Our institution has used echo examination to diagnose congenital dislocation of the hip since 1985. Echo diagnosis, in particular Graf's method, the most typical echo examination for CDH, has taken the place of X-ray, arthrography and CT examination. We present a practical examination and treatment based on Graf't method. A periodic observation is applied to Graf classification type I and IIa⁺. A continuous echo examination is applied to type IIa^- and IIb. Riemenbugel harness (Rb) is applied to type IIc or worse. Although type IV commonly requires operative treatment, we apply Rb for cases that respond and shift to type III by traction treatment. Rb is also applied to non-responding cases after additional period of traction. The operative treatment is enforced only against completely non-responding cases. Nearly 10% of type IV can acquire reduction by the use of Rb. After Rb treatment, sonographic observation is performed with an anterior approach. We have established and put into practice protocol for the diagnosis and treatment of CDH.

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Lumber spinal stenosis occupies an important position as a significant factor that reduces activities of daily living in aging society. One of the main lesions is degenerative ligamenta flava where changes such as inflammation, ossification, angiogenesis, cartilaginous degeneration, and calcinosis may be occurred. This time, using degenerative ligamenta flava collected intraoperatively, we compared mRNA expression levels of various genes, cyclooxygenase-2 (COX2)/osteocalcin/endothelin-1/angiopoietin-1/bone morphogenetic protein-2 (BMP2)/interleukin-8 (IL-8), possibly associated with the above changes by dividing into 3 portions as follows: histologically almost normal (unaffected) portion; strongly affected paramedian (interlaminar) portion; and strongly affected portion proximal to bone attachments in the articular capsule. Histological examination was carried out with HE staining of 7 μm-frozen sections derived from ligamenta flava collected intraoperatively using cryostat. The mRNAs were extracted with microdissection of the portions after Cresyl Violet staining of the membrane frozen sections. The cDNA clones were replicated, and comparison of expression levels was performed using real-time PCR after reaction with primers for these genes. In the unaffected portion, expression levels of the genes were expected to be less, though, it was higher in IL-8 associated with angiogenesis compared to the other portions. Repair mechanism to micro lesions may lead to scarring and collagen fibers deposition even in the almost normal portion. Moreover, IL-8 expression was observed in the interlaminar and capsular portions, though, angiogenesis may have been more strongly induced in the former. Increased endothelin-1, involving mechanical stress, expression in the capsular portion was expected to actively cause changes, though, various genes associated with cartilage degeneration, ossification, or inflammation were accordingly expressed in the both interlaminar and capsular portions. In the degenerative ligamenta flava, not only endochondral ossification may occur in the bone attachments, but also thickening with bone formation in the portions without continuity with bones.

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Rehabilitation medicine (hereinafter, rehabilitation) is a multidisciplinary practice involving attending and rehabilitation physicians, therapists and nurses. Rehabilitation must be performed in accordance with Rehabilitation Protocols (hereinafter, the protocols). However, it is unclear whether our hospital protocols are appropriate. We carried out an evaluation to clarify the status and to promote improvement of our hospital protocols. This study included 424 inpatients (excluding reconsultation and dysphagia evaluation) who consulted with the Rehabilitation Department between November 2007 and May 2008. In an in-house communication meeting held in December 2007, we requested that protocols be prepared, and based on this intervention, patients were divided into pre-intervention and post-intervention groups. Furthermore, to assess the short- and long-term effects of the intervention, the patients were divided into a pre-intervention group (155 requests for protocols), an early post-intervention group (121), and a late post-intervention group (148). Assessments were made regarding breakdown of wards among the three groups, number of protocols prepared and number of names signed by the patients in attendance. No significant differences were observed among the three groups. Significantly more protocols were prepared in the early post-intervention group (93/121 patients, 76.9%) than in the pre-intervention group (92/155 patients, 59.4%) (p = 0.002). The number of names signed by attendees was greater, although not significantly, in the early post-intervention group (51/93 patients, 54.8%) than that in the pre-intervention group (40/92 patients, 43.5%). Only a few protocols were prepared in our hospital and the attendees did not fully understand the importance of the protocols. Intervention promoted protocol preparation in the short but not long term suggesting that the awareness of the attendees regarding rehabilitation is poor. We need to develop usage of protocols suited to various situations in our hospital and to promote attendee understanding of rehabilitation.

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The puncture guided by ultrasonic diagnostic equipment plays an important role in the diagnosis of digestive organs. The use of a 4D probe has increased recently and bean applied to diagnosis and needle treatment. With a 2D screen it is difficult to locate the puncture and the target in a thickness direction. With puncture therapy it is essential to know the position of the needle, the circumference of the organ and the puncture site of the target tumor. Because deep localization of the needle and confirmation of its direction cannot often be determined, we studied the use of a 4D probe (GE Yokogawa Medical Systems Co., Ltd. Logiq 7 BT 07, equipped with a 4D 3 CL probe) to support the puncture with conventional MPR. We experimented with a development type RFA needle for therapy after puncture simulation under real time 4D. For the puncture we used tomographic ultrasound imaging (TUI). We used TUI by spurious tumor cauterization and HCC cauterization in a clinical case. The position of the RFA needle could be observed in the liver in real time and whether the needle covered the whole HCC. In addition, it was confirmed that in the hyperechoic area, cauterization covered the entire tumor. This Logiq 7 BT 07 GE Yokogawa Medical Systems Co., Ltd. 4D probe was able to provide puncture protocol under real time 3D (4D) TUI and increase the safety of puncture procedures. It is thought that we could improve the safety and an authenticity of the puncture with this method.

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Total extraction of the parathyroid glands followed by autografting for patients of severe secondary hyperparathyroidism (SHPT) resistant to internal treatment not only improves the quality of life (QOL) of these patients undergoing maintenance dialysis, but also contributes to improvement of the vital prognosis. We performed surgical treatment for SHPT in 220 patients between April 2001 and November 2008; the surgery was conducted as the initial treatment in 205 patients, and as a relief surgery for recurrences after the initial operation in the remaining 16 patients. Fifteen of the 16 patients included patients who had undergone the initial operation in other hospitals. We assessed the results of the operation and the postoperative problems in these 220 patients. The male-to-female ratio of the 205 patients who underwent the surgery as the initial operation was 107: 98. The patients ranged in age from 18 to 82 years (mean, 56.2 years). The preoperative dialysis period ranged from 1 to 33 years (mean, 13.7 years). The preoperative intact-parathyroid hormone (i-PTH) level ranged from 233 to 2616 pg/ml (mean, 836 pg/ml), and the i-PTH level in the immediate postoperative period ranged from 2 to 622 pg/ml (mean, 36.1 pg/ml). Fifty-three of the 205 patients had a history of percutaneous ethanol injection therapy. The mean number of parathyroid glands extracted was 3.95. In the evaluation of the postoperative results in the 205 patients who underwent the surgery as the initial operation from the point of view of the i-PTH level, 177 of the 205 patients (86%) were classified into the total extraction group (serum i-PTH in the immediate postoperative period of 60 pg/ml or under), and 28 of the 205 patients (14%) were classified into the persistent SHPT group (serum i-PTH in the immediate postoperative period of 61 pg/ml or over). The 5-year survival rate after the initial operation was as favorable as 96.7%. On the other hand, the postoperative problems included postoperative persistent SHPT, recurrent glandular hypertrophy in the cervical mediastinum, and recurrent hypertrophy of the autografted gland in the forearm. Re-operation was undertaken in one of the 28 patients with persistent SHPT, while the remaining 27 continued to receive internal treatment. All 7 patients with recurrent glandular hypertrophy in the neck were treated by re-operation of the neck with a retractor, and successful control of the i-PTH level was achieved in all of the patients. Seven of 9 patients who subsequently underwent excision of the autograft because of recurrent hypertrophy of the autografted gland in the forearm maintained a high serum i-PTH level. Several sessions of the operation were needed in seven of 9 patients. Extraction of a residual gland in the neck or the mediastinum was required in 7 patients. These results indicate that definite total extraction of the parathyroid glands at the time of the initial operation and reconsideration of a method of transplantation of the gland are necessary.

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Vascular calcification is common in patients with advanced and end-stage renal failure and is thought to contribute to their increased cardiovascular mortality. Recently, it became apparent that this calcification is an active, regulated process similar to osteogenesis. Several proteins have been implicated in this process. During the last decade, it was reported that Vitamin K-dependent proteins have been exclusively related to the regulation of tissue calcification. Matrix Gla (γ-carboxyglutamic acid) protein (MGP) is one of the vitamin K-dependent extracellular matrix proteins. Another important molecule is Osteopontin (OPN). OPN may be an important regulator of arterial mineral deposition under conditions of injury and disease. However the relation between vascular calcification and these proteins is still unclear in a uremic state. We examined the effect of vitamin K₂ (VitK₂) on experimental vascular calcification induced by vitamin D₃ (VitD₃) in adriamycin (ADR)-induced uremic rats. We evaluated the serum samples (Urea nitrogen (UN), Creatinin (Cr), Albumin (Alb), Calcium (Ca) and Phosphate (P)), histologic examination, calcification assay and genetic analysis. The results show that the MGP mRNA expression was significantly higher and the OPN mRNA expression was lower in the ADRDK group (Adriamycin + VitK₂ diet + Calcitriol i.p. 3 times/week) than in the ADRD group (Adriamycin + Nomal diet + Calcitriol i.p. 3 times/week). This in vitro experiment suggests that VitK₂ may have inhibitory effects on uremic vascular calcification.

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Approximately 30% of patients with depression are reported to be treatment-resistant, and a number of bio-psycho-social factors are known to influence responsiveness to pharmacotherapy. In the present study, we investigated whether pre-treatment frontal functions of patients with depression as measured by near-infrared spectroscopy (NIRS) would predict future responsiveness to pharmacotherapy. Thirty-two drug-naïve outpatients with major depressive disorder participated in the present study. All the patients were started with antidepressants and their clinical symptoms were evaluated twice with the Hamilton Rating Scale for Depression (HRS-D), on their first visit and 8-12 weeks after the beginning of pharmacotherapy. All patients received multi-channel NIRS on their first visit, and their frontal reactivity was measured by changes in oxy-hemoglobin concentration in the frontal lobes. Comparison of pre-treatment NIRS findings demonstrated that the overall increase of oxy-hemoglobin in responders was lower than that in non-responders, with significant differences in channels in the medial frontal areas. The results suggest that the treatment-responsive patients with depression demonstrated typical hypofrontality as has been reported in previous literature. In contrast, NIRS findings of the treatment-resistant depressive patients were similar to those reported in healthy persons, suggesting that patients with atypically preserved frontal reactivity may respond minimally to antidepressants. Pre-treatment hypofrontality of patients with depression as measured by NIRS may be useful for predicting future responsiveness to pharmacotherapy.

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We report three cases of adverse effects following the use of tosufloxacin ophthalmic solution. Case 1: An 88-year-old female visited our clinic with a corneal epithelial defect and was prescribed tosufloxacin ophthalmic solution 3 times daily. She returned complaining of whiteness in her cornea and a white corneal deposit was observed. The deposit was scraped off and she discontinued medication. Deposits were remarkably decreased on the following day. Case 2: A 78-year-old male with a herpetic corneal ulcer had a white corneal deposit after using ophthalmic solution containing tosufloxacin, atropin, and hyaluronic acid. The deposit decreased after discontinuation of the medication. Case 3: A 75-year-old female developed severe iritis after using tosufloxacin ophthalmic solution for conjunctivitis. The manifestation improved when medication and steroid therapy was discontined. The potential for a corneal deposit and iritis must be considered when prescribing tosufloxacin ophthalmic solution.

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McCune-Albright syndrome is associated with recurrent fractures due to fragile bones from fibrous dysplasia, causing deformed coxa vara (also called Shepherd's crook deformity) in the femur. We report a case of coxa vara after a fracture due to a fall in a child with McCune-Albright syndrome. The patient was a six-year-old female diagnosed with McCune-Albright syndrome. She received conservative therapy with traction treatment for the femoral trochanteric fracture due to a fall. She repeated synostoses and fractures during the course of the treatment. The fractures were completely united after about 8 months of treatment. However, the deformed coxa vara of the hip joint subsequently worsened without pain and in the unaffected side. We prefer conservative therapy taking into consideration the patients age, but surgical procedures are usually considered when bones are mature. Nevertheless, some repots suggest that this kind of case is often difficult to treat, even if surgical procedures are done. There are few reports on patients with McCune-Albright syndrome, and further reports are required.

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