Toxic epidermal necrolysis (TEN) is a rare skin condition, most often drug-induced, known for its skin detachment and high mortality. In general, acute TEN is considered a T-cell mediated, type IV hypersensitivity disorder. It mostly results from a cumulative effect of risks from the drug structure, drug metabolism, HLA alleles and T cell clonotypes. However, the precise mechanism of TEN is still unknown. Apoptosis or necroptosis causes keratinocytes to lose their shape and adhesion, and necrosis predominates within a few days. Total epidermal necrosis separates the epidermis from the dermis. TEN is regarded as an immune reaction with predominantly CD8+ T lymphocytes, monocytes/macrophages, and natural killer cells. Impaired regulatory T-cells, T-helper 17 cells, cytotoxic granules such as perforin-granzyme and granulysin, tumor necrosis factor α, annexin, microRNA-18a-5p, and drug metabolites are all thought to be involved. From what is known, it can be assumed their mechanism is complex, and there is still much to be investigated. New findings will contribute to the identification of effective active methods of intervention.

Background: The influence of varus insertion of femoral implants in uncemented total hip replacement arthroplasty (THR) remains unclear. Thus, in this study, we retrospectively assessed the clinical impact of uncemented THR with femoral implants that were inserted in varus on the basis of radiological findings. Materials and Methods: The study participants included 89 patients who underwent uncemented THR for 106 joints and were followed-up for >3 years. From clinical records, we retrieved Japanese Orthopaedic Association (JOA) pain scores and the range of motion (ROM) of flexion and abduction both preoperatively and at the final follow-up. The presence of varus insertion of the femoral implant and stress shielding were also retrospectively reviewed from X-rays. We defined varus insertion of the femoral implant as the axis of the femoral implant that was inclined to the femoral shaft by 2° or more. Stress shielding was judged in accordance with Engh's classification system. Results: Of the 106 joints, varus insertion was observed in 40 (37.3%) (the varus group) but not in 66 (62.3%) (the non-varus group). The JOA pain score significantly improved in both groups; however, there were no significant differences between the groups. Although ROM improved in both groups, there were no significant differences between the groups. The appearance rate of stress shielding of ≥third degree in the varus group was significantly greater than that in the non-varus group. Conclusion: These results revealed that varus insertion of femoral implants had no influence on short- to mid-term clinical outcomes because the pain score and ROM significantly improved in both the varus and non-varus groups. However, high rates of severe stress shielding appeared with varus insertion of femoral implants, suggesting an influence on long-term clinical outcomes.

Background: When percutaneous endoscopic gastrostomy is not feasible, a gastrostomy tube may be inserted for enteral access by a laparoscopic or open technique. The aim of this study was to compare the postoperative pain of laparoscopic versus open gastrostomy in patients with complete obstruction caused by advanced esophageal cancer. Methods: Fifteen patients who had undergone either a reduced port access laparoscopic gastrostomy/jejunostomy (LGJ, n=7) or open gastrostomy/jejunostomy (OGJ, n=8) between July 2011 and December 2015 were retrospectively studied. Variables examined comprised age, sex, body mass index (BMI), operative time, blood loss volume, and American Society of Anesthesiologist physical status (ASA-PS) scores. The degree of postoperative pain was also assessed in both groups during the first seven postoperative days. Results: The patients in the two groups were comparable in age, sex, BMI, ASA-PS scores, intraoperative blood loss or postoperative complication rates. Operative time was shorter in the LGJ group than the OGJ group. No patients in the LGJ group required conversion to open laparotomy. Tube feedings were started on postoperative Day 1 in both groups; there were no postoperative complications. The duration of rescue nonopioid analgesic use was significantly shorter in the LGJ than the OGJ group (1.3 versus 3.5 days; P=0.0005). There was a significant difference in frequency of postoperative nonopioid analgesic use: 7.9 times in the LGJ group versus 17.9 times in the OGJ group (P=0.0219). Conclusions: LGJ is associated with less postoperative pain than OGJ in patients with complete obstruction caused by advanced esophageal cancer.

Background: Cancer patients' satisfaction with their treatment decisions has been demonstrated to be associated with improved health outcomes, but few studies of this issue have been conducted in Japan. Objective: To explore key factors in enhancing patient satisfaction, we assessed the association between their satisfaction and their relationships with their physicians. Methods: We conducted cross-sectional questionnaire surveys among patients who had received cancer treatment. One source was outpatients from a cancer center hospital, and the other was through the website of Japan's most popular newspaper. The questionnaire included demographic questions and general self-rated life status issues, such as peace of mind, quality of life, daily activities, family relationships, rapport with attending physician, assessment of the physician's explanations, and feelings of happiness during the previous week. Results: Of 576 respondents, 383 subjects said they were satisfied and 193 dissatisfied. It was confirmed that the online survey was comparable to the paper-based survey in examining patient satisfaction. The dissatisfied group included more females and fewer subjects who were forced to retire from jobs than the satisfied group. The patients in the satisfied group had a more favorable subjective opinion of their recent life. The patients in the dissatisfied group received more chemotherapy and had more side effects than those in the satisfied group. Assessment of the physician's role showed significant differences between the two groups; the patients in the satisfied group felt more than those in the dissatisfied group that their physicians' explanations of treatment were sufficient and were satisfied with their rapport with their physicians. Multiple logistic regression analysis revealed that rapport with physicians was a significant factor (odds ratio=3.79, 95% CI=2.25-6.39). Conclusions: Rapport between physicians and patients is one of the most important factors in patient satisfaction with treatment decisions.

Background: In decompensated liver cirrhosis, hypoalbuminemia still persists even after they have been treated with branched-chain amino acid (BCAA) granules. We prospectively evaluated whether BCAA enriched nutrient switched from BCAA granules would increase the serum albumin level, and consequently extend the survival time after hepatocellular carcinoma (HCC) treatment. Methods: This study included 77 patients treated for liver cirrhosis with HCC. After the nutritional assessment, all patients initially received BCAA granules. In patients with unchanged or decreased serum albumin levels, BCAA granules were discontinued and BCAA enriched nutrient was started. Transcatheter arterial chemembolization (TACE) for HCC were performed in those with an improved Child-Pugh score. Results: TACE were performed following the aggressive intervention with BCAA nutritional education in 54 of 77 (70.1%) patients. Finally, survival time was significantly extended in the TACE group (P<0.0001). Conclusion: Timely aggressive nutritional intervention in Barcelona Clinic Liver Cancer stage B HCC, namely, early partial replacement with BCAA enriched nutrient may consequently improve the treatment outcome of HCC.

Severe trauma injuries, such as open pelvic fractures and degloving injuries, have recently become salvageable. However, extensive soft-tissue defects often remain and can lead to disuse atrophy of the extremities, prolonged hospital stays, and numerous other problems. Such injuries can be easily and effectively treated by a general trauma surgeon performing the pedicled omental flap technique. We report on 2 highly diverse and complicated cases of soft-tissue defect that were both successfully treated with this technique. One case was an extensive right-sided defect of the pelvic soft-tissue in a 20-year-old woman. The other case was in a 55-year-old man who underwent emergency artificial vessel replacement surgery for a femoral artery tear with severe damage to the surrounding muscle. Although the surgery was successful, a methicillin-resistant Staphylococcus aureus infection developed around the artificial vessel 10 days after surgery. In both cases, the pedicled omental flap technique was successfully performed and yielded epithelization without serious infection and with the infection subsiding with wound-area healing. To our knowledge, the pedicled omental flap technique has rarely been used to treat severe trauma, and our results suggest its usefulness for both preventing infection in large wounds and healing infected wounds.

Epidural analgesia is used to promote rehabilitation in patients with refractory complex regional pain syndrome (CRPS) who cannot bear physical programs due to intense pain. However, the actual rehabilitation process has not been focused in previous reports. Here, we outline our experience of treating a young woman with CRPS type 1 who underwent rehabilitation facilitated by a continuous lumbar epidural block. A 15-year-old girl developed throbbing pain from her left toe to her ankle, with no obvious cause. She was admitted to the hospital 2 months after symptom onset for an assessment of pain intensity, range of motion, weight-bearing, neglect-like symptoms, pain catastrophizing, and a CRPS severe score with impaired activities of daily living. The rehabilitation program was initiated under facilitation of continuous epidural block. Her rehabilitation program included physical therapy, motor imagery, mirror therapy, and cognitive behavioral therapy. The intensity of the exercise was gradually increased without exacerbating her symptoms. Ultimately, she recovered completely after a continuous epidural block for 21 days and rehabilitation for 80 days. A combination of continuous epidural block and intensive rehabilitation improved the symptoms of this patient. The treatment course would be helpful for planning rehabilitation programs in other patients with CRPS.

Background: Infundibular dilatation (ID) is a funnel-shaped enlargement of the origin of cerebral arteries. The coexistence of an aneurysm and ID is relatively rare. Patients with IDs are rarely followed up. However, some IDs have been reported to develop into aneurysms with subsequent rupture. Here we report on a case of an aneurysm that coexisted with ID of the posterior communicating artery. Case Presentation: A 51-year-old woman underwent magnetic resonance imaging (MRI) to check for aneurysms and other problems. MRI revealed an unruptured aneurysm of the right internal carotid artery, for which the patient was admitted to our hospital. Three-dimensional computed tomographic angiography revealed an aneurysm, which protruded outward, and ID of the posterior communicating artery, which protruded inward. A right pterional craniotomy was performed with aneurysm clipping. The postoperative course was uneventful. In this report, we demonstrate operative views of the aneurysm and ID with the use of neuroendoscopy. Conclusion: ID can develop into a true arterial aneurysm and potentially rupture. Therefore, we need to observe the patients with IDs carefully, particularly in young women.

Objective: Asymmetric dimethylarginine (ADMA) is an endogenous nitric oxide synthase inhibitor and a marker of vascular endothelial damage. Angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker (ARB) are reported to reduce the serum ADMA level. Our group administered either ARB or calcium antagonist to patients after cerebral infarction and discussed the ADMA changes observed. Methods: Hypertensives in the chronic stage of cerebral infarction were enrolled. These subjects included patients of atherothrombotic cerebral infarction or lacunar infarction. The patients received candesartan cilexetil (candesartan group) or amlodipine (amlodipine group). The blood pressure and serum ADMA concentration were measured and compared before the treatment commenced and at 1-3 months after the treatment commenced. Results: Seven subjects received candesartan and six received amlodipine. There was no difference between the groups in the change of blood pressure before and after the drug treatment. The ADMA level (nmol/mL) fell significantly from 0.57±0.10 (before administration) to 0.52±0.09 (after administration) in the candesartan group (P<0.05). The ADMA level did not change between before and after administration in the amlodipine group. Conclusion: Treatment with candesartan cilexetil reduced the level of ADMA in hypertensive patients in the chronic stage of cerebral infarction. Candesartan cilexetil may be useful in hypertensive patients at the chronic stage of cerebral infarction with expected anti-atherosclerotic effect.