A 10-year-old girl was given a diagnosis of mitral stenosis due to a small prosthetic valve. She had undergone intra-cardiac repair operations for a complete atrioventricular septal defect by a two-patch method at 6 months after birth, and for left atrioventricular valve insufficiency by replacement with a mechanical prosthesis (SJM-HP-17mm) at 2 years of age. The cause of mitral stenosis was considered to be that the existing prosthesis was too small for her body growth. Reoperation was done with a trans-septal approach, but despite the resection of the old prosthesis and peripheral fibrous tissue her left atrioventricular annulus was not big enough to insert a larger prosthesis. We thus cut the previous VSD patch about 1cm toward the apex, and sutured a patch for annular enlargement. After this annular enlargement, we could insert a larger prosthesis (SJM-HP-21mm). Her postoperative course was uneventful. There was no left ventricular outflow obstruction and no worsening of her mild right atrioventricular regurgitation. There are few established procedures for enlargement of a left atrioventricular annulus. Our method presented here is safe and effective for left atrioventricular annular enlargement, but can only be applied to patients with atrioventricular septal defect.

[Objective]To analyze and understand cases of adverse effects of acupuncture and moxibustion published in medical journals between 2007 and 2011.
[Methodology]We searched relevant articles with the Web of Japan Medical Abstracts Society and PubMed. We used keywords for acupuncture, moxibustion and related adverse events.
[Results]We located 39 papers reporting 39 cases that occurred in Japan:infection (7 cases), organ injury (11), foreign body or needle breakage (8), neurological damage (6), cutaneous disease (1), adverse effects of moxibustion (4), and others (2). As for cases published in foreign countries, we located 60 relevant papers:infection (19 cases including 2 outbreaks), organ injury (13), foreign body or needle breakage (5), neurological damage (9), cutaneous disease (5), adverse effects of moxibustion (2), and others (7).
[Conclusion]Although causal relationship has not been established in some cases, occurrences of infection, organ injury, and needle breakage/foreign body are still as high as they were before. This suggests that continual feedback to acupuncturists of information on safety is necessary.

We updated safety information on acupuncture and moxibustion, focusing on adverse events. Case reports published between 1998 and 2002 were searched, using “Ichushi Web” (Web version of Japana Centra Medio Medicina) and “PubMed”. Thirtysix cases of acupunctureassociated adverse events (13 infections, 11 dermatological problems, 6 organ injuries or foreign bodies, 5 nerve injuries etc.) and nine cases of moxibustionassociated adverse events (6 dermatological problems etc.) were located. Most cases were published in academic journals in the field of modern Western medicine, which clinical acupuncturists usually do not read. Therefore, our committee should play a role of collecting safety information and performing the feedback for the acupuncturists.
We also summarize the contents of the Workshop held by our committee on June 6, 2003. The most controversial issue was determining an appropriate method of needle insertion in terms of infection control. More evidence is needed for establishing a good manual for safety acupuncture.

Knowledge and procedures regarding safe acupuncture practices often include conjecture and anecdotes lack-ing scientific evidence. In order to improve the safety standards of acupuncture, we should collect, scrutinize, and apply evidence on the safe management of acupuncture. We, the Committee for Safe Acupuncture, have commenced collecting and reviewing relevant evidence published. Subjects in 2004 were as follows :
1. The present situation of safety education and damages (by Katai)
2. Hand washing and finger disinfection (by Ishizaki)
3. Disinfection of the needle insertion area (by Umeda)
4. Procedures of needle insertion and removal (by Miyamoto)
5. Safe insertion depth (by Yamashita)
6. Environmental sanitation (by Egawa)
We hope that the knowledge and questions which come to light through the present work will influence school education, clinical practice, manual editing and research activities.

We continued reviewing published evidence and information regarding the safety of acupuncture. Subjects in 2005 were as follows :
1. Safety during acupuncture stimulation
2. Quality and strength of acupuncture needle
3. Sterilization and storage of equipments
4. Hygienic handling of equipments
5. Relevant notices from the Government
6. Standards of notification regarding hygienic practice and contaminated wastes
We hope that the information here will influence the future school education, clinical practice, manual editing and research activities.

The purpose of this study was to examine the effect of physical inactivity, produced by prolonged bed rest, on the excitability of the spinal motor neuron pool in humans, using the activity of soleus H-reflex.
Eight healthy male subjects underwent continuous bed rest with 6 degree head-down tilt for 20 days (BR group) . Ten different healthy male subjects maintained their usual daily life during the observation period for 20 days (control group) . Recruitment curves of H-reflex and M-wave were obtained from every subject. H slope/M slope (H slp/M sip) which shows the excitability of spinal motor neurons was calculated by using data in the recruitment curve.
The H sip/M sip in the BR group significantly increased after BR, compared to the pre-BR values (p<0.05) . In the control group, however, there were no significant differences in the H slp/M sip between the pre and the post-observation values. At the baseline, the H slp/M sip showed no significant differences between the BR group and the control group. After the BR, the H slp/M sip in the BR group significantly increased compared to the control group after the observation period (p<0.05) .
This study suggests that the excitability of the monosynaptic spinal motor neuron pool is facilitated by physical inactivity during BR.

We have been collecting various ideas on safer acupuncture practice from participants in our workshop as well as members of the committee. Subjects and presentations of the present workshop were as follows:
1. Forgotten needles
  1) Ideas of prevention based on a questionnaire survey (Egawa and Ishizaki)
  2) Effect of incident reporting system (Yamashita)
2. Cleaner method of needle insertion and Oshide (needle-supporting fingers)
  1) Merits and demerits of sterilized fingerstall and glove (Miyamoto)
  2) History of the clean needle development (Umeda)
  3) A novel clean acupuncture needle device (Imai and Ishizaki)
Although there was not enough time for discussion, we collected some useful ideas from the participants. A novel clean needle invented by Imai gave a strong impression to the audience. We should continue to discuss a diverse impact when such new devices and concepts become widespread in traditional acupuncture practices. We welcome more ideas and opinions from relevant facilities, clinics and fields in order to further improve safety of acupuncture.

Continued from the previous year's theme of our workshop, we collected various information and ideas for safer acupuncture practice. Subjects and presentations of the present workshop were as follows:
1. Literature review of papers on adverse events published between 2003and 2006
1) Papers in domestic journals (by Ishizaki and Egawa)
2) Papers in foreign journals (by Yamashita and Umeda)
2. Debate on wearing sterilized fingerstall or glove
1) Present status of the use of fingerstall in acupuncture practice (by Katai and Minowa)
2) Practical side of clinical education of acupuncture using fingerstall (by Hatakeyama and Furuya)
3) Problem of using individual fingerstalls in acupuncture practice (by Handa and Miyamoto)
We will continue to provide information and discuss solutions in order to reach a common understanding and specific methods for safer acupuncture practice.