Antimicrobial effects of ozonated water for the planktonic cells and the biofilm cells of staphylococci were examined for clinical applications in the orthopaedic field. As a result, 7 mg/L of ozonated water showed antimicrobial effects for not only the planktonic cells but also for the biofilm cells. Additionally, antimicrobial activity of ozonated water was examined after destroying the biofilm using 1 M NaCl or proteolytic enzymes (proteinase K and trypsin). Interaction between ozonated water and biofilm destruction was statistically significant in 2 strains (SE21, MR23) out of 8 strains. However, the effects of proteinase K or trypsin with ozonated water were statistically significant only in MRSA MR23. MRSA MR23 was previously reported to be a proteinaceous biofilm producer, and its biofilm was destructed by various proteases.

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Pyogenic vertebral osteomyelitis is difficult to diagnose and treat. The duration of antibiotic therapy, the administration of treatment, and several other factors regarding pyogenic vertebral osteomyelitis remain controversial. The aim of this investigation was to examine its diagnosis and treatment and consider possible solutions. This was a retrospective study of 11 cases of hospitalized patients with pyogenic vertebral osteomyelitis, including their diagnosis, treatment, and other factors. The diagnosis of vertebral osteomyelitis was confirmed with the combination of imaging and biological evidence. The Erythrocyte Sedimentation Rate (ESR) level served as an index to determine the duration of therapy. The duration from symptom onset to diagnosis was 3–63 (median 10) days. Rate of positive blood cultures were obtained in 8 cases (72.7%). The most frequent comorbidity was infective endocarditis in 4 cases (36.6%). Affected vertebrae were lumber spine in 9 cases (81.8%) and multiple level involvement in 8 cases (72.7%). The mean duration of antibiotic therapy was 69.6 ± 17.9 days, with no recurrence. Patients diagnosed with pyogenic vertebral osteomyelitis require careful examination for infective endocarditis. Lumber level and multiple level involvement were more frequent than had previously been reported. Based on our experience, C-reactive Protein (CRP) is more useful than ESR as an index to evaluate the clinical response to therapy and may help determine the duration of treatment. It is important for general physicians to monitor vertebral osteomyelitis properly and provide an appropriate diagnosis and treatment.

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Unfractionated heparin (UFH) is widely used in the treatment and prophylaxis of thrombosis. The anticoagulant effect of UFH is monitored according to activated partial thromboplastin time (APTT). However, there are reports of cases in which hemorrhagic complications develop despite APTT being maintained within the therapeutic range. This indicates there are problems with the monitoring method using APTT during UFH treatment. To assess the actual anticoagulant effect in UFH therapy using APTT as a monitoring method, we investigated changes in APTT and thrombin generation (TG) potential in vitro with the addition of UFH to samples from 10 healthy adults. There were large individual differences in the degree of APTT prolongation with the addition of UFH to samples from healthy adults. Furthermore, individual differences in the degree of TG change exceeded those in APTT in 7 subjects with comparable APTT changes caused by UFH (coefficients of variation: 2–5% for APTT, 10–50% for TG potential). Thus, with UFH treatment, there are large individual differences in the degree of TG inhibition even when APTT is within the appropriate range for coagulation control. These findings provide invaluable information for resolving the problem of hemorrhagic complications during UFH treatment based on the current APTT method.

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Introduction: This retrospective study investigated the concurrence rate and clinical characteristics of recently developed malignancies with microscopic polyangiitis (MPA).
Materials and Methods: The subjects included 42 Japanese MPA cases (16 males and 26 females) that had been newly admitted to the hospital. Recent occurrences of malignancy (defined as malignancies diagnosed upon admission and up to two years prior to admission) and the presence of organ lesions were evaluated. As a control, recent occurrences of malignancy in 126 patients with rheumatoid arthritis (RA) were evaluated in a similar manner.
Results: Recently developed malignancies occurred significantly more often in the MPA group (19.0%) than in the RA group (6.3%; odds ratio (OR), 3.47 [95% CI, 1.21–9.93]; Fisher’s exact test, p = 0.029). All MPA-associated malignancies were solid cancers, and none were from hematopoietic origin. With regard to characterization of organ lesions, MPA cases with malignancies exhibited peripheral neuropathy significantly more often (75% vs. 32.4%; OR, 6.27; 95% CI, 1.09–36.25; p = 0.045) and glomerulonephritis less often (37.5% vs. 82.4%; OR, 0.13; 95% CI, 0.02–0.69; p = 0.020) than MPA cases without malignancies. Skin lesions were observed in approximately 50% of cases, and there was no significant difference between MPA groups with and without malignancies (26.5%; OR, 2.78; 95% CI, 0.57–12.51; p value, 0.236).
Conclusion: MPA coincided with malignancies at a higher ratio than did RA. Therefore, it is recommended that those admitted for MPA should be thoroughly screened for malignancies.

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Purpose: To evaluate prospectively the size of the synovial fold protruding into the radiohumeral joint using 3D isovoxel MR imaging in asymptomatic volunteers, and to find a new reference value of the synovial fold on MR imaging.
Materials and methods: Eighty asymptomatic volunteers (36 women, 44 men; age range, 23–56 years; median age, 39; 20 patients in each decade from 20s to the 50s) were examined in this study. MR imaging of both sides of the elbow was performed using 3D isovoxel fast field-echo sequence with selective water excitation. The width of the synovial fold, which is defined as the distance between the tip of the synovial fold and the outer edge of the radial head, was measured at eight locations on the radiohumeral joint. We analyzed the relationship between the results and age, sex, and handedness.
Results: The posterior synovial fold was largest (range, 0.2–11.6 mm; median, 6.9 mm; 95th percentile, 10.0 mm). The width of the lateral synovial fold and posterolateral synovial fold was larger in patients in their 50s than in their 20s (p < 0.05 and p < 0.01, respectively).
Conclusion: Most normal synovial folds are smaller than 10.0 mm in width. Aging is a factor which influences the width of lateral to posterolateral synovial folds.

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Few reports exist on the outcome of health checkups in the elderly. We conducted an investigation of the specific health checkup to clarify whether or not the risk factors of arteriosclerotic diseases in the elderly had been treated.
The subjects consisted of 478 elderly people selected from a larger group of 638 participants aged 65 years and older who underwent the specific health checkup at our hospital’s Health Care Center from April 1, 2013 to March 31, 2014 (this study). The investigation items were blood pressure, blood tests [triglyceride level, HDL cholesterol, LDL cholesterol, HbA1c (NGSP)], changes in the condition, and therapeutic regimen.
(1) Dyslipidemia [triglyceride level ≥ 150mg/dL or HDL cholesterol < 40mg/dL or LDL cholesterol ≥ 140mg/dL]: 38.4% were indicated as having had dyslipidemia the preceding year. A total of 22.8% (p < 0.01) underwent drug therapy from the preceding year onwards, and among these, improvement was observed in 47.6% regarding this study. (2) Hypertension [systolic blood pressure ≥ 140mmHg or diastolic pressure ≥ 90mmHg]: 34.7% were indicated as having had hypertension the preceding year. A total of 59.0% underwent drug therapy from the preceding year onwards, and among these, improvement was observed in 40.8% regarding this study. (3) Diabetes [HbA1c (NGSP) ≥ 6.5%]: 6.9% were indicated as having had diabetes the preceding year. A total of 60.6% underwent drug therapy from the preceding year, and among these, improvement was observed in 20.0% regarding this study.
It was suggested that commencing active treatment against dyslipidemia in the elderly and carrying out appropriate control of hypertension and diabetes were necessary. A specific advantage of being able to understand the outcome of patients who have not undergone treatment, which is unknown in actual clinical practice, may be achieved by conducting follow-ups regarding the status of the health checkup.

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Background: Goal-directed therapy (GDT) has been shown to reduce perioperative complications. However, whether the restriction of fluid volume in goal-directed therapy causes acute kidney injury (AKI) remains to be determined. The aim of this study was to determine intraoperative risk factors for AKI after hepatic surgery with goal-directed therapy using restricted fluid volume.
Methods: Anesthesia and medical records of 67 patients who underwent hepatic resection were analyzed. Central venous pressure (CVP) and stroke volume variation (SVV) were monitored continuously by arterial contour analysis using a FloTrack sensor^TM (Edwards life sciences LLC, CA, USA) for restrictive fluid management during portal triad clamping (PTC) with inferior vena cava (IVC) clamping. Low CVP (<5 cmH₂O) and high SVV (>12%) were achieved by restrictive fluid management during PTC. AKI was assessed using the AKI network definition.
Results: Eight patients developed stage-1 AKI (12%) after hepatic resection, but none of the patients required renal replacement therapy. The durations of anesthesia and PTC were longer in the AKI group than in the non-AKI group (P=0.006 and P=0.004). The IVC was clamped more frequently in the AKI group than in the non-AKI group (P=0.004). The amount of blood loss was larger and the necessity for blood transfusion was higher in the AKI group than in the non-AKI group (P=0.02 and P=0.001).
Conclusion: The duration of PTC with IVC clamping and blood loss affects the incidence of AKI after hepatic surgery using GDT with restrictive fluid volume management. We suggest that unstable hemodynamics during PTC with IVC clamping and blood loss contribute to AKI after hepatic surgery.

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Background We investigated whether portal venous pressure (PVP) measured immediately before surgery and then immediately after clamping of the Glissonian pedicle can be used to predict postoperative complications (ascites or jaundice) and thus select the extent of resection in patients with liver disease requiring hepatectomy.
Methods Thirty-seven patients with hepatic functional reserve near the advisable limit and in whom direct measurement of PVP was done just before surgery and after clamping of the Glissonian pedicle were divided into two groups, an Event group (n = 9) and a Non-event group (n = 28), according to whether postoperative complications developed. The relation between PVP and the complication rate was analyzed, and a PVP safety margin was identified.
Results PVP obtained after the Glissonian pedicle was clamped was significantly higher in the Event group than in the Non-event group (18.8 vs. 15.7 cmH₂O; p = 0.03). The PVP gradient (defined as PVP after Glissonian clamping – PVP before surgery) tended to be greater in the Event group (5.1 versus 3.6 cmH₂O; p = 0.13). PVP after Glissonian clamping plotted against the PVP gradient revealed safety margins of PVP gradient < 5 cmH₂O and PVP < 20 cmH₂O, respectively.
Conclusion PVP after Glissonian clamping and the PVP gradient may be useful for predicting post-hepatectomy complications.

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Background and Aim: Surgical site infection (SSI) remains an important concern in Japan. The Japanese Society for Infection and Prevention Control disclosed that the incidence of SSIs has been lowered only by a fraction over the past 10 years. The importance of taking steps to reduce the occurrence of SSIs is recognized by many hospitals, but to date, no truly effective countermeasures have been reported. We executed a plan to better understand the specific surveillance needs at St. Marianna University School of Medicine Hospital and then develop and institute procedures that would reduce the incidence of SSIs.
Methods and Results: In 2005, we began development of an enhanced SSI surveillance system. With our basic CDC-based surveillance system in place, we assembled a team of doctors and nurses to oversee surveillance. We practiced strict record keeping and data analysis, gleaned information from staff, and enlisted the cooperation of other departments. New procedures were established accordingly and implemented in three phases. Between 2005 and 2013, we witnessed informative fluctuations in the incidence of SSIs. Key components of our new system were standardized postoperative wound cleansing, use of buried absorbable sutures to close surgical wounds, consistent provision of 6 antibacterial agents, each one active against a common organ-specific pathogen, and establishment of a prophylactic protocol. New methods of information sharing were also instituted. We lowered the incidence of SSIs from 8% in 2006 to approximately 6.9% in 2012. We continue to monitor the number of SSIs occurring and are encouraged by a steady decline.
Conclusion: Establishment of the SSI team at our hospital has proven to be a useful multidisciplinary approach to nosocomial infection awareness and control. Gradual introduction of the system to the various departments and step-by-step implementation have decreased the occurrence of SSIs and the nosocomial spread of infectious agents.

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The patient was a 45-year-old man who had Down syndrome and hepatitis B virus (HBV) with a high virus load and the presence of hepatitis B e antigen. He had received lamivudine (100mg/day: per os) as nucleoside/nucleotide analogues (NAs) from April 2005 to December 2012. Although the initial response of HBV DNA was favorable, a high level of viral breakthrough without hepatitis reactivation occurred after 16 -months of lamivudine administration. In December 2012, the therapy with lamivudine was substituted with adefovir dipivoxil (ADV) and entecavir hydrate (ETV) after informed consent was obtained. Serum HBV DNA gradually decreased over 7 -months of this drug substitution; however, there was a gradual increase in the serum alkaliphosfatase (ALP) level without increase in the other hepatobiliary enzymes and nephrotoxicity. Since he was suspected as having drug-induced liver damage and nephropathy caused by NAs, ADV and ETV were administered every other day for 3 months, resulting in no improvement. The laboratory data was obtained in December 2013 as follows; peak 3 dominant in the ALP isoenzyme analysis, low levels of serum carcium, phosphorus and urinary acid, excessive urinary excretion of amino acid and increased level of serum creatinine. Thus, we suggested that he suffered from acquired Fanconi’s syndrome induced by ADV. Administration of ADV was then discontinued after 12 months of drug substitution and only ETV was prescribed. Six months after ADV discontinuation, some of the indicative markers of renal dysfunction, including Fanconi’s syndrome, were normalized and recovered to the same levels before the combined use of ADV and ETV. The patient had been treated with sodium valproate and carbamazepine for the unstable mental state and epilepsy before the lamivudine administration; however, the negative synergic action among these drugs and NAs was not evaluated sufficiently. Here, we report the earlier onset of Fanconi’s syndrome triggered by ADV, which is usually diagnosed after long-term ADV administration. We suggest that the adequate evaluation of renal function, including proximal tubular damage before administration of ADV and close observation from the early period during treatment with ADV, is required.

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Immunopositivity for neuroendocrine markers [NEs: synaptophysin (syn), chromogranin A (CGA), CD56, CD57, and neuron-specific enolase] is evidence of the presence of tumor cells with neuroendocrine cell differentiation in the breast. It has been reported that a certain type of breast cancer is immunopositive for NEs; such a breast cancer type has been named carcinoma with endocrine features or endocrine ductal carcinoma in situ (E-DCIS)．Here, we report a case of a patient in whom a portion of the E-DCIS lesion coexisted with intraductal papilloma. A 38-year-old woman had an irregular hypoechoic lesion of the right breast on ultrasonographic examination, and core needle biopsy (CNB) of mass lesion was performed. Histopathologically, the CNB specimen showed a fibrovascular core with ductal hyperplasia, indicating that the lesion was most likely an intraductal papilloma (IDP) with ductal hyperplasia. However, immunohistochemistry revealed that the CNB specimen from the right breast was focally positive for syn. We determined this lesion to be of the “indeterminate” type. An excisional biopsy of this right breast lesion was performed. This lesion was diagnosed as an E-DCIS lesion coexisting with intraductal papilloma. As such, the case presented suggests that immunopositivity for syn was a useful indicator for E-DCIS diagnosed by CNB.

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We report a case of a patient who demonstrated long-term survival following completion of concurrent chemoradiotherapy (CCRT) for stage IVB advanced uterine cervical cancer. When the patient was referred to us, her radiological findings showed para-aortic and supraclavicular lymph node (SCN) metastases. The CCRT for primary lesions and para-aortic lymph node (PAN) were performed, followed by radiotherapy for SCN, resulting in successful control of the lesions. After five and a half years of strict follow-up, recurrent PAN was observed with PET-CT. Systemic chemotherapy was re-stored and controlled recurrent PAN without signs of serious adverse events. The patient has showed no recurrent signs with any related symptoms for the past 8 years since the initial treatment. As seen in this case, favorable prognosis can be achieved even for stage IVB advanced uterine cervical cancer patients, when the distant metastases are located in lymph nodes where CCRT could fully cover.

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