Objective: To identify the clinical and epidemiological characteristics of pernicious anemia (PA) in patients treated at Miyagami hospital on Tokunoshima Island.

Methods: We evaluated 14 patients with PA who were enrolled and treated from March 2009 to May 2014.

Results: The majority of patients were older than 50 years of age and primarily consisted of elderly women. Routine medical examinations revealed macrocytic anemia in 6 of the 14 patients (43%), although they were clinically asymptomatic and subsequently diagnosed with PA. The average number of patients per year was reported to be 3 (95% confidence interval [CI]: 1.25-3.42).

Conclusions: The annual incidence of PA per 100,000 individuals on Tokunoshima Island is possibly much higher than that previously reported in Japan. An increase in the elderly population, a negligence of the disease, and an ethnic and regional diversity may explain this discrepancy. As the annual incidence of PA may be higher than that previously reported, anemia must be carefully evaluated in the differential diagnosis of PA.

A 12-year-old girl had relative graft stenosis following the reconstruction of type A interrupted aortic arch. At 25 days after birth she underwent ascending aorta-descending aorta bypass with a 7mm knitted Dacron graft, ligation of the patent ductus arteriosus and pulmonary artery banding. She had patch closure of a ventricular septal defect (VSD) as well at 20 months of age. At age 12 catheterization was carried out, because she had headache and dizziness on exertion. The pressure of the ascending aorta was 163/79mmHg and the pressure gradient between the ascending and the descending aorta was 65mmHg. Aortography revealed severe stenosis of the graft, which might have occurred according to her growth. An extra-anatomic bypass was placed between the right axillary and the right common iliac artery through the intrapleural and preperitoneal route with a 10mm Dacron graft. Six months later, the blood pressure was 108/63mmHg in the upper extremities, the pressure gradient between the upper and lower extremities was reduced to 18mmHg, and headache and dizziness had disappeared.

A 66-year-old woman with aortic stenosis and idiopathic thrombocytopenic purpura (ITP) underwent concomitant splenectomy and aortic valve replacement (AVR). High-dose trans-venous gamma-globulin therapy (400mg/kg/day) was performed for five days before surgery. The number of platelet, which was 6.0×10⁴/mm³ on admission slighty increased to 7.0×10⁴/mm³ before surgery. The aortic valve was replaced by an ATS 19mm prosthesis using cardiopulmonary bypass. Platelets were transfused postoperatively. Perioperative hemorrhage was moderate, and the postoperative course was uneventful. This was the second case we treated by concomitant cardiac surgery and splenectomy. It was safely performed after high-dose trans-venous gamma-globulin therapy.

Three-dimensional (3D) cultures are known to promote cell differentiation. Previously, we investigated the differentiation of rat dermal fibroblasts to α-smooth muscle actin (α-SMA)-positive myofibroblasts through transforming growth factor (TGF)-β production using a 3D culture model. Here, we investigated the phenotypic change from dermal mesenchymal cells (mostly fibroblasts) to osteoblast-like cells, being inspired by the roles of smooth muscle cells or fibroblasts during vascular calcification. Spindle-shaped cells that grew in heterologous populations out of dermal explants from 2-day-old Wistar rats were cultured within a collagen matrix. α-SMA and alkaline phosphatase (ALP) messenger RNA (mRNA) levels initially increased, followed by a rise in Runx2 and osteocalcin (OCN) mRNA levels without calcification. Calcium deposits were produced in the presence of a high concentration of inorganic phosphate (2.1 mM) or β-glycerophosphate (βGP, 10 mM) after 2 weeks of culture, and both were sensitive to an inhibitor of type III phosphate transporters. An ALP inhibitor decreased only βGP-induced calcification. Inhibition of TGF-β type-I receptors attenuated ALP mRNA levels and βGP-induced calcification, suggesting that endogenous TGF-β stimulates ALP activity and then βGP breakdown. An increase in the number of cells embedded in the collagen gel enhanced the mRNA levels of Runx2 and OCN, but not of ALP. Collectively, several factors are likely to promote the differentiation of dermal mesenchymal cells into osteoblast-like cells and ectopic calcification in a 3D collagen matrix, implying the utility of these cells as a potential autologous cell source for tissue engineering.
Actins ; Alkaline Phosphatase ; Animals ; Calcium ; Cell Differentiation ; Collagen ; Dermis ; Fibroblasts ; Myocytes, Smooth Muscle ; Myofibroblasts ; Osteocalcin ; Phosphate Transport Proteins ; Rats* ; Rats, Wistar ; RNA, Messenger ; Tissue Engineering ; Transforming Growth Factors ; Vascular Calcification

Background: Laparoscopy-assisted gastrectomy requires a lot of disposable products. So we compared the cost between laparoscopy-assisted gastrectomy and open surgery.Patients and methods: For comparison we used five cases each of open distal gastrectomy (ODG), laparoscopy-assisted distal gastrectomy (LADG), open total gastrectomy (OTG) and laparoscopy assisted total gastrectomy (LATG). In this study, we defined the profit of gastrectomy as below and we used the list price for all products. Profit of gastrectomy=Fee for gastrectomy-(Costs of all single use products-Demandable fee for single-use products)Results: Mean profits of ODG and LADG were 278,756.2 yen and 190,292.8 yen. The difference was 88,463.4 yen. Mean profits of OTG and LATG were 395,922.6 yen and 330,653.6 yen. The difference was 65,269 yen. Mean hospital charges, mean length of hospital stay, mean hospital charges per day of ODG, LADG, OTG and LATG were 1,390,464 yen, 21.4 days, 65,140.0 yen and 1,484,254.0 yen, 18.8 days, 80,805.4 yen and 1,956,664.0 yen, 24.4 days, 82,397.1 yen and 1,686,936.0 yen, 18.4 days, 91,894.8 yen, respectively.Conclusion: The turnover of laparoscopic gastrectomy was higher than open gastrectomy, but, the profit was lower because of high costs of disposable products. Hospital charges were not higher but the charge per day was higher because of a shorter hospital stay.
Gastrectomy ; Laparoscopy ; Hospitals ; Mean ; Financial cost

Recently, in addition to standard surgical operations, reduction therapy (endoscopic mucosal resection and endoscopic gastrectomy) is indicated for early gastric cancer. However, the indication should be limited to the casesof early gastric cancer without lymph node metastases.
During the past 25 years, we have surgically treated 2, 246 cases of early gastric cancer. The percentage of lymph node metastasis in 1, 242 mucosal cancer cases was 1.8% and that in 1, 004 submucosal cancer cases was 16.9%. In the mucosal cancer cases, lymph node metastasis did not occur in the depressedtumors with a diameter of less than 10mm and the elevated tumors with a diameted of less than 20mm. In the submucosal cancer cases, lymph node metastasis did not occur in the elevated tumors less than 10mm in diameter. So, the cases of gastric cancerof these types require the reduction therapy.
However, in the mucosal cancers that have been diagnosed during the last 5 years, the percentage of preoperative correct diagnosis as for thedepth of invasion was 69.4%. In the submucosal cancers, the rate was 60.1%. Many of the cases diagnosed incorrectly had ulcers in the lesion. As for the infiltration type, INFβ and γ were noticeable in these cases. As for the histological type, most of the cases wereof the undifferentiated type.
Moreover, if should be noted, the percentage that the histological type of preoperative ensoscopic biopsy specimens agrees with that of postoperative ones is 50-60% except for tubl of mucosal cancers.

Objective: The benefits of combining cancer screenings with clinical surveys have become increasingly obvious as cancer morbidity and mortality have steadily increased. This paper discusses a study on the current status of and issues surrounding breast cancer screening in a clinical survey. The study also investigated the patients' awareness of the benefits of breast cancer screening. A secondary aim of the study was to promote mammographic screening.;Subjects and Methods: During the 72 months between April 1999 and March 2005, a total of 36,505 women underwent clinical surveys in our hospital. In October 2002, mammographic examination was included as an optional part of the routine physical examination. We evaluated the results of breast cancer screening with or without mammographic examination and used a questionnaire to investigate the patients' awareness of the benefits of breast cancer screening.;Results: Compared with the pre-2001 results, the detection rate of breast cancer significantly increased after 2003 when physical examination was combined with mammographic examination. Our study also found that both elderly patients and those residing in the suburbs of Sapporo City tended to choose physical examination alone rather than combining it with mammographic examination. An analysis of the questionnaires collected from these patients indicates they had a poor understanding of and lacked awareness of the benefits of mammographic examinations during breast cancer screenings.;Conclusions: The inclusion of mammographic screenings with clinical surveys was found to be significantly useful in the detection of breast cancer. Further continued education is needed for women, particularly the elderly and residents in the suburbs, so they understand the benefits of breast cancer screening by mammographic examination for the early detection of breast cancer and, consequently, decreased mortality of the disease.
Breast neoplasm screen NOS ; Clinical ; benefits ; Awareness ; Surveys

Clinical training programs play an extremely important role in the new postgraduate clinical training system introduced in 2004 because facilities for clinical training now include various health-related institutions in addition to the university hospitals and special hospitals for clinical training used in the previous system. Although educational goals have been established by the Ministry of Health, Labour and Welfare, trainees may have difficulty achieving these goals, even under the guidance of staff at the various facilities. There are differences in the function and quality of health-related institutions in the community. For the practical and convenient application of educational goals, we have attempted develop a “model program” to supplement the objectives indicated by the learning goals with more specific objectives. These supplementary objectives can be modified by individual institutions. We hope that this “model program” contributes to the development of objectives for each institution and helps improve the quality of the postgraduate training system in Japan.

Background/Aims: Restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis and handsewn anastomosis for ulcerative colitis requires pulling down of the ileal pouch into the pelvis, which can be technically challenging. We examined risk factors for the pouch not reaching the anus. Methods: Clinical records of 62 consecutive patients who were scheduled to undergo RPC with handsewn anastomosis at the University of Tokyo Hospital during 1989–2019 were reviewed. Risk factors for non-reaching were analyzed in patients in whom hand sewing was abandoned for stapled anastomosis because of nonreaching. Risk factors for non-reaching in laparoscopic RPC were separately analyzed. Anatomical indicators obtained from presurgical computed tomography (CT) were also evaluated. Results: Thirty-seven of 62 cases underwent laparoscopic procedures. In 6 cases (9.7%), handsewn anastomosis was changed to stapled anastomosis because of non-reaching. Male sex and a laparoscopic approach were independent risk factors of non-reaching. Distance between the terminal of the superior mesenteric artery (SMA) ileal branch and the anus > 11 cm was a risk factor for non-reaching. Conclusions Laparoscopic RPC with handsewn anastomosis may limit extension and induction of the ileal pouch into the anus. Preoperative CT measurement from the terminal SMA to the anus may be useful for predicting non-reaching.

Background/Aims: Patients with achalasia-related esophageal motility disorders (AEMDs) frequently present with dilated and sigmoid esophagus, anddevelop esophageal diverticulum (ED), although the prevalence and patients characteristics require further elucidation. Methods: We conducted a multicenter cohort study of 3707 patients with AEMDs from 14 facilities in Japan. Esophagography on 3682 patients were analyzed. Results: Straight (n = 2798), sigmoid (n = 684), and advanced sigmoid esophagus (n = 200) were diagnosed. Multivariate analysis revealed that long disease duration, advanced age, obesity, and type I achalasia correlate positively, whereas severe symptoms and integrated relaxation pressure correlate negatively with development of sigmoid esophagus. In contrast, Grade II dilation (3.5-6.0 cm) was the most common (52.9%), while grade III dilation (≥ 6 cm) was rare (5.0%). We found early onset, male, obesity, and type I achalasia correlated positively, while advanced age correlated negatively with esophageal dilation. Dilated and sigmoid esophagus were found mostly in types I and II achalasia, but typically not found in spastic disorders. The prevalence of ED was low (n = 63, 1.7%), and non-dilated esophagus and advanced age correlated with ED development. Patients with right-sided ED (n = 35) had a long disease duration (P = 0.005) with low integrated relaxation pressure values (P = 0.008) compared with patients with left-sided ED (n = 22). Patients with multiple EDs (n = 6) had lower symptom severity than patients with a single ED (P = 0.022). Conclusions The etiologies of dilated esophagus, sigmoid esophagus, and ED are considered multifactorial and different. Early diagnosis and optimal treatment of AEMDs are necessary to prevent these conditions.