We retrospectively compared two groups of patients with hip fractures and severe complications. One group had been treated surgically; the other group had been treated conservatively to prevent worsening of general status, with transfer to wheelchair as soon as possible. This study aimed to determine if early prognosis after conservative treatment would be worse than that following surgical treatment. Materials and Methods: Subjects were patients (n=230) with hip fracture who had been admitted and treated at our hospital from 1993 through 2006. Patients' medical records were retroactively investigated to obtain information on age, sex, complications, type of fracture, and course of subsequent hospitalizations. Additional information for conservatively treated patients included reasons for avoiding surgery and time-to-transfer to wheelchair. In case of death, the cause and timing of death were investigated. Results: Of the 230 patients, 22 (mean age, 83.5 years) were treated conservatively. Complications at admission included cardiac disease, respiratory disease, malignancy, renal disease, dementia, and other conditions. Multiple complications were commonly seen. The reasons for selecting conservative treatment were cardiac function disturbance in 13 cases and decision of patients' families in 9 cases. Almost all patients were able to transfer to wheelchair. A total of 9 patients died in the hospital: 8 were in the surgical treatment group and 1 was in the conservative treatment group. The patients who died in the surgical treatment group had a mean age of 80.3 years, and pneumonia was the main cause of death. The timing of death ranged from 12 to 129 days after surgery. The number of perioperative deaths was 3 (1.4%). Discussion and Conclusion: This study showed that in patients with hip fractures, severe complications, and poor general conditions, early prognosis after conservative treatment aiming for early transfer to wheelchair is no worse than that following surgical treatment. Thus, conservative treatment should be considered for patients with poor ability for activities of daily living.

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Aim: The aim of the present study was to elucidate the clinical characteristics of pregnancy-associated maternal deaths. Methods: We performed a retrospective analysis with medical records and autopsy reports of cases of pregnancy-associated deaths. We collected information on all maternal deaths related to pregnancy that occurred in 3 hospitals affiliated with Nippon Medical School in Japan from January 1, 1984, to December 31, 2014. Data analyzed were maternal age, past medical history, parity, gestational age, clinical signs and symptoms, cause of death, and maternal autopsy findings. Results: A total of 26 maternal deaths occurred during the 31-year study period. Autopsies were performed for 16 patients (61.5%). The 26 deaths included 19 (73.1%) classified as direct maternal deaths and 7 (26.9%) classified as indirect maternal deaths. The mean maternal age at death was 33.1±4.3 years (range, 26-41 years). The highest percentage of women was aged 35 to 39 years (38.5%). Of the 26 maternal deaths, 69% occurred at 32 to 41 weeks of gestation. In cases of direct maternal death, the leading causes were amniotic fluid embolism (7 cases, 27.0% of all deaths) and hemorrhage (6 cases, 23.1% of all deaths). In cases of indirect obstetric deaths, the causes included cardiovascular disorders, cerebrovascular disorders, sepsis due to group A streptococcal infection, and hepatic failure of unknown etiology. Conclusions: Amniotic fluid embolism was the leading cause of maternal deaths and was followed by obstetric hemorrhage. To prevent and reduce the number of maternal deaths in Japan, further basic and clinical research on amniotic fluid embolism is required.

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Background: Many previous studies have demonstrated that botulinum toxin A (BTX-A) injections satisfactorily reduce spasticity. Nevertheless, BTX-A, with or without an adjuvant therapy, effectively improves the direct functional movement in few patients with spastic upper extremity paralysis. Therefore the present study aimed to determine the effectiveness of task-orientated therapy on spasticity and functional movement by using electromyography-triggered functional electrical stimulation (EMG-FES) after BTX-A injections. Design: Open-label, prospective clinical trial Method: The subjects were 15 patients with spastic paresis (12 male, 3 female; age range, 17-74 years; 14 due to stroke, 1 due to spinal cord injury) who received BTX-A injections. Before the study was started, all subjects had undergone task-orientated therapy sessions with EMG-FES for 4 months. Despite all patients showing a various extent of improved upper extremity function, upper extremity function reached a plateau because of upper extremity spasticity. After BTX-A injection, all patients underwent task-orientated therapy sessions with EMG-FES for 4 months. The outcomes were assessed with the modified Ashworth scale, the simple test for evaluating hand function, box and block test, grip and release test, finger individual movement test, and grip strength. Assessments were performed at baseline and 10 days and 4 months after BTX-A injection. Results: The median modified Ashworth scale score decreased from 2 at baseline to 1 at 10 days and 4 months after BTX-A injection. The finger individual movement test score increased slightly at 10 days (p=0.29) and further increased at 4 months (p<0.05). The simple test for evaluating hand function, grip and release test, box and block test, and grip strength decreased after 10 days (p<0.05, p=0.26, p<0.01, and p<0.01, respectively) but increased after 4 months (p<0.01, p<0.05, p<0.01, and p=0.18, respectively). Conclusion: Task-orientated therapy with EMG-FES after BTX-A injection effectively reduced spasticity and improved upper limb motor function. Our results also suggest that spasticity occurs as a compensation for the force of the affected muscles and leads to misuse movements and ostensible dexterity in many patients. In addition, we hypothesize that BTX-A injection initializes the abnormal adapted movement pattern and that more active hand movements with facilitation of the paretic muscles when using EMG-FES induce an efficient muscle reeducation of the inherent physiological movement pattern that ultimately could prove useful in the activities of daily living.

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Superior dislocation of the patella without patellar ligament injury is an extremely rare condition. A review of the English-language literature found only 23 reported cases. In addition, the primary factor for dislocation in most of these cases was considered to be osteophytes in the inferior pole of the patella and the anterior surface of the femoral condyle; only 1 case had no osteophytes. We treated a 19-year-old woman who sustained a painful locking of the left knee after colliding with a friend. Plain radiography and computed tomography showed superior-lateral dislocation of the patella and an interlocking between notches in the inferior pole of the patella and the anterior surface of the femoral condyle. Closed reduction without sedation was performed without difficulty, and the patient was able to walk home without pain. After 1 week, the knee was without problems. The patient had no osteophytes in the knee and had no other common risk factors, such as patella alta, ligamentous laxity, genu recurvatum, and paralytic disorders. After a comparison with previously reported cases of superior patella dislocation, we concluded that the primary factor in the present case might have been a different condition.

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We report on a rare case of blunt traumatic hepatic arteriovenous fistula arising from a pseudoaneurysm in a 35-year-old woman. Transarterial embolization was performed with n-butyl-2-cyanoacrylate, under inflow control with loose coil packing within the pseudoaneurysm and outflow control by balloon occlusion of the hepatic vein. A promising therapeutic outcome was achieved without any serious adverse events. Thus, the combination of these techniques to control inflow and outflow was successfully used to treat this rare hepatic vascular injury.

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Purpose: To report our findings in a case of childhood refractory interstitial keratitis successfully treated with 0.1% topical tacrolimus. Methods: A 12-year-old boy presented with a 3-year history of interstitial keratitis. For the recurrent interstitial keratitis he had been treated with topical and systemic acyclovir, steroids, and topical cyclosporine for 3 years. Our examinations revealed severe stromal infiltrates and neovascularization. Treatment was changed from topical 0.5% cyclosporine to topical 0.1% tacrolimus combined with topical acyclovir and betamethasone. Results: After 2 weeks of treatment with topical tacrolimus, the degree of stromal infiltrates decreased. Although the improvements were slow, the stromal infiltrates resolved somewhat, and neovascularization and topical acyclovir and betamethasone were tapered and stopped in 18 months. Since then, the patient has not shown any recurrence for 9 months without medication. Conclusion: Our findings indicate that topical tacrolimus should be considered for treating refractory interstitial keratitis in children.

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We report a case of the extremely rare condition Epstein-Barr virus (EBV)-positive T-cell lymphoproliferative disease (LPD) which occurred after umbilical cord blood transplantation. A 25-year-old Japanese man underwent cord blood transplantation from a male human leukocyte antigen 4/6-matched donor due to acute myeloid leukemia with trisomy 8. Bone marrow examination on day 30 showed chimerism with at least 90% donor cells and complete hematological response. Chronic symptoms of graft-versus-host disease appeared only on the skin and were successfully treated with cyclosporine alone. Three years later, however, the patient experienced repeated cold-like symptoms and was hospitalized with liver dysfunction. A high fever developed and was followed by significant edema of the right side of the face. The EBV DNA copy number in whole peripheral blood was 2×10⁴/mL. Liver biopsy showed invasion of EBV-infected CD8-positive T cells. Southern blotting analysis of the whole peripheral blood showed that the T-cell receptor Cβ1 rearrangement was positive. On the basis of these results, EBV-positive T-cell LPD was diagnosed and treated with prednisolone, cyclosporine, and etoposide, followed by cyclophosphamide, doxorubicin, vincristine, and prednisone. However, the patient died of cardiac function failure, pneumonia, and pulmonary hemorrhage, all of unidentified cause. Most cases of EBV-related LPD after hematopoietic stem cell transplantation consist of EBV-positive B-cell LPD, and, to our knowledge, de novo EBV-positive T-cell LPD subsequent to transplantation has not been previously reported.

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