Background: Combination treatment with bevacizumab and paclitaxel has been approved for treating human epidermal growth factor receptor 2(HER2)-negative metastatic breast cancer(MBC) in Japan. Japan has no official economical guideline showing decision criteria for the approvals of new drugs. However, the National Institute for Health and Clinical Excellence(NICE) in UK hardly recommends the combinational use of bevacizumab for HER2-negative MBC, because of its poor cost-effectiveness.　Objective: The evaluation of the cost-effectiveness of additional bevacizumab as primary chemotherapy for HER2-negative MBC in accordance with the clinical practice guideline in JapanMethods: A Markov cohort simulation was used to follow the clinical course of typical patients with MBC. Transition probabilities were estimated from randomized clinical trials. Direct medical costs were assessed from the perspective of the Japanese health-care system. This study used quality-adjusted life year(QALY), and both costs and QALYs were discounted 3% annually. The time horizon was 10 years. Both a univariate and probabilistic sensitivity analyses were conducted. Results: The additional use of bevacizumab to paclitaxel required an additional cost of JPY 9.12 million(USD 114,000) for obtaining a gain of 0.26 QALYs, and the incremental cost effectiveness ratio was JPY 35 million(USD 437,000). Conclusion：By assuming of GBP 20,000-30,000(JPY 2.5-3.75 million and USD 31,000-46,900) to be an index value threshold by NICE, combination treatment with bevacizumab was found to be hardly cost-effective. Based on the fair and adequate distribution of medical resource, economical guidelines reflecting the Japanese health-care system are necessary. (Jpn J Pharmacoepidemiol 2013；18(1)：1-12)

A 75-year-oldm an with an aortocaval fistula as a complication of aortoiliac aneurysm visited our hospital. He complained of shortness of breath and melena. Physical examination revealed a pulsating abdominal mass with thrill and continuous murmur. Chest X ray showed cardiomegaly with pulmonary congestion. CT scan showed infrarenal aortoiliac aneurysm and echo Doppler scan revealed aortocaval communication at the inferior caval bifurcation. Aortoiliac bifurcated graft and patch reconstruction of IVC were performed. The postoperative course was uneventful, and his congestive heart failure and hepatorenal dysfunction immediately improved.

A 32-year-old woman with Marfan's syndrome who had had a heart murmur in childhood was admitted due to congestive heart failure. Her echocardiography showed anterior and posterior leaflet prolapse of the mitral valve, and also severe mitral valve regurgitation. Her chest CT scan showed no evidence of an enlarged ascending aorta. We performed mitral valve replacement using a mechanical valve, because the long-term results of mitral valve repair for Marfan's syndrome are unknown. We reviewed the literature for other examples of this rare adult case with isolated mitral regurgitation associated with Marfan's syndrome.

Reoperations after operations for acute type A aortic dissection were performed in two cases under deep hypothermic circulatory arrest. In case 1, the aortic arch replacement was performed with an inclusion technique seven years ago. The reason for reoperation was the leak from the suture lines of all anastomosis sites. Three sites of leak were closed putting sutures with pledgets. In case 2 the graft replacement of the ascending aorta was performed five years ago. The reason for reoperation was the persistent dissection from the aortic arch to the thoracic descending aorta due to the new entry formation at the site of the aortic clamp. At first the graft replacement of the thoracic descending aorta was performed, followed by arch replacement. As these conditions are preventable, we should perform the open distal anastomosis technique without using a clamp and graft replacement of aortic arch with the branched graft. Moreover, deep hypothermic circulatory arrest may appear to be a valuable adjunct for reoperation after operation on acute type A dissection.

[Objective]The present study investigated the relationship between subjective symptoms of katakori (shoulder stiffness) and shoulder hardness which was examined both with clinical palpation and a mechanical device, as well as the correlation between these two measurements.
[Methods]Subjects were enrolled to the study if they had a stiff shoulder on the day of the visit (katakori group, n = 60) or if they had no experience of katakori in their lifetime (non-katakori group, n = 10). The intensity of the katakori was evaluated with a visual analogue scale (VAS). Shoulder hardness was evaluated at acupoint Jianjing (GB21) and at the point where the subject felt the most intensive symptom by both palpation of experienced acupuncturists who were unaware of the allocation and a hardness meter. The method of acupuncture treatment was decided by acupuncturists who were not an evaluator of the hardness.
[Results and Discussion]There was no significant relationship in the hardness measured with the device and palpation between the katakori group and non-katakori group. Also, the intensity of katakori (VAS) and the changes after treatment showed no significant correlation with the hardness and its changes. These results support the validity of our clinical experience that patients who complain of severe shoulder stiffness do not always have a hard shoulder.

Cordyceps militaris has been known to produce an anticancer agent, cordycepin. Investigation on optimum culture condition for C. militaris had been performed. In the research program for discovering a novel function in the culture of C. militaris, the culture media was applied to a proliferation assays using various cell lines. The media showed significant anti-proliferative activities against al cell lines, especially to human leukemia cell line HL-60. The activity-guided purification of active ingredient was performed to obtain uracil. To the best of our knowledge, uracil has not been reported to possess anti-proliferative activity. However, the uracil obtained from the culture media was subjected to ICP-MS analysis to reveal that sodium, potassium and magnesium were found to co-exist with uracil, which might show anti-proliferative activity. Further study on the mechanism of the expression of the activity is now underway.

Aortoduodenal fistula is rare complication of nonoperative abdominal aortic aneurysm. We successfully treated a case of primary aortoenteric fistula associated with Behcet's Disease with two surgical intervention. The patient was 41 years old man. He admitted to our hospital because of severe shock due to enormous gastrointestinal hemorrhage. Emergency laparotomy revealed the inflammatory abdominalaneurysm ruptured into the duodenum. As the saccular aneurysm was densely adherent with duodenum and retoroperitoneum, graft replacement was abandoned. Primary closure of the perforated area of duodenum and the neck of aneurysm were performed. Axillofemoral bypass restored blood flow of the lower extremities. Three month after the operation, aortoduodenal fistula recurred. On the second operation, abdominal aorta was divided through retroperitoneal approach. However, primary closure of the enteric perforation with graft replacement of the aorta is considered as the first choice of the surgical treatment for aortoenteric fistula. In a case of difficult condition such as this patient with severe shock or retroperitoneal fibrosis, repair of the duodenum wall and division of the abdominal aorta with axillofemoral bypass is an alternative method of choice.

A 46-year-old man who developed fever and general fatigue was referred to our hospital with suspicion of infective endocarditis. A ventricular septal defect had been previously diagnosed. Transthoracic echocardiography revealed vegetation on the aortic, mitral, and pulmonary valves, and each valve had significant regurgitation. An emergency operation was performed because of congestive heart failure. The aortic and mitral valves were replaced with mechanical valves. The pulmonary valve was repaired ; the anterior leaflet was resected and replaced by glutaraldehyde-treated autologous pericardium. The patient's postoperative course was uneventful. Recurrence of infection was not observed for 3 years after the operation. Triple-valve endocarditis, especially that involving a combination of the aortic, mitral, and pulmonary valves, is rare. Involvement of multiple valves on both sides of the heart may be attributed to a congenital intracardiac shunt. Early surgical intervention may be useful to control infection and heart failure, as in the present case.