Between 2015 and 2023, the Department of Legal Medicine at Showa University School of Medicine conducted 26 autopsies commissioned by the Ibaraki Prefectural Police Department. Given our expertise in drug analysis, we frequently investigate cases of suspected stimulant drug （amphetamine and methamphetamine） use. Ten cases, accounting for just under 40%, were suspected to be stimulant-related deaths. We examined the distribution of these stimulants in body tissues and their potential role in the cause of death. Samples were collected from cerebrospinal fluid, blood, body cavity fluids, bile, urine, hair, cerebrum, myocardium, lung, liver, kidney, and gastric contents. Samples were pretreated using the QuEChERS method, and analyses were conducted on a Shimadzu GCMS-TQ8040 gas chromatography–tandem mass spectrometry system. Amphetamine and methamphetamine were identified and quantified using the “Quick-DB Forensic” drug and poison database. Amphetamine and methamphetamine were detected in liquid samples from seven cases, although none reached lethal levels. In six cases, concentrations were within the toxic range, and in five, the stimulants were considered contributory to death. Urinary concentrations of these stimulants were 5 to 17 times higher than that observed in blood, suggesting consumption shortly before death. In cases where organ samples were available, stimulant concentrations in the brain, liver, and myocardium were comparable to or higher than those in blood, indicating that amphetamine-type stimulants tend to accumulate in these organs. These findings suggest that amphetamine-type stimulants possibly contribute to death by exerting their effect on organs, even when blood concentrations are below reported lethal thresholds.

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Studies on daily medication use among people with disabilities remain limited. This study sought to investigate medication-related issues and strategies for supporting medication use and formulation adjustments among people with disabilities. A questionnaire survey about medications for people with disabilities was conducted among patients receiving care at the Dentistry for Persons with Disabilities of Showa Medical University Dental Hospital, as well as their caregivers/guardians. Overall, 100 patients with a median age of 24.5 years who were taking oral medications and visited the clinic between July 2023 and December 2023 were enrolled. The most common reasons for hospital visitation were dental cleaning （91 patients） and cavity treatment （40 patients）. The most common dosage forms of oral medication were powder （55 patients） and tablets （45 patients）, with 29 patients requiring dosage form modification. Mixing of medication with food or beverages for ingestion was reported in 32 patients. The frequency of medication refusal was “never” in 79％ of the patients and “almost every time” in 4％. The time required for patients to take their medication was approximately 1 min per instance, with a maximum of approximately 30 min. Caregivers required a median of 2 min per instance, with a maximum of approximately 30 min. A few patients were reluctant to take their medications. However, our results showed that taking medications was time-consuming for patients and their caregivers, making it a source of daily burden. Despite the small number of people with disabilities who had medication-related issues, individualized support for medications and formulation adjustments tailored to specific issues are necessary to reduce patient burden, such as spending 30 min taking medications.

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Optical impression techniques have been routinely used at the Cleft Lip and Palate Center at Showa Medical University since 2019. Previous studies have reported no significant differences between plaster models created using conventional alginate impressions and digital images obtained with intraoral scanners. This study aimed to evaluate differences in measurement accuracy between optical and conventional impression methods in patients with unilateral cleft lip and palate （CLP） and to assess postoperative changes in alveolar cleft width. This study included 20 infants （12 boys and 8 girls） who underwent primary cheiloplasty for complete unilateral CLP at Showa Medical University Fujigaoka Hospital between October 2019 and November 2024. Measurements obtained using intraoral scanners （Scan group） were compared with those derived from plaster models created with conventional alginate impressions （Model group）. No significant differences in alveolar cleft width measurements were observed between the Model and Scan groups. Similarly, no significant differences were found in alveolar cleft width immediately before primary cheiloplasty and before palatoplasty between the two groups. A significant reduction in alveolar cleft width was observed following primary cheiloplasty. However, no significant associations were found between the timing of primary cheiloplasty, the interval until palatoplasty, and the rate of change in alveolar cleft width. Optical impression techniques are effective for obtaining morphological data in patients with CLP. The results demonstrated no significant relationship between surgical timing, the interval until palatoplasty, and the degree of cleft width reduction. Further studies are warranted to investigate the effect of preoperative cleft morphology and surgical techniques on alveolar cleft width.

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To evaluate the proliferation of cancer-associated fibroblasts （CAFs） in cutaneous malignancies—including basal cell carcinoma （BCC）, squamous cell carcinoma （SCC）, and malignant melanoma （MM）—and to examine their association with the cell adhesion plaque protein hydrogen peroxide-inducible clone-5 （Hic-5） using immunohistochemical analysis. Patients with cutaneous malignancies treated at the Departments of Dermatology and Plastic Surgery, Showa Medical University Hospital, between 2004 and 2019 were included. Immunohistochemical staining with monoclonal antibodies against α-SMA, CD10, D2-40, FAP, and Hic-5 was performed on histopathological tumor specimens. Protein expression in CAFs proliferating within peri-neoplastic tissue was evaluated semi-quantitatively, and cases were classified as showing either low or high expression. After dermatopathological review, 50 cases each of BCC and SCC and 21 cases of MM were analyzed. CAF identification by α-SMA staining differed significantly among histological types （p＝0.0078）. High expression was observed in 28％ （14/50） of BCC, 46％ （23/50） of SCC, and 10％ （2/21） of MM cases. FAP staining showed similar trends （p＝0.0001）, with high expression in 28％ （12/50） of BCC, 60％ （30/50） of SCC, and 10％ （2/21） of MM cases. Hic-5 expression also varied significantly （p＝0.003）, with high expression in 32％ （16/50） of BCC, 54％ （27/50） of SCC, and 5％ （1/21） of MM cases. Hic-5 was broadly expressed in CAFs across cutaneous malignancies, with expression patterns differing by histological type. These findings suggest that Hic-5-mediated vascular lesion formation and tissue fibrosis may contribute to localized cancer progression through CAF activation in BCC, SCC, and MM.

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The parapharyngeal space contains several major blood vessels and nerves, making adequate visualization essential for surgical safety. However, surgical maneuvers are performed within an anatomically restricted visual and physical field, making these surgeries technically challenging. Herein, we report a case of transoral excision of a parapharyngeal space schwannoma using endoscopy combined with the continuous aspiration syringe （CAS） method. The CAS method involves continuous aspiration of the tumor using a syringe while performing extracapsular dissection. A 29-year-old female presented with pharyngeal discomfort beginning in September XX. In December XX, she noticed pharyngeal swelling and was referred to our hospital in January XX＋1. Imaging revealed a 40×55×20mm lesion beneath the right middle pharyngeal mucosa, suggestive of a schwannoma arising from the underlying sympathetic nerve. The tumor was excised transorally in one piece using endoscopy combined with the CAS method. Postoperative pathological examination confirmed the diagnosis. In conclusion, the CAS method facilitates effective tumor removal from anatomically obscure regions such as the parapharyngeal space.

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Bisphosphonates （BPs） are widely used to treat conditions characterized by excessive bone resorption, such as osteoporosis, bone metastases, and multiple myeloma. However, BPs are associated with a serious complication known as BP-related osteonecrosis of the jaw （BRONJ）. In this report, we present a case of a patient with multiple myeloma who developed extensive mandibular osteonecrosis following long-term intravenous BP therapy. An 82-year-old male patient presented with bleeding and purulent discharge from a mandibular ulcer. His medical history was notable for refractory multiple myeloma, esophageal cancer, hypopharyngeal cancer, cerebral hemorrhage, heart failure, and septic pulmonary embolism. He received 4mg intravenous zoledronic acid monthly for 67 cycles over 5 years and 7 months （total dose: 268mg） and underwent radiotherapy for esophageal and hypopharyngeal cancers. Following a tooth extraction in 2021, he experienced delayed healing and developed mandibular osteonecrosis. Initial conservative management included debridement, irrigation, and topical sugar-iodine ointment. Due to persistent fistula drainage, local debridement and placement of Penrose drains under local anesthesia were performed. After 6 months, inflammatory symptoms improved, no further progression of osteonecrosis was observed, and the patient maintained oral intake and a good quality of life. This case highlights the multifactorial etiology of BRONJ, including BP use and previous radiotherapy. Conservative management, selected considering the patient’s frail condition, successfully controlled the disease and preserved quality of life. Careful treatment planning based on the systemic health and functional status is essential for managing extensive mandibular osteonecrosis.

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Basal cell carcinoma （BCC） is a malignant skin tumor arising from basal cells of the interfollicular epidermis or hair follicles. Approximately 80％-85％ of BCCs occur in the head and neck region, most frequently involving the eyelids, external nose, and upper lip. We report a rare case of BCC originating in the nasal vestibule, along with a brief literature review. An 80-year-old man presented with a two-month history of a tumor in the left nasal cavity. The lesion was initially suspected to be benign and was excised en bloc under local anesthesia. Histopathological examination confirmed BCC. Assessment of tumor cell infiltration at the surgical margin was inconclusive. Although additional treatment was advised because of the possibility of positive margins, the patient declined further intervention, and careful observation was chosen. Two years after surgery, there has been no evidence of recurrence or distant metastasis. Despite the anatomical continuity between the nasal vestibule and the nasal cavity proper, they differ histologically and give rise to distinct pathological entities. BCC is typically diagnosed by dermatologists through clinical examination, including inspection and palpation, but dermoscopy has recently become a standard diagnostic adjunct. When evaluating tumors of the nasal vestibule, cutaneous neoplasms should be included in the differential diagnosis. Collaboration between otolaryngologists and dermatologists is essential for accurate diagnosis and optimal management.

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We present the case of a 35-year-old male patient who developed peri-implantitis approximately 1 month after initiating immunotherapy with CEDARCURE^Ⓡ Japanese Cedar Pollen Sublingual Tablets while continuing treatment with MITICURE^Ⓡ House Dust Mite Sublingual Tablets. The patient had undergone upper right premolar implant insertion in 2010. In 2012, pus discharge was noted, and a diagnosis of peri-implantitis was made at another hospital. The patient first presented to our clinic in 2018. Despite 2 years of treatment, the peri-implantitis did not improve, and in 2020 the patient was transferred to another clinic for follow-up. In July 2022, he was re-examined for peri-implant tissue bleeding and pus discharge. He had begun regular use of MITICURE^Ⓡ in June 2021 and started CEDARCURE^Ⓡ in June 2022. In August 2022, surgery was performed to remove granulation tissue and plaque from the implant surface. However, pain and hemorrhage recurred in November 2022. The shape of the implant-supported dental prosthesis was modified between January and June 2023, after which the inflammatory findings subsided from July 2023 onward. The exacerbation of inflammation 1 month after starting CEDARCURE^Ⓡ may have been associated with oral swelling promoting plaque accumulation, thereby worsening symptoms. An allergic reaction may also have been involved. Patients with a history of peri-implantitis may require pharmaceutical management that integrates dental treatment considerations with the prescribing physician’s guidance. Further data on peri-implantitis cases are needed, and the occurrence of oral inflammatory symptoms following sublingual immunotherapy warrants investigation.

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A 43-year-old male patient underwent further evaluation of a 10-cm mass on the ventral side of the gastric body, which was incidentally observed on computed tomography. On preoperative examination, there were few malignant findings, and laparoscopy showed no evidence of invasion into surrounding organs. A marginal resection was performed, and pathologic examination of the specimen confirmed a diagnosis of well-differentiated liposarcoma. The patient subsequently underwent imaging follow-up every 4 months. At 52 months postoperatively, a 3.5-cm simple cystic mass was identified on the dorsal side of the gastric fundus. Given the gradual increase in its size, a second laparoscopic marginal resection was performed, which also revealed a well-differentiated liposarcoma. Although recurrence was initially suspected, the second mass arose in a compartment separated by the omental bursa and appeared a significant time after the first mass. Moreover, its imaging and macroscopic characteristics were distinct, indicating an extremely rare case of asynchronous multicentric liposarcoma. Marginal resection, combining diagnosis and treatment based on laparoscopic assessment of dissemination and macroscopic invasion potential, should be considered for intra-abdominal tumors with challenging preoperative diagnosis.

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Atopic dermatitis （AD） is a chronic skin disease that shows fluctuations in signs and symptoms with remission and relapse. Topical therapy is the primary treatment, but some patients can develop treatment resistance. Such patients were often referred from clinics to acute care hospitals, and systemic administration of cyclosporine or corticosteroids might be initiated in these cases. However, the use of these drugs requires consideration of systemic side effects, and the administration period must be kept as short as possible. Dupilumab, a recombinant human IgG4 monoclonal antibody, was approved in Japan in 2018 for the treatment of moderate-to-severe AD that is not adequately controlled with topical prescription therapies or in cases in which these therapies are not advisable. In this study, we examined patients with AD referred to Showa University （now Showa Medical University） Fujigaoka Hospital over the last 10 years. To evaluate the impact of dupilumab, 135 patients from the first 5-year period （October 2013-September 2018） were compared with 268 patients from the second 5-year period （October 2018-September 2023）. The number of patients referred through medical-hospital collaboration and referring clinics was higher in the second 5-year period （n＝167; 66 clinics） than in the first 5-year period （n＝73; 38 clinics）. Among patients in the second 5-year period, 93 were administered dupilumab, and their average Investigator’s Global Assessment （IGA） and Eczema Area and Severity Index （EASI） scores at the start of treatment were 3.3 and 29.6, respectively. Of the 93 patients, 77 （82.8％） were followed up for 16 weeks after administration, and of these, 58 （75.3％） achieved a 75％ reduction in the EASI score （EASI75） at 16 weeks. Side effects were observed in 12 cases （12.9％）, including 2 systemic and 10 local side effects, with the most common side effect being conjunctivitis （9 cases）. Hence, dupilumab appears to be particularly effective for patients with moderate-to-severe AD. The increase in referrals of patients with AD since 2018 may be due to improved recognition of the effectiveness of dupilumab by referring medical clinics. Therefore, dupilumab may have had a significant impact on hospital-clinic collaboration for AD. On the other hand, there was a tendency for dupilumab to be less effective among patients with thymus and activation-regulated chemokine （TARC） levels of ≥10,000pg/mL. In addition, 62 patients （66.7％） are still receiving the drug, which suggests a requirement to review the need for continuous administration and determine when to discontinue drug administration.

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