This is a report on a case of delirium due to a small amount of ketamine with voriconazole. A 58 year old male was treated for multiple myeloma and hip pain due to an extramedullary tumor following the administration of oxycodone, and voriconazole was administrated for his suspected mycotic pneumonia. His pain was refractory, so we started the administration of a small dose of ketamine (4 mg/hr) for analgesia, added to oxycodone. About 30 hours later, the delirium appeared but he complained of worsening hip pain, so we added 2 mg of ketamine rapidly. Immediately after the additional administration of ketamine, his delirium became more serious. We think the reason why a small amount of ketamine induced delirium is an interaction of ketamine and voriconazole. Ketamine is metabolized to norketamine, which is thought to be more harmless than ketamine, by cytochrome P 450 (CYP) (a part of by CYP3A4) and voriconazole is an inhibitor of CYP3A4. In cases of patients treated with voriconazole, ketamine should be more carefully administrated.

Introduction. The principal therapy for gallstones was open cholecystectomy. Recently, however, with remarkable advances in laparoscopic surgery on the biliary tract in particular, laparoscopic cholecystectomy has become preferred treatment for symptomatic cholelithiasis. To assess our experience in surgical treatment for gallstones and determine the best method to reduce postoperative discomfort, cases of cholecystectomy performed in our institution were reviewed.
Patients.-During the past 14 years, 524 patients were treated for cholelithiasis (cholecystolithiasisin 412, choledocho-cholecystolithiasis in 75, choledocholithiasis in 36, intrahepatic stones in 1). The ratio of men to women was 1: 1.7 and the average age was 61 years. Results.-Only cholecystectomy was performed on 86% of the patients with cholecystolithiasis and 91% had accompaning open surgery with laparoscopic cholecystectomy in latest years. Open cholecystectomy by inserting a T tube was done on 61% of choledochocholecystolithiasis cases. In some cases papilloplasty and/or choledochoduodeno or choledochojejunostomy followed. Almost all patients with choledocholithiasis had open cholecystectomy with T-tube insertion and additional procedures to remove stones in thebiliary tract in earlier years. In these years, no more addidional procedures except for choledochotomy with T-tube insertion had been performed in any cholelithiasis cases.
Conclusions.-Laparoscopic cholencystetomy is a safe and effective procedure and should be preferred for symptomatic cholelithiasis except for cases with acute cholecystitis, common bile duct stones, gallbladder cancer and other severe complications.

We report two cases of farm chemical poisoning which were treated successfully. Two elderly men separately swallowed down paraquat/diquat solutions in an attempt to kill themselves, and resultantly developed pulmonary fibrosis. After steroid therapy, clinical symptoms desappeared, although a slight degree of abnormality remained on chest X-rays. Case 1: a 57-year-old man; the amount of ingestion, 100 ml; hospitalized 2 hours after ingestion; shock, (-); urinary PQ reactoin, (2); serum PQ level, 1.14 ug/ml; pulmonary injury at first examinatoin, (-); pulmonary manifestation of symptoms, at day 3 after hospitalization; minimum Pao₂, 67.6 mmHg. Case 2: a 65-year-old man; the amount of ingestion, one gulp; hospitalized 27 minutes after ingestion ; shock, (-); urinary PQ reactoin, (3+); serum PQ level, 6.6ug/mg; pulmonary injury at first examination, (-); pulmonary manifestation of symptoms, at day 5 after hospitalization; minimum Pao₂, 58.3mmHg. For treatment, gastrointestinal lavage, forced diuresis and direct hemoperfusion were performed in both cases. Steroid pulse therapy was followed by repeated oral administration of large doses of steroid.
Hepatic and renal disorders were transient. Pao₂ was normal when the patients were discharged. The primary reasons we could save their lives are probably that the amount of PQ ingestion was relatively small, hemodialysis was performed repeatedly at early stages, and that large amounts of steroid were used immediately after the onset of pulmonary fibrosis.

The Saku Central Hospital classified muscular relaxants, potassium products and the like as “high-risk medicines”, but when it came to insulin, did not take any standardized measure against it to prevent accidents. Having organized a team of personnel from a wide variety of job, our hospital has recently carried out a campaign for improvements in medical care. With pharmacists playing a leading role, we grappled with measures for the prevention of errors in the administration of insulin using quality control (QC) methods. As a consequence, the campaign served to decrease the number of medical mistakes. As there still occur many incidents involving medication, the role played in risk management by pharmacists remains significant. In future, pharmacists will hopefully play a constructive role in risk management to prevent medical incidents involving medical supplies. That said, a campaign for improvements inmedical care through the practical use of QC methods seems likely to bring about favorable results.
Role ; Quality Control ; Analysis ; Avoidance ; ERROR

Methods: Thirty patients with ASD aged ≥50 years who were admitted to our hospital between July 2016 and September 2019 were included in this study. X-ray parameters (i.e., sagittal vertical axis, pelvic tilt, and pelvic incidence minus lumbar lordosis) were evaluated from the full-length standing radiographs of the subjects. Trunk and hip extensor strength was evaluated using a hand-held dynamometer. Dynamic postural changes (i.e., sagittal trunk shift during standing, sagittal trunk shift during gait, and delta sagittal trunk shift) were assessed using a three-dimensional motion analysis system. The relationships between dynamic postural change and various X-ray parameters, as well as trunk and hip extensor strength, were examined using multivariable analysis. Results: Multivariable analysis showed that hip extensor strength is the factor most strongly associated with dynamic postural change among the X-ray parameters and physical functions assessed in this study (β=−0.41, R2=0.12). Conclusions We demonstrated the association between dynamic postural change and hip extensor strength in patients with ASD. Our results may be useful to healthcare providers treating patients with ASD. Interventions for dynamic postural change in patients with ASD should focus on hip extensor strength.

Methods: Thirty patients with LSS scheduled for spine surgery participated in this study. Lower limb pain was assessed using the Visual Analog Scale (VAS), and the patients were divided into two groups based on the mean scores (patients with scores above and below the mean were classified as the high-VAS and low-VAS groups, respectively). The kinematics of the spine, pelvis, and hip joints during gait were then measured using a 3D motion analysis system. Student paired t -tests were used to compare the angles of the spine, pelvis, and hip during gait between the two groups. Results: Compared to those in the low-VAS group, the spine was significantly extended and bent toward the more painful lower limb side, and the pelvis was significantly anteriorly tilted among individuals in the high-VAS group. Conclusions Patients with LSS experiencing severe pain in their lower limb tend to keep the spine in a more extended position, bend laterally toward the painful side, and have an anteriorly tilted pelvic posture. The dynamic spinal and pelvic alignment was closely related to the intensity of the lower limb pain.

OBJECTIVE: To retrospectively evaluate the frequency and risk factors for developing thrombus in a systemic vein such as the infrarenal inferior vena cava or the iliac vein, in which a balloon-occluded retrograde transvenous obliteration (B-RTO) catheter was indwelled. MATERIALS AND METHODS: Forty-nine patients who underwent B-RTO for gastric varices were included in this study. The B-RTO procedure was performed from the right femoral vein, and the B-RTO catheter was retained overnight in all patients. Pre- and post-procedural CT scans were retrospectively compared in order to evaluate the development of thrombus in the systemic vein in which the catheter was indwelled. Additionally, several variables were analyzed to assess risk factors for thrombus in a systemic vein. RESULTS: In all 49 patients (100%), B-RTO was technically successful, and in 46 patients (94%), complete thrombosis of the gastric varices was achieved. In 6 patients (12%), thrombus developed in the infrarenal inferior vena cava or the right common-external iliac vein. All thrombi lay longitudinally on the right side of the inferior vena cava or the right iliac vein. One of the aforementioned 6 patients required anticoagulation therapy. No symptoms suggestive of pulmonary embolism were observed. Prothrombin time-international normalized ratio and the addition of 5% ethanolamine oleate iopamidol, on the second day, were related to the development of thrombus. CONCLUSION: Development of a thrombus in a systemic vein such as the inferior vena cava or iliac vein, caused by indwelling of the B-RTO catheter, is relatively frequent. Physicians should be aware of the possibility of pulmonary embolism due to iliocaval thrombosis.
Adult ; Aged ; Aged, 80 and over ; Balloon Occlusion/*methods ; Catheters, Indwelling/*adverse effects ; Esophageal and Gastric Varices/etiology/*therapy ; Female ; Femoral Vein ; Humans ; International Normalized Ratio ; Iopamidol/administration & dosage ; Male ; Middle Aged ; Oleic Acids/administration & dosage ; Prothrombin Time ; Retrospective Studies ; Risk Factors ; Statistics, Nonparametric ; Tomography, X-Ray Computed ; Treatment Outcome ; Venous Thrombosis/drug therapy/*etiology/*radiography

BACKGROUND/AIMS: Mesalazine is an effective drug for treating ulcerative colitis (UC), but causes allergic symptoms in a few cases. Therefore, the objective of this study was to evaluate the usefulness of the drug-induced lymphocyte stimulation test (DLST) for the diagnosis of mesalazine allergy. METHODS: Patients with UC treated with mesalazine with or without a history of associated adverse events (AEs) were enrolled at Kyorin University Hospital from July 2016 to April 2017. RESULTS: The DLST was performed in 104 patients with UC, of which 24 had a history of AEs due to mesalazine treatment. The control value of DLST was 337.4±296.3 counts per minute (cpm) in the AE+ group and 408.0±371.9 cpm in the AE− group. The measured value of DLST was 578.8±424.7 cpm in the AE+ group and 476.5±471.8 cpm in the AE− group. The stimulation index (SI) was 243.9%±291.1% in the AE+ group and 119.8%±53.0% in the AE− group. The SI value and DLST positivity were significantly higher in the AE+ group than in the AE− group (P=0.030 and P=0.029, respectively). The test sensitivity and specificity were 0.240 and 0.805, respectively, and the false-positive and false-negative rate was 0.195 and 0.760, respectively. CONCLUSIONS: The DLST for mesalazine showed low sensitivity and high specificity, suggesting that it may be useful for the definitive diagnosis of allergy to mesalazine.
Colitis, Ulcerative ; Diagnosis ; Humans ; Hypersensitivity* ; Lymphocyte Activation* ; Lymphocytes* ; Mesalamine* ; Sensitivity and Specificity