In recent years, diagnostic imaging methods, such as computed tomography, magnetic resonance imaging, and ultrasonography, have improved greatly and are now used to examine most internal organs. Recently, cytological diagnosis has been actively performed with diagnostic imaging, and treatment can often be started without diagnosis by excisional biopsy. However, few institutions perform rapid cytological diagnosis, and the usefulness of this rapid cytological diagnosis is not widely known. In our hospital, rapid cytological diagnosis has been performed routinely for 20 years. We perform rapid cytological diagnosis at the outpatient clinic, during operation, and even at autopsy, and have confirmed it to be useful. The main purpose of rapid cytological diagnosis at the outpatient clinic is to relieve patients from anxiety as soon as possible by providing early diagnosis and treatment. Rapid cytological diagnosis is often done for superficial sites, such as the breasts, thyroid glands, salivary glands, and lymph nodes. Intraoperative rapid cytological diagnosis has been performed to increase diagnostic accuracy. It is useful for body fluids, necrotic tissues, and small tissue samples that are not suitable for frozen section. Furthermore, if an infectious disease, such as tuberculosis, is suspected, an impression cytology specimen fixed in an alcohol solution is useful for biosafety. A rapid diagnosis at autopsy is important to inform the bereaved family about the cause of death and to ensure an accurate death certificate. Moreover, it is significant to diagnose by impression cytology for biosafety. Furthermore, we discuss about the usefulness of a rapid immunostaining method which is actively performed in our department for a rapid cytological diagnosis.

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Hypoxia, the disruption of oxygen homeostasis induced by low oxygen supply, is critical in the development and progression of a large number of tumors. Various solid tumors are basically in a hypoxic condition, when growth exceeds vascular supply. Under such conditions, cellular oxygen concentration redirects cellular biosynthetic pathways to promote adaptation and enable survival. Recently, a transcriptional factor called hypoxia-inducible factor (HIF)-1α has been shown to play a crucial role in the regulation of many genes involved in the hypoxia adaptive pathway, especially vascular endothelial growth factor (VEGF). Under hypoxic conditions, many tumor cells promote angiogenesis via HIF-1α. Meanwhile pituitary tumors are solid tumors in which the regional oxygen saturation is lower than that of normal pituitary gland and the vasculature is usually poor. Despite expression of HIF-1α was confined in pituitary adenomas, its function driving to angiogenesis, apoptotic induction, and cell invasion, even though these issues have been extended in the other malignant tumors in recent years, has not yet been discussed. We have investigated the expression of microvascular density, HIF-1α, and VEGF in primary human pituitary adenomas focusing on the co-localization, and subsequently in vitro study, elucidated gene profiling regulated by HIF-1α. Our previous studies indicated that HIF-1α immunoreactivity was confined to the nucleoplasm, but was present in both tumor cells and vascular endothelial cells. There was no difference in microvascular density by histotype. ACTH-producing adenomas showed the lowest level of HIF-1α, whereas PRL-producing adenomas and HIF-1α-positive microvessels showed the highest (p<0.001). There was no significant correlation in the expression levels of HIF-1α mRNA and VEGF mRNA in pituitary adenomas. Both of HIF-1α and VEGF proteins expressed in pituitary adenoma and they were, in part, co-localized. Transfection with specific siRNA duplexes knocked down HIF1-α mRNA and protein expression in hypoxia-exposed cells by approximately 80%. Microarray analysis indicated that HIF1-α down-regulated caspase-10, but up-regulated of laminin β2 (4.26 folds), SAP90 (3.34 folds), and BNIP3 (3.24 folds). Conclusively in these poorly vascularized tumors, HIF-1α may not mainly regulate the VEGF expression in pituitary adenoma. In vitro studies strongly suggest that HIF 1-α exerts an antiapoptotic role in HP-75 in hypoxia mediated by down-regulation of caspase-10 and that hypoxia can potentially enhance the cell invasion properties of a pituitary adenoma cell line through elevated expression of laminin β-2. The mechanism of tumor angiogenesis and cell invasion in pituitary adenomas may differ from that in the other cancer cells.

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We present here a case of dicephalus conjoined twins diagnosed with transvaginal ultrasound at 11 weeks' gestation. In this case, a shared heart was recognized in the twins. The mother and her husband elected to undergo pregnancy termination. The earliest prognostic diagnosis of conjoined twins is desirable.

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Keloids and hypertorphic scar often present difficulties in treatment, and they are a severe problem for every surgeon. In our department, keloids have been treated with multimodal therapy including excision, postoperative electron-beam irradiation, tranilast medication and pressure treatment using silicon gel sheets or bandages. Moreover, we have added a new protocol of electron-beam irradiation which the dose is changed by keloid sites. This trial proposes a new method. In this paper, we introduce some new twists to prevent recurrence of keloid being in use in our department, along with the future prospects of keloid treatment.

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One of the most clinically important objectives of therapy for atrial fibrillation is the prevention of stroke/thromboembolism. The risk of ischemic stroke in patients with atrial fibrillation may be related to multifactorial pathogenesis. The only therapy for atrial fibrillation with the effect of reducing mortality is anticoagulation with warfarin, not antiarrhythmic therapy. However, the management of atrial fibrillation includes a lot of modulating factors and should be carefully carried out on a case-by-case basis.

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A 75-year-old man with histories of myocardial infarction, cerebellar infarction and benign prostatic hyperplasia was transferred to our critical care center because of progressive dyspnea and disturbance of consciousness. He was intubated for the treatment of hypoxemia under 10 L/min oxygen inhalation with a mask-reservoir bag device. He showed septic shock, and initially we treated him as a case of sepsis due to pneumonia, as indicated by a chest X-ray. But his condition worsened despite the treatment for severe sepsis, which was carried out in accordance with guidelines published in 2004¹. We performed a systemic examination by CT scan and found slight hydronephrosis due to incompletely incarcerated urolithiasis at the second hospital day. We diagnosed pyelonephritis, performed nephrostomy and drained pyuria. Subsequently he became hemodynamically stable and was transferred to another hospital for rehabilitation.

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