D information offers further knowledge and understanding of the anatomy and biomechanics of the TCL. It could also help in the accurate assessment of radiographic images and treatment of various wrist injuries and diseases when performing such procedures as carpal tunnel release, Guyon's canal release, trapeziectomy, hook of hamate excision, or arthroscopy.

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Background: Current standard 12-lead electrocardiogram (ECG) criteria for diagnosing pulmonary hypertension (PH) have a low sensitivity. Although the right-sided chest ECG (V3R-V5R) increases the diagnostic accuracy, these additional leads are not routinely recorded. The aim of the present study was to assess the usefulness of the synthesized right-sided chest ECG (Syn-ECG), generated from 12-lead ECG information, in the detection and evaluation of PH. Patients and Methods: The Syn-ECG waveforms in 30 patients with PH, defined as an estimated pulmonary arterial systolic pressure (PASP) >35 mmHg, were compared to those in 30 age- and gender-matched normal subjects. Results: The R wave amplitude and R/S ratio in the Syn-ECGs were significantly (P<0.01) greater in patients with PH than in the controls. The R wave amplitude in the Syn-ECGs exhibited a significant and better correlation (correlation coefficient 0.513-0.596, P<0.001) with the PASP than lead V1 (correlation coefficient 0.375, P=0.02). A receiver-operating characteristic curve analysis showed that the R wave amplitude (AUC 0.802, P<0.001) and R/S ratio (AUC 0.823, P<0.001) in the synthesized V5R was a good predictor of PH. New criteria, including 1) an R in V5R>0.12 mV, and 2) R/S ratio in V5R>0.42, had an improved sensitivity (0.63 and 0.73, respectively) and comparable specificity (0.93 and 0.87, respectively) to the conventional criteria (sensitivity 0.10-0.43, specificity 0.90-1.00). Conclusion: The diagnostic criteria derived from the Syn-ECG provided better diagnostic accuracy than the known conventional criteria from the standard 12-lead ECG. This technique described in the present study may be useful for diagnosing and evaluating PH.

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Chondromas originating from the sella turcica are rare, and the most common initial symptoms are headache and visual disturbance. We describe a case of sellar chondroma with endocrine impairment as an initial manifestation that completely resolved after surgery. A 40-year-old Japanese woman with amenorrhea and galactorrhea for the last 2 years was referred to our department of neurosurgery for the evaluation of high prolactin levels and a tumor in the sella turcica. A biochemical assessment indicated endocrine dysfunction. Magnetic resonance imaging and computed tomography indicated a tumor in the sella turcica. The patient's presentation favored the preoperative diagnosis of pituitary adenoma or Rathke's cleft cyst. However, because calcification was detected, other types of tumors, such as craniopharyngioma, meningioma, and chordoma, were also considered. Endoscopic transsphenoidal surgery was performed, and the possibility of a bony tumor was recognized. Finally, the tumor was completely removed, and the histopathological findings confirmed chondroma. The postoperative course was uneventful, and endocrine function improved. Five years after surgery, the patient is doing well without pituitary insufficiency, pituitary hormone medications, or signs of tumor recurrence. In cases of sellar chondroma, endocrine dysfunction sometimes precedes other symptoms, such as headache and visual disturbance. When examining a patient with an intrasellar tumor harboring calcification, clinicians must consider the possibility of sellar chondroma. Furthermore, to the best of our knowledge, this case is the first of sellar chondroma treated with endoscopic surgery to be reported.

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Hobnail hemangioma is a small, solitary, benign vascular tumor that shows a biphasic histological pattern of dilated vascular spaces in the superficial dermis and narrow vascular structures in the deeper dermis. In the superficial dermis, dilated, irregular, thin-walled vascular spaces are lined by plump endothelial cells with large nuclei which protrude into the lumina like hobnails. A 43-year-old Japanese man presented with an 11×8-mm bluish-red macule surrounding a 6×3-mm violaceous, slightly elevated papule of the lumbar region of 6 months' duration. Total resection was performed under local anesthesia. Microscopic examination revealed a biphasic pattern with dilated superficial vessels whose endothelial cells were plump with intraluminal papillary projections, showing a "hobnail" appearance, in the papillary layer and upper dermis, and vascular spaces forming slitlike spaces, some of them dissecting collagen fibers, in the deeper dermis. Neither true atypia nor mitotic figures were present. The findings were consistent with those of hobnail hemangioma. Immunohistochemical analysis of the endothelia of the superficial vessels showed that CD31 and D2-40 were expressed, factor VIII was focally expressed, and CD34 and α-SMA were not expressed. In the endothelia of the deeper vessels, CD31, CD34, factor VIII, and α-SMA were expressed, but D2-40 was not expressed. These findings suggest that hobnail hemangioma also shows a biphasic immunohistochemical pattern because of its origin from both lymphatic vessels and blood vessels.

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Placental lesions, including placental infarction, are associated with fetal and neonatal mortality and morbidity. We present a case of fetal growth restriction associated with an old, diffuse placental infarction. Because the placenta had only a single viable cotyledon, the others being atrophic, the lesion appeared to be a placental tumor on prenatal ultrasonography. The patient did not have pregnancy-induced hypertension. At 31 weeks of gestation, a cesarean delivery was performed because of fetal growth arrest and breech presentation. A small-for-gestational age infant was delivered with Apgar scores of 8 at both 1 and 5 minutes, and the infant had cleft palate and cleft lips. Pathological examination of the placenta revealed an old, diffuse infarction without neoplastic change. In cases in which a placental tumor causing fetal growth restriction is strongly suspected, diffuse placental infarction should be considered as part of the differential diagnosis, because placental tumors are associated with poor maternal prognosis.

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We describe a case of pulmonary nocardiosis due to Nocardia asiatica in an immunocompent 64-year-old-female. Wadowsky-Yee-Okuda-α-ketoglutarate (WYOα) agar, a selective media for Legionella species, was useful for the detection based on the growth-inhibition of normal oral flora and growth-promotion of Nocardia species.

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We investigated perinatal outcomes in pregnant Japanese women who habitually consumed alcohol during pregnancies managed at our hospital. Of the 4,791 Japanese women with singleton deliveries at ≥22 weeks' gestation, 44 (0.9%) were found to have habitually consumed alcohol during pregnancy. Multiple logistic regression analyses suggested that habitual alcohol consumption during pregnancy was not associated with adverse perinatal outcomes. However, 64% of the women who habitually consumed alcohol during pregnancy also habitually smoked; smoking leads to increased risks of a low birth weight and placental abruption.

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The first name of Yukinao Sakai was given incorrectly as Naoyuki.

WRONG: Naoyuki Sakai　→　CORRECT: Yukinao Sakai

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