Progressive hemifacial atrophy (PHA) is a self-limited atrophy of subcutaneous tissues (and less frequently of hard tissues) on one side of the face. It is a sporadic, slowly progressing disease whose pathogenesis is still unknown. As a rule the asymmetry caused by PHA (usually of soft tissue) is treated by volume augmentation that involves free tissue grafting or a pedicled flap transfer.We describe a rare case of hard tissue PHA. The atrophic changes occurred in the left molar tooth, maxilla and mandible and were associated with moderate soft tissue atrophy. The left side of the patient's mouth was higher on the right side, and the occlusal plane was severely inclined in spite of normal occlusion. After no alteration and no progression of the atrophy were established, the patient was treated with orthodontic surgery. To correct the inclined occlusal plane and asymmetry profile, we performed a Le Fort I and intraoral vertical ramus osteotomy. In the 3-year follow-up, there were good occlusal balance and improved symmetrical profile without relapse or recurrence of the atrophy. Thus, orthodontic surgery was effective as a first procedure to treat hard tissue atrophy that appeared with moderate soft tissue atrophy.

Pre- and postoperative left ventricular (LV) function was assessed by Doppler echocardiography in 95 infants who underwent open heart surgery during the past two and half years. The patients were divided into three groups: 43 patients with ventricular septal defect (VSD group), 37 with atrial septal defect (ASD group) and 15 with the tetralogy of Fallot (TOF group). Echocardiography was performed before and at an early stage after surgery (average: 11.6 days) in all cases. The forward flow velocity pattern was evaluated by Doppler echocardiography, placing the sample volume at the pulmonary vein (PV) and the LV inflow portion. At the PV, the peak velocity of the S wave during systole (p-PV_S) and the D wave during diastole (p-PV_D) in patients with ASD were significantly lower (p<0.01) postoperatively. In patients with VSD, only p-PV_D was significantly lower (p<0.05) postoperatively, showing a decrease of pulmonary blood flow. These results are thought to reflect a difference in the compliance of the left atrium between the two groups. At the LV inflow portion, the ratio of peak velocity of the wave during atrial systole to R wave on rapid inflow during diastole (A/R) was significantly lower in patients with VSD (p <0.01) postoperatively. At the same time, LV ejection fraction and fractional shortening were significantly lower (p<0.01), but these values remained within the normal range. These results suggest that LV can maintain a sufficient systolic performance against the decrease in preload and the increase in afterload as well as the improvement of diastolic function during the early period after surgery in the VSD group. In patients with ASD or TOF, there were no significant differences in parameters of LV function between preoperative and postoperative periods.

Introduction : To promote disease management in the community, general physicians should refer their patients to specialists in a timely and appropriate manner. In this study, we propose an indicator for evaluation of such referrals.
Methods : We analyzed all referrals in an urban clinic from September 1, 2011 to August 31, 2012. Symptoms and diagnoses documented by general physicians were collected from medical records, and the final diagnoses by specialists were collected from their reports. The symptoms and diagnoses were classified using the International Classification of Primary Care second edition (ICPC-2). Referral rates, hospitalization rates, and place of referral were analyzed.
Results : The average number of encounters in the candidate clinic was 1402 per month, and the mean number of referrals was 23 (1.6% of encounters). Of patients who received a referral, 6.75 (29.1%) were admitted to hospitals. The symptoms and diagnoses of the referred patients were distributed across all chapters (A to Z) of ICPC-2. Diagnoses of admitted patients included pneumonia (R81) (24%), urinary tract infection (U70 and U71) (9%), and acute gastroenteritis with dehydration (D73 with T11) (9%).
Conclusion : We identified the referral rates, hospitalization rates, and distribution of referral patients as indicators of the triage function of primary care physicians. These should be evaluated further as potential indicators of “the quality of medical care.”

We administered Japanese Kampo medicine for seven patients with Grade 3 or more idiopathic sensorineural hearing loss who could not be administered enough amounts of steroids for some reasons. They all exhibited deficiency patterns, and which were all dual deficiency patterns of qi and yin. All patients were administered hochuekkito and hachimijiogan. Six patients were cured, and one patient was recovered.

Pruritus of external auditory canal is often treated with blood-enriching formulation and heat-clearing formula. Here, we report a case of intractable pruritus of external auditory canal successfully treated with tokishigyakukagoshuyushokyoto, which did not improve with blood-enriching formulation or heat-clearing formula. Our patient was a 52-year-old woman. She had itching in her left ear from the age of 45, and was treated by 5 otolaryngologists, but her symptom did not improve. I treated her with tokiinshi, shofusan, yokukansankachimpihange, unseiin, jumihaidokuto and keishibukuryogankayokuinin, but they had no effect. After reconsideration of sho, she was diagnosed as interior cold pattern, and she had tenderness in groin area. So I treated her with tokishigyakukagoshuyushokyoto, and her itching disappeared. We should consider interior cold pattern as one of the differential diagnoses of pruritus of external auditory canal.

We experienced 2 patients with clinical diagnosis of subacute necrotizing lymphadenitis who were successfully treated with shosaikoto. Case 1 is a 37-year-old woman. Left neck swelling and pain appeared from 12 days before, and temperature went up thereafter. Antibiotics were administered at another hospital, but she did not improve. There were multiple swollen lymph nodes of the left neck, and blood test showed decreased white blood cells and increased LDH. So we clinically diagnosed her as subacute necrotizing lymphadenitis. After administration of shosaikoto, fever resolved, and cervical swelling also markedly improved on the third day. On day 10, both symptom and findings disappeared. Case 2 is a 12-year-old man. Left neck swelling and pain appeared and temperature went up from 8 days before. An antibiotic was administered at another hospital, but he did not improve. There were multiple swollen lymph nodes of the left neck, and blood test showed decreased white blood cells and increased LDH. So we clinically diagnosed him as subacute necrotizing lymphadenitis, and administered shosaikoto. Then fever resolved on the third day, and cervical swelling diminished and tenderness disappeared on day 10. On day 18, both symptom and findings disappeared.

The cause of dizziness is often phlegm-rheum, and most of them are treated with drugs, which eliminate excessive fluids. However, in recent years, the causes of dizziness have become diversified and complicated, and in some cases it is difficult to treat with general-purpose agents. This time, we present a case of chronic refractory dizziness successfully treated with goshakusan. The patient was a 70-year-old woman. She had wobbled while walking for 2 years, and consulted nearby doctors. No particular abnormality was pointed out, and oral treatment was performed, but there was no improvement. In our department, ryokeijutsukanto, hangebyakujutsutenmato, goreisan, hochuekkito, kamishoyosan, chotosan, and shinbuto were prescribed by the doctor at the first visit. However, there was no improvement, and the author took over the charge. We diagnosed her with orthostatic dysregulation and prescribed tofisopam, but her dizziness did not improve. We conducted oriental medical examination, and diagnosed that phlegm-rheum associated with food accumulation was the main pathological condition, and that qi stagnation and blood stasis were combined. After 16 weeks of administration of goshakusan, her dizziness improved.

Sleep disorders may be involved in unexplained dizziness. This time, we report 2 cases of dizziness with sleep disorders improved with keishikaryukotsuboreito. Case 1 is a 67-year-old woman. She had had vertigo attacks for 4 years, was very anxious about the attacks, had trouble falling asleep, and was aware of dizziness even between the attacks. After 4 weeks of administration of keishikaryukotsuboreito, her anxiety disappeared and she was able to sleep soundly. After 10 weeks, the lightheadedness disappeared and the medication was terminated at 17 weeks. Case 2 is a 38-year-old woman. She was exhausted because she had a personnel change in her workplace 3 months ago and she was concerned about many things. From 2 months ago, she had trouble falling asleep at night. After 2 weeks of administration of keishikaryukotsuboreito, she was able to sleep soundly. The dizziness disappeared after 6 weeks, and the medication was terminated at 10 weeks.

In cases of pulsatile tinnitus, the presence of organic disease should be suspected, and many of them can be treated once the cause is identified. However, there are idiopathic cases in which the cause cannot be identified, and there is no established treatment for them. Here, we report 2 cases in which Kampo medicine was effective for idiopathic pulsatile tinnitus. Case 1 was a 50-year-old man. He had been stressed for half a year due to the change of job title in his workplace, and he had left pulsatile tinnitus a month ago. We administered saikokaryukotsuboreito, and his tinnitus disappeared in a week. Case 2 was a 30-year-old woman. She gave birth 4 months ago, and after giving birth, she had less sleep and was tired and stressed. She started to notice right pulsatile tinnitus and dizziness from a month ago. We administered nyoshinsan, and her tinnitus and dizziness disappeared in 2 months. In both cases, they were aware of hot flashed on their face as a symptom of qi counterflow, and Kampo treatment improved the symptom together with pulsatile tinnitus. It is possible that blood flow in the head increased with qi counterflow, causing relative stenosis of the blood vessels in the head, leading to turbulence in the lumen of the blood vessels, and hearing pulsatile tinnitus.