Progressive supranuclear palsy (PSP) comprises psychiatric, neurological and physical complications. In the late stage, most patients with PSP are bed-bound because of motor disability. PSP manifests as predominantly axial abnormality in posture and abnormal muscle tone, resulting in cervical retroflexion and somatic pains. Severe retroflexion of the neck is frequently a cause of repeated aspiration pneumonia that affects survival expectancy. We injected botulinum toxin (BTX) for severe retroflexion using a CT-guided procedure to confirm the anatomical locations of paravertebral muscles and to localize the paravertebral target muscles for a patient with PSP who had repeated pneumonia caused by retroflexion-related dysphagia. BTX injection treatment markedly ameliorated the cervical dystonia and concomitant dysphagia. The patient has recovered and may be able to be discharged to home. There are few reports on the BTX injection technique, but BTX has analgesic effects and induces relaxation of abnormal muscle tension. Therefore, it may be applicable to other movement disorders at the late stage.

A case of left ventricular pseudoaneurysm formation at an atypical site in the left ventricle is described. A 32-year-old man underwent mitral valve replacement and he was taken to the intensive care unit (ICU) in good condition. Two hours later, he sustained massive bleeding from the chest drainage tubes, hypotension, and shock. We reopened the sternotomy in the ICU and found massive bleeding from the lateral wall of the left ventricle. Under cardiopulmonary bypass and cardiac arrest, the myocardial laceration was closed with Teflon felt-buttressed interrupted sutures and then the involved area was covered with a Xeno-medica^TM patch. Postoperative echocardiography, computed tomography, and left ventriculography revealed pseudoaneurysm formation at antero-lateral wall of left ventricle. Because the patient was asymptomatic, he was discharged from our hospital without reoperation. However we are closely following him in the outpatient clinic.

Objective: Treatment of tinea unguium with topical drugs alone is difficult, and medication with oral terbinafine hydrochloride is necessary in many cases.  Since Trychophyton infects the nails in not only men but also women at a reproductive age, the influence on a fetus of the drug ingested during early pregnancy is a matter of concern of many women.  The objective of this study was to investigate the influence of oral terbinafine hydrochloride on fetuses.
Methods: The outcomes were investigated in pregnant women who ingested terbinafine hydrochloride and visited the ‘Outpatient Services for Consultation on Pregnancy and Drugs (Teratology Information Services)’ of Toranomon Hospital, and cases were collected.
Results: Fifteen pregnant women ingested the drug during the organogenic period, in which the teratogenic risk is the highest.  All 15 pregnant women gave birth to healthy babies.
Conclusion: This is the first survey concerning newborns delivered by women who ingested terbinafine hydrochloride during pregnancy in Japan.  All investigated women gave birth to healthy babies, and the incidence of congenital abnormalities did not markedly exceed that in the general population.  Since the number of cases was small, it is necessary to perform a cohort study to investigate details of the safety for fetuses.

Objective: Novel antipsychotic agents less frequently cause extrapyramidal side effects compared to conventional antipsychotic agents, contributing to improvement in the QOL.  Recently, these agents have also been increasingly prescribed to females who may become pregnant.  In Japan, no epidemiological survey regarding the application of novel antipsychotic agents in pregnant women has been published.  In this study, we investigated the influence on fetuses in pregnant women receiving novel antipsychotic agents.
Methods: In pregnant women on novel antipsychotic agents who consulted the Pregnancy and Drug Consultation Outpatient Clinic of Toranomon Hospital, the outcome of pregnancy was confirmed.
Results: Twenty-nine pregnant women took novel antipsychotic agents in the organogenesis phase, in which the risk of teratogenicity is the highest.  The agents consisted of olanzapine in 8 patients, risperidone in 11, quetiapine fumarate in 7, and perospirone hydrochloride hydrate in 4.  The outcomes of pregnancy were full-term delivery in 24 patients, premature delivery in 1, spontaneous abortion in 2, and artificial abortion in 2.  Of the 29 patients, 15 (60%) had continuously taken these agents until delivery.  All 25 neonates were healthy without malformation.
Conclusion: This report describes the first prospective survey in Japan regarding infants delivered by pregnant women receiving novel antipsychotic agents.  All patients delivered healthy neonates; the incidence of congenital anomalies did not exceed that in the general population.  This survey included a small number of patients; cohort studies should be conducted to evaluate the safety in fetuses.

Objective：An actual-condition survey was conducted to verify the validity of reference values of higher brain function necessary for patients with brain injury to resume automobile driving.　Subjects：Of the 74 patients admitted to the Tokyo Metropolitan Rehabilitation Hospital between November 1, 2008 and November 30, 2012, who underwent evaluation using the hospital's automobile driving resumption system at the time of discharge, 71 patients with brain injury who were judged capable of resuming driving were included in this study. Methods：Questionnaires were sent at least 1 year after discharge, to determine whether the subjects had actually resumed automobile driving. Subjects were classified by admission date into two groups：1）A provisional reference group that included patients admitted between November 2008 and November 2011 who had resumed driving；and 2) verification group that included patients who had been admitted between December 2011 and November 2012 and had resumed driving. The relationship between results on the higher brain function test for the verification group and provisional reference values was investigated. Results：The provisional reference value group included 29 patients, and the verification group included 13 patients. In the verification group, the results of 9 patients with brain injury on the higher brain function test were within provisional reference values. Conclusion：The results of the paper-based test are a reliable predictor of whether a patient is capable of resuming driving, but do not represent an absolute standard. Therefore, the safety of resuming driving should be investigated on a case-by-case basis.

The initial case was a man in his 50s. He received 2 cans a day of ProSure^®, while undergoing radiation and chemotherapy with carboplatin and docetaxel for adenocarcinoma in the lung. His body weight rose from 62.4 kg on admission to 63.7 kg before discharge, CRP decreased from 3.08 mg/dl to 0.48 mg/dl, and albumin fell from 3.6 g/dl to 3.5 g/dl. The second case was a man in his 60s. He was diagnosed as having squamous cell carcinoma in the lung and administered with 2 cans a day of ProSure^® and antibiotics. One-and-a-half months later, he underwent chemotherapy with carboplatin and S-1 and radiation. His body weight stood at 47.0 kg on admission and 47.2 kg before discharge, CRP dropped from 15.45 mg/dl to 3.26 mg/dl, and albumin was retained at 2.6 g/dl to 2.7g/dl. The administration of ProSure^® brought about improvements in the nutritional status and anti-inflammatory effects in the patients with chemotherapy.

A 28-year-old man was involved in a traffic accident that sandwiched his chest between a wall and a truck. Shortness of breath and other symptoms started to appear several years later. Echocardiography at that time showed severe tricuspid regurgitation due to a failed valve and ruptured chordae in the anterior leaflet. He was followed up with medication. Leg edema developed at the age of 62 years and worsening symptoms of heart failure over a period of 6 months indicated a need for surgery. Intraoperative findings revealed the ruptured chordae attached to the anterior leaflet and a scarred myocardium at the septomarginal trabeculation. The tricuspid valve was surgically repaired, the anterior leaflet chordae were surgically reconstructed, an annuloplasty ring was implanted to address the tricuspid regurgitation and atrial fibrillation was treated using the Maze procedure. Surgery 34 years after trauma has improved hemodynamic cardiac function and normalized the cardiac rhythm in this patient.

Background: In terminally ill patients with cancer, sleep disturbance makes worse their quality of life. Midazolam has not ever been used for the treatment of sleep disturbance in general wards of our hospital, used in palliative care unit of other hospital, however. Method: This is a retrospective study based on chart review. Twenty-eight patients who were treated with midazolam for sleep disturbance included in this study. We designed evaluation methods to strictly follow the actual chart descriptions. Efficacy was rated as good, fair, or poor. Safety was defined by the presence or absence of respiratory depression and hypotension. Results: The median administration periods and initial doses were 6 days (range, 1-151) and 5.0 mg/night (1.8-20.0), respectively. Fourteen patients showed good sleep a night after midazolam infusion, four and nine patients showed fair and poor sleep, respectively. No patient demonstrated a respiratory rate of less than 8/min and systolic blood pressure of <60 mmHg at any point during and after midazolam infusion. Conclusion: Intravenous midazolam appeared to be safe for sleep disturbance of terminally ill patients with cancer in general wards. A future improvement administration methods are necessary to treat for sleep disturbance more effectively as well as PCU.

Objective : We conducted a fact-finding survey for the consecutive past 3 years to establish whether inpatients with brain injury who had wished to resume driving after discharge from our hospital had in fact resumed driving after discharge. The survey included both driving status and information about collisions. Methods : Patients who had been evaluated for resumption of driving and were discharged more than 1 year ago were sent a fact-finding survey questionnaire aimed at establishing whether they were currently driving. The patients who had resumed driving (resumers) were compared with those who had not resumed driving (non-resumers). From the questionnaire results we investigated driving status and whether collisions had occurred. Results : We obtained effective responses from 40 of the 54 people (48 males, 6 females) who were sent the questionnaire ; the collection rate was 74.1%. Of these, twenty-nine people had resumed driving, all were male. There were no significant differences between the resumers and non-resumers in higher brain function tests. In regard to driving ability, hemiparesis impairments were significantly milder in the resumers than in the non-resumers. Two respondents had hit posts or walls within the year. All these collisions occurred when parking. One respondent had a collision while driving along a road. Conclusion : We hope to provide patients with useful and appropriate information on resuming driving so that we can support them in a safe return to the driving environment.

Objective : Although an endoleak is the most common complication after endovascular abdominal aortic aneurysm repair (EVAR), the proper and noninvasive method for the detection of endoleaks is not established. The purpose of this study is to investigate whether plasma levels of D-dimer and fibrin degradation product (FDP) could be predictors of endoleaks after EVAR. Methods : Between June 2011 and January 2014, 65 consecutive patients underwent EVAR at our institution. We evaluated 55 patients excluding 10 patients pre-existing conditions such as aortic dissection, arterial or venous thrombosis, conversion to open surgery, and difficulties in making outpatient visits. Enhanced computed tomography (CT) examination was performed during 12 months after EVAR. Persistent endoleaks and maximum aneurysmal diameter were evaluated at each follow-up time. Patients were divided into groups according to CT findings at 12 months after EVAR. There were 26 patients with endoleaks vs. 29 non-endoleak patients, 34 with unchanged aneurysm findings vs. 21 with shrinkage. No patient showed aneurysmal enlargement. Plasma levels of D-dimer, FDP, counts of platelet, prothrombin time (PT), and activated partial thromboplastin time (APTT) were also measured at the time of CT examinations. Results : There was no operative death and no major complication. Endoleaks in all patients were identified as type II. None of them required re-intervention. In the endoleak group, plasma levels of D-dimer and FDP were significantly higher than in the non-endoleak group in each postoperative period. In addition, postoperative counts of platelet were significantly lower in the endoleak group. PT and APTT test results showed no significant difference in the two groups. In the unchanged aneurysm group, postoperative D-dimer and FDP tended to be higher compared with the shrinkage group. Postoperative counts of platelet also tended to be lower in the unchanged group. There were no differences in PT and APTT test results. Conclusion : Plasma levels of D-dimer and FDP are potentially useful predictors of endoleaks after EVAR.