We report a very rare case of placement of a superior vena caval (SVC) filter for upper extremity deep venous thrombosis. A 67-year-old woman with left axillary pain was admitted. Lower extremity deep venous thrombosis was diagnosed. CT scan and venography revealed acute thrombosis of the left brachial, axillary, subclavian, common jugular and innominate veins. We performed thrombolytic therapy and placement of a temporary filter within the SVC, because CT scan and a ventilation-perfusion scan revealed pulmonary embolism. After one week, due to lack of improvement, we placed a Greenfield filter within the SVC. It is necessary to place a SVC filter in high risk patients if anticoagulation therapy fails or if there is recurrence, proximal/wide range thrombosis, or pulmonary embolism.

The effect of forearm and upper limb muscles vibration during extension and flexion movement of wrist and elbow was studied in 10 normal human subjects. In first experiment, a vibratory stimulation was applied to either the flexor carpi ulnaris (FCU) or the biceps brachii (BB) muscle during simple and simultaneous extension movement about wrist and elbow. In second experiment, vibratory stimulation was applied to either the extensor carpi radialis (ECR) or the triceps brachii (TB) muscle during simple and simultaneous flexion movement about wrist and elbow. The main new findings of the present study are as follows. During simple and simultaneous extension-flexion movements of the elbow, the application of vibration to the FCU or to the ECR produced an undershoot of the target position. However, no undershoot was observed by the application of vibration to the BB or the TB during simultaneous extension-flexion movements of the wrist. From these results, it was revealed that although there are cases where the phenomenon of undershoot resulting from vibration of the wrist and elbow during simple and simultaneous movements corresponds to the type of synaptic connection from muscle spindle group Ia sensory inputs to alpha motor neurons, as identified by Cavallari & Katz (1989) and Cavallari et al. (1992), the manifestation of undershoot is influenced by differences between the movement patterns of the wrist and elbow joints, as well as the differences between simple movement and simultaneous movement.

Bradycardia or asystole during epileptic seizure are referred to as ictal bradycardia syndrome. Ictal asystole is very rare, and there is no report about ictal bradycardia syndrome caused by brain metastases. A 62-year old man was diagnosed as having lung cancer and had multiple brain metastases. The patient had no history of epilepsy and syncope. The patient developed cardiac asystole with sinus arrest for up to 16 seconds. The bradycardia was associated with other signs and symptoms, including abdominal pain, nausea, low blood pressure, sinus arrest, decreased level of consciousness, and staring at a single point. Electroencephalograms showed multiple sharp waves. Repeated seizures, ictal asystole, and coexisting symptoms disappeared after improved treatment of brain metastases by radiation therapy. Therefore, a diagnosis of ictal asystole caused by brain metastases was made. There is no recommended treatment for ictal bradycardia syndrome. However, in the case of ictal bradycardia syndrome caused by brain metastases, treatment of the metastatic tumor might be useful. When patients with cancer present with syncope or sick sinus syndrome, we should consider the possibility of cardiac arrest caused by an epileptic seizure.

Object : The purpose of this study was to test the response of the decline in heart rate (HR) induced by compression on the eyeball (eyeball pressure : EP) and voluntary non breath (VNB) after pedaling exercise. Methods : EP ; Nine male subjects performed exercise for 3 min in a supine position using a bicycle ergometer. Immediately after the exercise all subjects received EP for 10 seconds. After that, subjects undertook the same protocol without EP (CON-E). VNB ; Four male and two female subjects performed exercise for 5 minutes using a bicycle ergometer. Immediately after the exercise subjects received VNB for 7 seconds. After that subjects undertook the same protocol without VNB (CON-V). Results : The slope of the decline in HR recovery (HR_DS) after exercise in EP increased significantly more than that in CON-E (p<0.05). However, time constant (HR_TC) in CON-E declined faster than that in EP. Thereby, the relationship between HR_DS in EP and HR_TC in CON-E correlated (r=-0.562). The HR_DS of VNB was greater than that of EP and CON-V. However the relationship between HR_DS in VNB and HR_TC in CON-V did not correlate. Conclusion : We suggest that EP affects vagal nervous activity and VNB affects strength of baroreflex sensitivity. Therefore HR_DS of EP might evaluate vagal nervous activity.

Background/Aims: The etiology of superficial non-ampullary duodenal epithelial tumors (SNADETs) remains unclear. Recent studies have reported conflicting associations between duodenal tumor development and Helicobacter pylori infection or endoscopic gastric mucosal atrophy. As such, the present study aimed to clarify the relationship between SNADETs and H. pylori infection and/or endoscopic gastric mucosal atrophy. Methods: This retrospective case-control study reviewed data from 177 consecutive patients with SNADETs who underwent endoscopic or surgical resection at seven institutions in Japan over a three-year period. The prevalence of endoscopic gastric mucosal atrophy and the status of H. pylori infection were compared in 531 sex- and age-matched controls selected from screening endoscopies at two of the seven participating institutions. Results: For H. pylori infection, 85 of 177 (48.0%) patients exhibited SNADETs and 112 of 531 (21.1%) control patients were non-infected (p<0.001). Non-atrophic mucosa (C0 to C1) was observed in 96 of 177 (54.2%) patients with SNADETs and 112 of 531 (21.1%) control patients (p<0.001). Conditional logistic regression analysis revealed that non-atrophic gastric mucosa was an independent risk factor for SNADETs (odds ratio, 5.10; 95% confidence interval, 2.44–8.40; p<0.001). Conclusions Non-atrophic gastric mucosa, regardless of H. pylori infection status, was a factor independently associated with SNADETs.

Objectives: Spiritual pain is not formally defined. The aim of this study was to clarify the beliefs about spiritual pain among Japanese palliative care physicians and liaison psychiatrists and to compare their beliefs. Methods: A nationwide questionnaire survey was conducted by mail August, 2019 on certified palliative care physicians and liaison psychiatrists. We asked 9 questions about spiritual pain (i.e. current status, definition, and the delivery of care) using a 5-Likert scale. Result: 387 palliative care physicians (response rate, 53%) and 374 psychiatrists (45%) responded. 72% (76% of the palliative care physicians/69% of the psychiatrists) reported that spiritual pain was distinct from depression, but 69% (66/71) reported that it was not defined adequately; and 59% (59/60) perceived the risks of using the words ambiguously. Only 43% (40/47) recommended the universal definition of spiritual pain, and opinions about how spiritual pain should be defined (i.e, higher being, meaning/value, or specific terms) differed among physicians. Perception about spiritual pain of the physicians were significantly associated with their religion, while beliefs about spiritual pain were essentially similar between palliative care physicians and psychiatrists. Conclusion: Although physicians regarded the definition of spiritual pain as being inadequate, the opinions about preferable definition differed among physicians. Discussion about the value of developing a consensus of spiritual pain is needed.

Objective：To assess the risk for hyperkalemia caused by treatment with angiotensin Ⅱ Type 1 receptor blockers （ARB） in clinical practice with Japanese medical database.Design：A cohort study in patients treated with ARB alone and those treated with calcium channel blockers （CCB） alone as control.Methods：The Diagnosis Procedure Combination （DPC） database provided by Medical Data Vision Co., Ltd. was used to identify patients who received a diagnosis of hypertension (ICD-10 codes, I10 to I15) and were treated with ARB or CCB from April 2008 to June 2017. A logistic regression model was applied to estimate adjusted odds ratios （OR） and their 95％ confidence intervals （CI） in these patients. The outcome in the logistic model was hyperkalemia （serum potassium≧5.5 mEq/L） and the covariates were sex, age, renal insufficiency, hepatic insufficiency, and baseline serum potassium levels. And, subgroup analysis was also performed in patients with and without renal insufficiency.Results：The incidence of hyperkalemia （per 1000 person-years） with ARB was 39.4 and that with CCB was 32.6. And, median periods from the index date to the date of occurrence of hyperkalemia for both exposure and control groups were 36 days （Min-Max：12-85） and 51.5 days（Min-Max：8-88）respectively. However, treatment with ARB was not associated with occurrence of hyperkalemia （OR 1.26, 95％CI： 0.58-2.75). The risk for hyperkalemia among those with renal insufficiency was higher （OR 3.31, 95％CI： 1.39-7.88）and as baseline serum potassium increased, the risk increased as well （OR 9.20, 95％CI： 3.52-24.10). And, the subgroup analysis also showed that rare occurrence of hyperkalemia by ARB and elevation risk for hyperkalemia by baseline serum potassium.Conclusion：The clinical data showed rare occurrence of hyperkalemia caused by ARB, indicating that renal insufficiency and baseline serum potassium levels affected the onset of the disease in clinical practice. Previous studies also reported the effects of renal insufficiency and other factors on the onset of hyperkalemia. ARB should be prescribed carefully in patients with these factors, as is conventionally done.