When medical records went digital at our hospital, we also went filmless. In the general radiography department, we were forced to change the workflow, so we created a new one. We introduced a system of quality assurance for images between consoles and PACS. As our original improvement, we added to the system a function to automatically narrow down patient images and a function to automatically sort images. We divided quality assurance for images into 1st and 2nd quality assurance and defined and managed it. In addition, we measured the time for each process of the workflow with and without film use. We compared 10 cases of chest and abdomen radiographs with 10 cases of bone radiographs. As a result, by using this system of quality assurance for images, we were able to cut three minutes from each examination, leading to quicker work.

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A 55-year-old male began to feel precordial pain after meals in the end of April, 2001. He was in hospital to receive the steroid therapy for dermatomyositis since December 2000.
Endoscopic examination showed a large ulcer and mucosal bridges resulting from laceration of the submucosal layer, which produced a false channel throughout the middle and distal esophagus. The patient was first managed conservatively to refrain from any drinks and meals for two weeks. In the middle of May, esophagoscopy showed retention of fluid and food in the false channel of the esophagus. On 28 of May, the mucosal bridge of the esophagus was cut through with a diathermy knife under endoscopic control. The false channel was abolished. The patient was able to drink water 20 days after the endoscopic treatment and to eat meals 26 days after it. Endoscopic examination after 5 months showed almost perfect epitherization of the esophageal mucosal membrane. The endoscopic treatment to open the false channel by cutting the mucosal bridge shortened the admission period. It is recommended that the mucosal bridge should be cut through endoscopy as soon as possible.

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A 31-year-old woman was admitted to the hospital because of severe abdominal pain. Her abdomen had severe tenderness, rebound tenderness, and muscle defense which presented with peritonitis. A chest X-ray showed free air under her diaphragm. She had emergency surgery. A perforation about 9mm in diameter was observed in the ileum 40cm proximal from the Bauchin valve. We found two longitudinal ulcers in the resected ileum within a perforation and checked the other small intestine with intraoperative endoscopy through a corrugated tube. We were able to find other two ulcers in the remnant ileum and remove the ileum with ulcers as shortly as possible.

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A very rare case of malignant lymphoma of the duodenum is reported. A 67-year-old woman was found to have a cobble stone-like lesion around the papillar of Vater by screening gastroduodenalscope. Histopathology revealed follicular malignant lymphoma. Pylorus preserving pancreatoduodenectomy was successfully performed. The patient has been alive without tumor recurrence since 24 mouths postoperatively. There have been 70 cases of malignant lymphoma of the duodenum in the Japanese reports. And then, follicular lymphoma of the duodenum was detected three cases. Two of them were cobble stone-like appearance endoscopically.

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【目的】

わが国は今後著しい後期高齢者の増加により，急性期病院からの早期在宅復帰が更に求められると予想される．入院となる疾患として多い脳卒中は，高齢者に発症しやすく，脳卒中の高齢化は更に進むと予想される．本研究の目的は，高齢脳卒中患者を前期高齢者と後期高齢者に分け，急性期病院の在宅復帰率と在宅復帰した高齢脳卒中患者の特徴を明らかにすることである．

【方法】

過去5 年間に急性期病院で理学療法を実施した65 歳以上の脳卒中患者である838 例を対象に全例，前期・後期高齢者別の在宅復帰率を診療録より調査した．急性期病院から在宅復帰し，調査の同意が得られた100 例に対して診療録より基本情報を抽出し，連続歩行距離，外出時の補助具の有無，在宅復帰後に必要性を感じた知識に関する追跡調査を行った．解析は前期・後期高齢者で群分けをし，連続歩行距離はMann-Whitney のU 検定，外出時の補助具の有無，在宅復帰後に必要性を感じた知識はχ² 検定を行った．本研究は

の倫理委員会の承認を得て実施した．〔結果〕後期高齢者の在宅復帰率は約30％であった．連続歩行距離は，500m 以上可能な例が80％以上を占め，前期高齢者と後期高齢者に差はなかった．外出時に補助具が必要な例は，前期高齢者が約10％，後期高齢者が約30％であり，有意差を認めた．在宅復帰後に必要性を感じた知識については，介護保険の知識をあげた例が最も多く，約20％を占めていた．

【結語】

今後も急性期病院から30％以上の在宅復帰が可能と予想された．急性期病院から在宅復帰を果たした高齢脳卒中患者は大半が500m 以上の連続歩行が可能なことから一般高齢者の身体機能と大きな差はないと示唆された．しかし，後期高齢者では今後更に入院中から補助具の使用を検討する必要性があると考えられた．また，今後は急性期病院と地域支援事業との連携や介護保険に関する説明の必要性があると考えられた．

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【はじめに、目的】

ロボット支援根治的前立腺全摘除術後(RARP)の尿失禁は骨盤底筋トレーニング(PFMT)での改善が報告されている。しかし、 尿失禁の予防において、術後早期の理学療法(PT)が術後1ヶ月後に与える予防的効果が明らかとなっていない。本研究の目的は、術後早期のPTが尿失禁予防に与える効果を明らかにすることである。

【方法】

本研究は前向き観察研究とし、対象は2022年8月から2023年3月までにRARPを行い、本研究への同意を得られた患者とした。対象は、理学療法士の指導の群(PT群)、パンフレットのみの配布(control群)の2群に分類して解析した。PT群は、術後早期から退院日までバイオフィードバック療法を用いたPFMT指導、退院後の尿失禁への対処法の説明やKnackの指導を行った。 Control群は尿失禁の予防に関するパンフレットを配布した。 調査項目は、術後1ヶ月の1日のパッド枚数、24時間パッドテスト、キング健康調査票(KHQ)とした。統計解析は2群の各調査項目に対して正規性の検定後、対応のないt検定と Mann-WhitneyのU検定を用いて比較し、有意水準は5%とした。

【結果】

対象は、PT群18名(年齢71.5±1.2歳)、control群6名(年齢71.3 ±3.8歳)であり、全対象は術後1ヶ月において尿禁制以外のBIが全て自立していた。各群 (PT群/Control群)のKHQの下位項目は、生活への影響が54.8±8.3/75.0±16.0、家事・仕事の制限が34.5±7.9/62.5±8.0、社会的活動の制限が24.6±6.3/55.6 ±13.6、心の問題が30.0±6.7/52.8±7.0で有意差を認めた (p<0.05)。その他の項目は有意差がなかった。

【考察】

本研究では、PT群はControl群に比べKHQの日常生活や社会復 帰の制限に関連する項目のQOLが高かった。PT群は、PFMTに加えて、患者個々の生活スタイルや身体機能に合わせた指導を行っており、この指導が尿失禁予防に対する術後早期のPTの効果であったと考える。しかし、尿失禁予防に対するPTは、術後 1ヶ月の失禁量に影響を与えない結果であった。先行研究では、周術期のPFMTのアドヒアランスはP Tの介入頻度に関連することを報告しており、今後、PFMTの練習方法やアドヒアランスと合わせて術後早期の尿失禁量の予防について検討する必要がある。

【倫理的配慮】

本研究は

倫理委員会の承認を得て実施した(承認番号：2021-126)。また、当院ホームページにて研究内容の公開を行い、オプトアウトの機会を設けている。

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A clinico-statistical analysis of 149 pediatric patients with luxated teeth who visited the after-hours clinic of the oral and maxillofacial surgery of Saitama Medical Center, Saitama Medical University between January 2003 and December 2006 was performed.
1. The ratio of male to female patients was 1.32: 1.
2. By age distribution, 3-year-old patients showed a higher rate of incidence than the others.
3. The most common cause of the tooth injury were falls and drops (67.1%).
4. The most common site of the tooth injury was maxillary anterior deciduous tooth luxation (62.0%).
5. The most common treatment for luxated teeth was tooth fixation (42.2%).

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Before the PiCCO system became available, patients with delayed vasospasm were treated in order to control circulating blood volume from the viewpoint of several systemic factors associated with pressure such as central venous pressure, pulmonary arterial wedged pressure, etc. Since, however, these factors are well-known to not always reflect the circulating blood volume, excessive intravenous administration induces over-hydration in patients who are either aged and/or are experiencing symptomatic vasospasm, leading to serious conditions such as pulmonary edema and cardiac failure. The PiCCO system has enabled us to treat patients with symptomatic vasospasm by more precisely estimating circulating hemodynamics. Taking into account the data obtained from the PiCCO system, we discuss its advantages and disadvantages. Out of patients who underwent acute surgery from June 2006 to May 2007, a total of 18 patients with Fisher 3 in CT grading of SAH who were thought to be likely to suffer from cardiac failure or pulmonary edema were selected. The average age was 63.2. The number of patients of preoperative Hunt and Kosnik Grade II, III, IV and V was 3, 10, 3 and 2, respectively. Angiographic vasospasm was revealed in 10 patients, 7 of whom were symptomatic. The in- and out-put control in these 18 patients was executed using the PiCCO system. None showed clinical symptoms associated with cardiac failure or pulmonary edema.
We conclude that the PiCCO system is very useful to control the systemic hemodynamics in the treatment of patients with delayed vasospasm.

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透析療法の選択のプロセスが重要と言われている．当院でもしっかり情報提供を行い，Home hemodialysis：HHDについてもしっかり情報提供ができる体制を持っている．実際にHHD，腹膜透析，腎移植を管理することで透析スタッフは全ての腎代替療法に関わることが可能であり，どの患者さんにもHHDを提示するようになった．HHDは多くの透析スタッフの専門性を生かして行われているが，医師の役割はあまりクローズアップされていない．そこで，当院における導入期を中心とした医師の役割について振り返ってみた．

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A 20-year-old female patient with mental disease intentionally swallowed a pair of nail clippers and was treated at our hospital. Abdominal X-ray showed the clippers in stomach and endoscopy was performed. The clippers were located in the body of the stomach. A gastric mucosal lesion with mild redness and hemorrhaging was observed. We were unable to grasp the nail clippers using grasping forceps, snare forceps or basket forceps. We therefore switched to a 2-channel endoscope. First, we inserted a guide wire through the hole in the handle of the clippers with a cannula used in ERCP. We then grasped the guide wire using the biopsy forceps, which were extended from the channel for forceps, and pulled the guide wire towards the channel for forceps. With the clippers suspended from the guide wire we removed the fiberoptic scope. Because an overtube was used, we were able to retrieve the nail clippers without damaging the esophagus or oral cavity. We have occasionally encountered cases of esophageal and gastric foreign bodies. It is important to utilize safe procedures for foreignbody removal in order to minimize damage to the intestinal mucosa.

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We report a rare case of rectal carcinoid diagnosed by vaginal invasion.
A 65-year-old woman was pointed out vaginal bleeding when she had a group examination for uterine cancer. Biopsy of the vaginal wall revealed carcinoid. Endoscopic examination of the vagina showed yellowish, bleeding surface with ulceration in the left posterior side of the vaginal fornix. Colonoscopy revealed yellowish submucosal tumors in the rectum ; one is located in the middle rectum, and the other in the lower rectum. Biopsy specimen of the two rectal lesions were compatible with carcinoid. Magnetic resonance imaging showed a mass, measuring 3 cm in diameter, was located between the left upper side of the vagina and rectum. Computed tomography and ultrasonography showed multiple liver metastases.
The operative findings were classified into stage IV〔H₃P₀N (－) A₂ (SE) 〕. Abdomino-perineal resection of rectum with hysterectomy, partial resection of vagina, bilateral oophorectomy, and hepatic arterial cannulation was performed. Histological examination of the resected specimen revealed subepithelial infiltration of rectal carcinoid.
In the Japanese literature (1978.6～1998.6) there are no case reports other than ours in which vaginal bleeding was a clue to the diagnosis of rectal carcinoid.

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We report herein a rare case of bleeding jejunal ulcer successfully treated with colonoscopic clipping.
A 57-year-old man underwent Hartmann's operation for perforation of cancer of the rectosigmoid. He developed disseminated intravascular coagulopathy and septis by mechycilin resistant staphylococcus aureus postoperatively. Twelve days after the operation, he suddenly presented with melena which resulted in hypovolemic shock. Emergency angiography revealed extravasation from the branch of the jejunal artery. Hemostasis of the jejunal lesion was achieved by transarterial embolization using gelatine sponge. Five days after the embolization, he presented with melena again.
A colonoscope was introduced into the jejunum perorally. An arterially bleeding small ulcer located 25 cm distally from the Treitz's ligament was successfully clipped. Although he died of hypercalcemia 43 days after the operation, no bleeding from the ulcer was seen until death.
Our experience suggests that colonoscopic clipping is one of the effective methods of hemostasis for bleeding ulcer of the upper jejunum especially in poor-risk patients.

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