Background: Endoscopic submucosal dissection (ESD) is a novel endoluminal endoscopic technique with a greater en bloc resection rate than conventional methods of endoscopic mucosal resection. We introduced ESD for early gastric cancer (EGC) and expanded the indication of endoscopic treatment. After introduction of ESD, the number of ESD cases increased and now comprise the majority of treatments for EGC. Patients and Methods: A total of 302 lesions in 274 patients were treated by ESD at Tenri Hospital from May 2005 to December 2009. Based on histological diagnosis, the resected specimens were assigned into three groups: a guideline group, an expanded indication group and an out-of indication group. In this study we investigate the outcomes and problems of ESD for EGC. Results: The rate of en bloc resection was 98.7% for the guideline group, 94.5% for the expanded indication group and 92.1% for the out-of indication group, with no significant differences between any of the groups. The overall complete resection rate was 86.8%. The rate of complete resection for the guideline and the expanded indication group was 92.8%. Perforation was seen in 4.4%, and delayed bleeding in 4.0%. There was no treatmentrelated mortality. In the histological assessment, the curative resection rate was 81.1%. 233 patients (85.0%) underwent follow-up after ESD at our institution, with a median follow-up period of 30 months. No local recurrence or metastasis was observed after complete resection. However, two of the patients (0.9%) suffered local recurrence, and one died of gastric cancer in the non-curative group. Nineteen patients (8.2%) had synchronous multiple gastric cancer lesions and twelve (5.2%) developed metachronous multiple gastric cancer lesions. Conclusion: In our study, ESD for EGC, using expanded criteria, gave an excellent outcome. This is only a study of the short term, and a long-term follow-up study is called for encompassing all cases, especially in the non-curative and expanded indication groups.

Background: Serum TARC has been used since 2008 as an indicator of the severity and activeness of atopic dermatitis (AD). Its clinical utility has not been established in children, however. Methods: We obtained data for the serum TARC level in 37 patients. Serum IgE level and blood eosinophil count was also measured in these patients. We evaluated the severity of AD and determined the relation of its severity to serum TARC level, serum IgE level and blood eosinophil count. Patients younger than two years and older were studied separately. Results:The serum TARC level of the 'severe' AD group was significantly higher than in the other groups. The median TARC value in children less than 2 years old was 8320 pg/ml in the 'severe' group, 2285 pg/ml in the 'intermediate' group, 919 pg/ml in the 'mild' group, and 1030 pg/ml in the 'no AD' group. The median TARC value in children of age 2 years and above was 11020 pg/ml in the 'severe' group, 838 pg/ml in the 'mild' group, and 548 pg/ml in the 'no AD'group. No child of age >= 2 years was in the 'intermediate' group. For the older children the serum IgE level in the 'severe'AD group was significantly higher than in the other groups. The median IgE value in the older children was 8700 IU/ml in the 'severe' group, 1400 IU/ml in the 'mild' group, and 300 IU/ml in the 'no AD' group. In children younger than 2 years, however, the serum IgE level was not related to the severity of AD. In the younger children the blood eosinophil count of the 'severe' group (the median: 2250/μl) was significantly higher than that of the 'mild' group (251/μl) and the 'no AD' group (173/μl). The blood eosinophil count was not related to the severity of AD in the older children. There was a positive correlation between serumTARC and house dust mite-specific IgE levels in the older children (r=0.65,P=0.019). Conclusion: In children, serum TARC level was higher in the 'severe' group than in the other groups, and was more strongly correlated than serum IgE level or blood eosinophil count with severity of AD.

Background: There are only a few reports of the results of preoperative transarterial infusion chemotherapy (TAI) for breast cancer, in particular with cysplatin included. Object: The aim of this paper is to determine the long-term results of TAI containing Cysplatin (CDDP) for stage IV breast cancer in our hospital. Patients: From 1992 to 2003, 13 patients with stage IV and T3-4 breast cancer underwent preoperative TAI containing CDDP. Method: Adriamycin, Mitomycin and CDDP were delivered through the internal thoracic artery and subclavian artery using Seldinger's method. Results: The efficacy of TAI was PR in 12 and NC in 1. Breast-conserving surgery was performed in 7 patients, and mastectomy in 6. The 3-year survival rate was 77%, and 5-year survival was 54%. Conclusion: TAI containing CDDP for stage IV breast cancer showed satisfactory long-term benefits, indicating that multi-drug chemotherapy containing CDDP is worthwile as a systemic therapy for advanced or metastatic breast cancer.

Purpose: Insulin injection is an important treatment in diabetes, but its procedures are complicated and it may reduce the quality of life of diabetic patients. This study was designed to determine how diabetic patients suspend their neutral protamine Hagedorn (NPH) insulin at self-injection. Methods: The subjects were 55 diabetic patients (27 men and 28 women) who perform NPH insulin self-injection using a pen-type injection device. We used a questionnaire to interrogate them about their self-injection of insulin, focusing especially on the suspension. We examined whether the duration and uniformity of the insulin mixture, based on the frequency with which they tip and roll it, are correlated with the level of HbA1c, and with the frequency of nocturnal hypoglycemia. Results: 95% of the patients answered that they tip and roll their NPH insulin at self-injection,and 91% do not mind the time and effort involved. 87% of patients confirmed that NPH insulin is suspended adequately before self-injection. However, 63% of patients replied that they tip and roll their NPH insulin less than 10 times, and 71% do so for less than 10 seconds. The level of HbA1c did not correlate significantly with the number of times or the duration of agitation of the insulin mixture. The number of times and the duration did not differ significantly between patients who experienced nocturnal hypoglycemia and those who did not. Conclusion: It is speculated that not many patients agitate their NPH insulin suspension satisfactorily. Our questionnaire appears to be effective in finding those patients who do not tip and roll their NPH insulin correctly. Certified diabetes educators should ask patients how they tip and roll their NPH insulin at the time of self-injection and instruct them in the correct procedure.

Toxic shock syndrome (TSS) is a serious multisystem disease, first described in 1987 by Todd. We report TSS following segmental mandibulotomy. A57-year-old man underwent this operation following recurrence of tongue cancer. Two days later he had high-grade fever, nausea, vomiting and watery diarrhea. Methicillin-resistant Staphylococcus aureus (MRSA) was observed in a culture from the wound. The infection progressed rapidly to fulminant septic shock with severe hypotension and multiple organ dysfunction. Microbiological examination was positive for toxic shock syndrome toxin-1 (TSST-1). Based on the CDC criteria, our case was diagnosed with high probability as TSS. He was admitted to our intensive care unit and was treated with antibiotics, gamma globulin, and Polymixin B immobilized fiber-direct hemoperfusion (PMX-DHP). By day 57 after surgery he had recovered, and was discharged. TSS is a potentially life-threatening postoperative complication. Considerable suspicion is needed if rapid diagnosis is to be made, and morbidity prevented.

A neonatal case is reported of food protein-induced enterocolitis syndrome (FPIES). A 10-day old girl was admitted to our hospital with diarrhea and fever. Her white blood cell count was not elevated, although there was a marked left shift of neutrophil. CRP was slightly elevated. We diagnosed her as having viral enterocolitis and gave her infusion therapy, but her symptoms did not improve. By the treatment with antibiotics, her temperature had tended to fall, but high fever reappeared and CRP was increased. She had taken a cow's milk-derived formula, and lactose intolerance or cow's milk allergy was therefore suspected. After she started to take soy bean-derived formula, her symptoms and laboratory data improved within a few days. After she had been discharged from our hospital and again fed with cow's milk-derived formula, fever, poor temper and diarrhea appeared, and we found leucocytosis with a marked left shift and high levels of CRP (8.4 mg/dl) and procalcitonin (11 ng/ml). Lymphocyte stimulation test for α-casein was positive. A cow's milk challenge test proved positive at age 11 months. Attention should be paid to FPIES cases with symptoms and laboratory data indicating severe bacterial infection, as in this case.

In the era of evidence-based medicine (EBM), most clinicians maintain their practice separate from their research, in contrast to clinicians a century earlier. Clinicians routinely perform diagnostic and therapeutic procedures after observing patients and discerning their problems,and it is normal for them to reflect on the outcomes from their practices. Based on this routine work, some clinicians conceive of hypotheses related to the clinical courses of their patients,and theymay intend to verify these hypotheses. The actions of such clinicians in fact constitute a form of research, which may be made public as a case report. Case reports that are carefully prepared by practicing clinicians are likely to be the most significant in furthering medical wisdom. Clinicians should therefore take full responsibility for their patients, whose problems may be the means of future resolution of issues in clinical medicine. Educators should accept the task of assisting trainees in the research mentality.

Non-parametric tests, such as the log-rank test and Cox regression based on the proportional hazards model, have prevailed in cancer survival analysis for more than 30 years. With improvements in cancer therapy and longer-term follow-up, the limitations of the Cox model and the merits of the Boag parametric model have been recognized by some investigators. The Boag model supposes that a proportion of the patients in a group are cured of the cancer, and the failure time of the remaining incurable patients follows a log-normal distribution. We contrast the strengths of the Boag and Cox models from the clinician's perspective. The advantage of the Boag model is that its three parameters allow us to disentangle and evaluate two effects of treatment: cure, and delaying of death from cancer. The Cox model fails to distinguish between these two effects and it is liable to overestimate the effects of palliative treatment when follow-up is immature. Also, the diagnostics to check the proportional hazards assumption are unreliable. Furthermore, non-parametric tests which inherently lack information on survival length are inadequate for measuring survival benefit, since survival benefit generally increases with survival length. However, the Boag model suffers from the disadvantages that the parameter estimation does not always converge (depending on the initial estimate), that the cause of death needs to be determined, and that longer follow-up is required. To confirm the validity of a model, clinicians need life-long follow-up of their patients.