Total elbow arthroplasty is useful for pain relief and functional reconstruction. Good long-term results are achieved by resurfacing and Kudo total elbow arthroplasties. The humeral components are maintained without any long-term concerns, but ulnar component may require revision surgery due to loosening. However, few studies have assessed the biomechanical stress analysis around ulnar components. An individual finite element model based on computed tomography （CT） images was developed and used to evaluate the bone stress around the ulnar stem. A three-dimensional CT model with artificial elbow joint simulation was subjected to computational analysis. Finite element analysis was performed, with muscle and joint reaction force being calculated using a musculoskeletal model simulation system as a boundary condition. The highest stress and strain occurred at the medial part of the coronoid process. A strain of no more than 3,000µ was observed during the 30°-120° elbow flexion, which is the range of motion typically obtained after elbow arthroplasty. The Kudo elbow prosthesis provided good results from a biomechanical perspective when the implant was placed in the optimal position. Future studies should focus on the analysis and verification of various factors that may cause changes in bone stress around the ulnar component, such as the stem’s insertion angle.

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Secondary knee osteoarthritis in young patients frequently occurs after subtotal meniscectomy. Partial meniscus reconstruction （PMR） surgery is performed if no other treatment option for such patients is available and only when the posterior meniscal section remains intact after trauma. PMR surgery was performed using autologous tendons by creating bone tunnels at different positions of the tibia in an osteoarthritic rabbit model. The effects on femoral condyle cartilage and osteophyte formation degeneration were then histologically examined. The medial meniscus of 15 rabbits was partially resected and reconstructed with an autograft of the extensor digitorum longus tendon. Posterior bone tunnels were created on the tibial articular surface for graft tendon fixation （articular surface group） in the rabbits’ right knees. Posterior bone tunnels were created at the medial tibial angle （extra-articular group） in the same rabbits’ left knees. Every 2, 4, 8, 12, and 18 weeks after surgery, three rabbits were sacrificed. Granular area injury in the femoral condyle cartilage and osteophyte formation were histologically evaluated as per Kamekura’s grading system. The results showed no significant difference in the femoral condyle cartilage injury and osteophyte formation between groups, except for low-grade osteophyte formation at four weeks after surgery for the extra-articular group （p＜0.05）. These results suggest that the advantage of creating posterior bone tunnels at the medial tibial angle is ameliorating tibial articular cartilage injury and tendon autograft, as we reported in a previous paper, rather than ameliorating femoral condyle cartilage injury and osteophyte formation, which were tested in the current study. At present, we recommend an extra-articular surface rather than an articular surface as the site for creating bone tunnels for fixing the tendon graft for better knee osteoarthritis prognosis. Further studies are warranted to establish the clinical implication of the current animal experiments.

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Surgical treatment guidelines for retained placenta remained unclear. Thus, this study aimed to investigate the validity of a guideline for selecting surgical techniques based on the uterine muscular layer thickness of the placental attachment and the presence of placental blood flow. In this study, we compared the guidelines with the performed techniques retrospectively for 12 patients who underwent surgery for retained placenta after undergoing magnetic resonance imaging scans at our hospital from December 2015 to December 2020. We selected trans cervical resection with laparoscopy （lapa-TCR） in cases with a thickness of ＜5mm regardless of blood flow, TCR in cases with a thickness of ≥5 mm and blood flow, and dilation and curettage （D&C） in cases without both. The planned techniques were lapa-TCR in 1 case, TCR in 8 cases, and D&C in 3 cases. Of the 2 cases requiring changing techniques, 1 was transferred to laparoscopy because of perforation during TCR and 1 to TCR because of difficulty in removal during D&C. The assumed techniques based on guidelines were lapa-TCR, TCR, and D&C in 1, 7, and 4 cases, respectively. The assumed and actual techniques were the same in 9 out of 12 cases. Out of 3 cases that differed, in 2 cases of assumed D&C technique the attending physician chosed TCR , which was the same actual technique. 1 case of assumed TCR techniques was perforated and shifted to laparoscopy. The perforation was attributed to a bicornuate uterus, placental attachment site around the fallopian tube angle, and intraoperative blind manipulation. The risk of perforation was higher in these cases, so we partially improved the guidelines. They are consistent with the actual techniques and outcome and are generally appropriate. In the future, we plan to prospectively examine the patients using these guidelines.

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Hemophilia A is an X-chromosome-linked recessive inherited congenital bleeding disorder that is caused by coagulation protein factor Ⅷ deficiency or dysfunction. Herein, we report a case of mild hemophilia A diagnosed after a postoperative bleeding event following palatine tonsillectomy, indicating the importance of the patient’s bleeding history than the laboratory test results in predicting postoperative bleeding. A 3-year-old boy underwent bilateral palatine tonsillectomy and adenoidectomy for snoring and apnea. The activated partial thrombin time （APTT） measurements in two preoperative coagulation screening tests were 34.9 s and 45.6 s, suggesting no necessary specific interventions. The surgery was performed without complications, but bleeding occurred on the third postoperative day, requiring emergent hemostasis. On postoperative day 6, he required transfusion and mechanical ventilation under general anesthesia because of a rebleeding event that was difficult to control even with emergent hemostasis. His APTT did not increase in the subsequent examination. However, his factor Ⅷ level decreased to 26.3％, leading to a hemophilia A diagnosis. A detailed interview after the postoperative bleeding revealed a hematoma due to an upper lip strip suturing injury at 9 months of age. Here, a mildly prolonged APTT of 45.6 s was detected in only one of the three coagulation screenings. Postoperative hemorrhage could have been prevented by considering hemophilia if the patient’s hemostatic disorder history had been preoperatively analyzed in detail. In conclusion, boys with a history suggestive of hemostatic disorder should be considered to have mild hemophilia even if APTT is not prolonged.

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We observed a case of Kawasaki disease complicated with arthritis during the subacute phase. Differentiating arthritis in Kawasaki disease from systemic juvenile idiopathic arthritis （sJIA） is challenging. The cytokine value was determined by cytokine profiling. The laboratory data did not show characteristics of sJIA, and the symptoms improved without medications. Measuring the cytokine and serum ferritin levels is suggested to help differentiate Kawasaki disease from sJIA.

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This study aimed to review original studies and published reviews in the past 10 years in the field of nursing practice for collagen disease in Japan to clarify current research trends and identify future research issues. We electronically searched the literature using “disease” and “adult Still’s disease” as broad search terms. The first list was narrowed by searching for 〜10 target diseases. These disease-specific studies were reviewed to extract nursing topics. Key nursing search words included nursing, psychology/cognition, patient experience, living condition, self-care, and difficulty. Of the 88 identified studies, 62 did not focus on collagen disease and were excluded. The target diseases of the 26 analyzed papers were as follows: 2 cases of autoimmune disease, 4 cases of systemic lupus erythematosus, and 20 cases of rheumatoid arthritis. Patient confusion about changes in appearance and personal conflicts about finances and roles, as well as anxiety about illness, its treatment, and the future, are important themes for nursing practice in this review. Nurses help patients adjust to life events, leverage social resources （including family members）, and connect with multiple occupations. Patient education about dealing with a chronic disease and quantitative studies related to medical treatment behavior and patient quality of life are future research opportunities.

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Congenital absence of permanent teeth and anomalous crown morphology can cause dental occlusal abnormalities and esthetic disorders. It is difficult to obtain satisfactory functional and esthetic results in such cases, even if orthodontic treatment or prosthodontic treatment alone is attempted to improve the situation. However, the overall quality of treatment can be improved by implementing a plan that combines both orthodontic and prosthodontic treatment. This study aimed to present a case of a patient with congenitally missing teeth and a peg tooth who was treated with orthodontic and prosthodontic treatment with satisfactory functional and esthetic results. A 20-year-and-4-month-old woman presented for improvement of spaces and treatment of malocclusion of the left molars. She had skeletal class Ⅲ malocclusion with congenital absence of the maxillary right lateral incisor and the mandibular left second premolar, peg maxillary left lateral incisor, distal inclination of the mandibular left first premolar, and mesial inclination of the mandibular left first molar. The treatment plan was decided in collaboration with the prosthodontist. The orthodontic treatment was a nonextraction treatment. The teeth were aligned, and the spaces were controlled with an edgewise appliance. The congenitally absent teeth and the peg tooth were aligned to create a space for prosthodontic treatment, and the spaces were closed with implants. Thus, a class I molar relationship was established. Protrusive guidance by the central incisors and lateral guidance by the canines were also obtained. The spaces were closed by prosthodontic treatment, the midline of the face and dentition were aligned, and the teeth were arranged symmetrically, resulting in an esthetic and functional occlusion.

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A 16-year-old male patient was referred from the pediatrics department to our center due to elevated levels of liver enzymes in his blood test. All markers of viral hepatitis were negative. At the first visit, the immunoglobulin G （IgG）, IgG4, and antinuclear antibody levels were 2,292mg/dl, 141mg/dl, and 320×, respectively. Ultrasonography of the abdomen and magnetic resonance cholangiopancreatography showed extrahepatic and intrahepatic bile duct stenosis and dilation at the hepatic hilum center. Percutaneous liver biopsy was performed near the stenotic and dilated intrahepatic bile duct at the hilum of the liver for diagnosis because a larger amount of tissue samples is obtained using this method compared to endoscopic retrograde cholangiopancreatography. Histopathological results showed marked infiltration of lymphoid and plasma cells with storiform fibrosis around the bile duct. Moreover, many lymphoid cells in those areas were IgG4-positive. The patient comprehensively met the IgG4-sclerosing cholangitis （SC） diagnostic criteria, and a definite diagnosis was established. Immunosuppressive therapy was initiated with 40-mg/day （0.6mg/kg/bodyweight） prednisolone （PSL） before 600-mg/day ursodeoxycholic acid （UDCA）. The levels of liver enzymes in the blood improved from approximately four weeks after the start of prednisolone treatment and normalized after two months. Primary sclerosing cholangitis is generally suspected in liver disorders associated with bile duct stenosis, particularly in young males. However, IgG4-SC was suspected in this case because of the high serum IgG4 level and bile duct stenosis localized to the hepatic portal. In conclusion, the pathological findings obtained using the percutaneous liver biopsy at the hepatic portal region led to the definitive diagnosis of IgG4-SC.

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MicroRNA （miRNA） expression of cancer stem-like cells in cultured breast cancer cells （BRCA1-mutant MDA-MB-436 and BRCA1-wild type MDA-MB-231） was examined using CD44, a breast cancer stem cell marker with or without the addition of the anticancer drug, gemcitabine. CD44-positive cells were collected using the bead method, and the expression of 84 miRNAs was examined using a miRNA PCR array. Changes in miRNA expression induced by gemcitabine were analyzed using the ΔΔCt method. The expression of the miR-1, miR-155, miR-186, and miR-31 were higher in CD44-positive MDA-MB-436 cells than in CD44-positive MDA-MB-231 cells. The higher expression of miR-1 and miR-186 were observed in both MDA-MB-436 and MDA-MB-231 cells after adding gemcitabine. The expression of miR-155 and miR-31 was increased in MDA-MB-436 after adding gemcitabine but decreased in MDA-MB-231. Our results suggested that BRCA1-mutant breast cancer stem cells are characterized by increased miR-1, miR-31, miR-155, and miR-186. Moreover, miR-155 and miR-31 are not decreased after administration of anticancer drugs, which may be associated with therapeutic resistance and malignancy.

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