The incidence of subarachnoid hemorrhage（SAH）is declining worldwide, and is also declining in Japan, although the incidence in Japan is the highest in the world. On the other hand, the incidence of SAH in elderly women is high, and estrogen depletion is thought to be a factor. The treatment of SAH in Japan has shifted from surgical clipping to endovascular coil embolization. In a study on the relationship between SAH and unruptured cerebral aneurysm（UCA）, the treatment rate of UCA was low, and the effect of reducing the incidence of SAH was considered to be small. The incidence of SAH in Japan has been declining due to improvements in lifestyle habits such as hypertension and smoking, suggesting the significance of lifestyle guidance provided by brain docks. The epidemiology and outcome of SAH are discussed in this report.

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The use of bioprosthetic valves in aortic valve replacement surgery is increasing due to the aging of patients, dietary restrictions associated with anticoagulation therapy, and avoidance of bleeding risks. However, some reports have raised concerns about the durability of the Mitroflow valve, and we investigated the remote results of the Mitroflow valve in our department. The subjects were 15 patients who underwent aortic valve eplacement using the Mitroflow valve from December 2013 to August 2022. The mean age was 77.5±5.6 years, all were female, the mean body surface area was 1.3±0.1m2, and all valve sizes were 19mm. One patient was lost to mediastinitis in the early postoperative period, but the others were discharged from the hospital without any complications. One patient underwent aortic valve replacement due to structural valve deterioration at 2.7 years postoperatively. Another patient had rapidly progressive stenosis of the Mitroflow valve（SVD）at 5.6 years postoperatively. There were 3 remote deaths（heart failure at 7.5 years postoperatively, acute myocardial infarction at 4 years postoperatively, and senility at 3.8years postoperatively）. By the Kaplan-Meier method, the cardiac associated mortality free rates were 100% at 1 and 3 years, 88% at 5 and 7 years, and the all-cause mortality free rates were 93% at 1 and 3 years, and 72% at 5 and 7 years. Reoperation and SVD free rates were 100% at 1 year, 90% at 3 and 5 years, and 77% at 7 years. Two of 15 patients with 19mm Mitroflow valves in our department had early SVD, suggesting the need for stricter indication and postoperative follow-up for Mitroflow valves.

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[in Japanese]

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The Izumo PCA system has been in operation since 2014 so that medical narcotics injections at home can be started smoothly and quickly in this area. To promote this operation, we regularly hold PCA pump workshops to give lectures and exercises on the use and cooperation of PCA pumps. ［Purpose］To clarify the number of Izumo PCA systems used and the service area. ［Method］For the first 2 years, we investigated the patient's age, gender, start date, end date, collaborative medical institution, collaborative home-visit nursing station, drug injection for medical use, presence / absence of combined use of home oxygen therapy, and posting on an Excel sheet Extracted and tabulated. The rest of 3 years, only the start date, end date, and home oxygen combination rate were calculated in the same way. ［Findings］There were 152 system uses in about 5 years from March 2014（18 cases in 2014, 22 cases in 2015, 36 cases in 2016, 43 cases in 2017, and 33 cases in 2018）. ［Conclusions］It is important to be able to promptly change to another route of administration and adjust the dose even when it becomes difficult to take medical narcotics. It is hoped that cooperation such as Izumo PCA system can be built in each region.

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We report a case of pleomorphic adenoma on the nasal septum that recurred after 17 years. 　25-years-old female complained of left epistaxis. A tumor had arisen from the nasal septum. The CT scan showed a 21× 12mm soft tissue mass in the anterior left nasal cavity. The pathological diagnosis was a pleomorphic adenoma. We remove the tumor with endoscopic surgery. The tumor recurred 17years after the initial operation. The tumor was multilocular with a maximum size of 35× 27mm and was accompanied by bone destruction of the nasal septum. Therefore, due to the possibility of malignancy, the tumor was removed by lateral rhinotomy. Pathological findings showed a tumor with abundant stromal components, which is considered to be prone to recurrence.

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[in Japanese]

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[in Japanese]

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A 34-year-old man was transferred to the emergency room of our hospital because of vomiting, diarrhea, and epigastralgia 1 day after drinking alcohol and eating raw fish. He was provisionally diagnosed with acute enteritis and admitted to our hospital. He was treated by a non-per-oral approach with hydration and antibiotics. CT at the admission revealed pneumomesiastinum. The next day, although esophagography revealed no contrast leakage, computed tomography revealed a shadow thought to be an abscess in the area of the middle mediastinum, surrounded by the diaphragm, descending aorta, and esophagus, along with left pleural effusion. Therefore, we diagnosed him with spontaneous rupture of the esophagus, and thoracic/mediastinal drainage was urgently performed that night via left video-assisted thoracic surgery. Streptococcus parasanguinis was detected in the abscess and Streptococcus intermedius in the pleural effusion. He restarted drinking water on post operative day （POD）9 and eating on POD11. He was treated by antibiotics until POD14 and discharged on POD17. Spontaneous rupture of the esophagus can be definitively diagnosed when esophagography reveals contrast leakage, although there are rare cases without leakage, similarly to the present case. It is important not to hesitate to perform surgical treatment in cases suspected of having spontaneous rupture of the esophagus based on the clinical course and other imaging findings besides esophagography.

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[in Japanese]

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A 67-year-old female had abdominal pain and diarrhea. She saw a primary care physician and was prescribed medicine, but she did not improve, and fever and nausea began to be observed. Two days later, she was admitted to our hospital with a diagnosis of acute colitis and peritonitis. However, abdominal pain was exacerbated, and there was also a decrease in oxygenation and blood pressure, which was also exacerbated by abdominal CT at the next day. An emergency colonoscopy was performed for the purpose of understanding the pathological condition. Pseudomembrane formation and ulcer findings were observed, and the CD antigen was also positive. The diagnosis was fulminant pseudomembranous colitis. Emergency surgery was performed, and the life was saved. It was later discovered from her medication book that she had been given antibiotics about two weeks prior to her ｈospitalization.

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[in Japanese]

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There is a lack of evidence regarding the efficacy of stent therapy for acute occlusion of the main intracranial artery. We report a case in which the stent for cerebral aneurysms was successfully used to save the life of a patient with repeatedly worsening vertebrobasilar artery occlusion. The patient was a 58-year-old man. He developed paralysis of the right upper and lower limbs, and MRI of the head showed scattered posterior ｃirculation infarct. On the evening of the 2nd day and the 3rd day, re-occlusion and decreased level of c onsciousness were observed. On the evening of the third day, another occlusion was observed, and it was determined that PTA alone would not sustain the patient, so a stent for cerebral aneurysm was implanted. Postoperatively, the patient's level of consciousness did not decline, and he improved to the point where he was able to perform ADL training. Although Wingspan is the only insurance-approved rescue stent for intracranial main artery occlusion, there may be situations in which other stents must be considered. The effectiveness of the stent for cerebral aneurysms in acute intracranial main artery occlusion has also been reported in the literature and will be discussed.

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