Objective: Endovenous laser ablation (EVLA) has been covered by the Japanese Health system since 2011. The aim of this study was to evaluate the results of interventions for varicose veins after the introduction of EVLA in 2012 at this hospital.

Methods: From January 2012 to March 2017, 602 surgeries for varicose veins (530 patients and 683 limbs) were studied. Surgeries were as follows: 495 EVLA, 196 high ligation, 4 stripping, and 22 perforator ligation (alone) operations. The main preoperative risk factors were hypertension (31.3%), cardiovascular disease (13.6%), cerebrovascular disease (4.7%), and old age (over 80 years old) (7.2%). The patients were as sessed by clinical examination and venous duplex ultrasonography at 2 days, 1 week, and 1 month of fol low-up under team medical care.

Results: Four postoperative complications (0.7%), 3 EHIT class 3 cases and 1 hematoma requiring resection, were observed. Four re-interventions were needed after high ligations, but no re-interventions were needed after EVLA.

Conclusion: The interventions for varicose veins were satisfactory. In the EVLA era, team medical care may be important for patients with preoperative risk factors.

Purpose: Morphine has been recommended for the palliation of dyspnea in patients with amyotrophic lateral sclerosis (ALS); however, there is little evidence for its effectiveness or safety. The purpose of this study was to evaluate the usefulness of morphine for dyspnea management in patients with ALS.

Methods: We retrospectively reviewed the medical records of 10 consecutive patients with ALS who were administered morphine to relieve dyspnea. Morphine was used with advice and support from the multidisciplinary palliative care team in collaboration with physicians and nurses of our neurology ward. Palliation of dyspnea was defined as ≥1 increase in the dyspnea subscale of the ALS Functional Rating Scale-Revised (ALSFRS-R).

Results: The median morphine doses on the first day of administration were 10 mg/day (6–20 mg/day) enterally and 4.8 mg/day (2.4–12 mg/day) by continuous subcutaneous infusion. Dyspnea was palliated in 9 patients (90%). Patients with higher Palliative Performance Scale (PPS) scores at the time of morphine introduction tended to have improved ALSFRS-R dyspnea subscale scores (Spearman’s rho 0.77, p = 0.009). Beneficial changes were observed in the following living activities: alleviation of insomnia (n = 6) and increased food intake (n = 3). The median maximum daily doses of morphine were 21.5 mg/day (8–35 mg/day) enterally and 4.75 mg/day (2.4–24 mg/day) by continuous subcutaneous infusion. The median survival after morphine administration was 21 days (3–96 days), which was significantly correlated with PPS at the time of morphine introduction (Spearman’s rho 0.79, p = 0.006). Regarding adverse effects, all patients developed constipation, and three developed delirium. Eight patients died without the need for sedation, while two required sedation with midazolam.

Conclusion: Morphine is useful for dyspnea management in patients with ALS. Further studies are required to clarify the optimal timing for morphine introduction and the safe dosage.

Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type (MALT lymphoma) frequently occurs in the stomach, but can also arise in epithelial tissues/organs other than the gastrointestinal tract, often in the setting of long-lasting antigenic stimulation due to chronic bacterial infections or autoimmune disorders. Recurrent chromosomal translocations in MALT lymphoma have been identified. The first patient (case 1) was a 66-year-old female who presented with a left parotid gland tumor. She had been diagnosed with Sjögren syndrome and immune thrombocytopenia. Seven years after surgical resection, she relapsed involving the palatine tonsil and ileocecum. She then received R-CHOP chemotherapy, leading to complete resolution of the tumor. The second patient (case 2) was a 66-year old male who presented with symmetric enlargement of the bilateral parotid glands. He had been treated for rheumatoid arthritis with prednisolone and methotrexate followed by intravenous tocilizumab. He was treated with R-CHOP, and achieved complete response. Pathological specimens from both cases revealed salivary gland tissues diffusely infiltrated by CD20⁺ lymphoma cells, which generated the lymphoepithelial appearance. Lymphoma cells were medium to large in size, with cytomorphological features of diffuse large B-cell lymphoma (DLBCL). The cells were CD5⁻, CD10⁻, CD19⁺ , CD21⁻, CD22⁺ , and CD23⁻, and expressed surface immunoglobulin µδ/κ. G-banding and FISH demonstrated t(X;14)(p11;q32) in both cases. The breakpoints were localized at intron 1 (case 1) and coding exon 3 of GPR82 (case 2), which is located 27-kb downstream of GPR34, and breakpoints in IGH were within the switch region associated with IGH Cα2. These two cases were characterized by three factors; background of long-lasting autoantigenic stimulation, the t(X;14)(p11;q32) translocation, and intermediate features between low-grade MALT lymphoma and DLBCL on both cytomorphology and clinical behavior. This translocation results in high GPR34 expression and is considered to be involved in tumorigenesis.

In Japan, patients with aortic stenosis (AS) are increasing due to the aging society, and transcatheter aortic valve implantation (TAVI) was introduced in October, 2013. We implemented TAVI in June, 2014, and have currently performed 46 procedures. Acquired von Willebrand syndrome in patients with aortic stenosis, known as Heyde’s syndrome, is not well understood and its prevalence is unknown. Since 1958, there have been 10 cases reported by Dr. Heyde in the New England Journal Medicine magazine. Gastrointestinal bleeding is caused by the deficiency of high-molecular-weight multimers of von Willebrand factor and angiodysplasia. Patients with this syndrome demonstrate complete recovery after aortic valve re placement and recently with TAVI. Here, we report the initial results of 36 TAVI procedures performed at our institution until June 2016, and present the cases of Heyde’s syndrome in which the von Willebrand high-molecular-weight multimer levels were improved by TAVI.