A 13-year-old girl was admitted to our hospital with a history of syncope after exercise. Neither left ventricular (LV) function nor hypertrophy was detected by transthoracic echocardiography. However, 24-h Holter electrocardiogram demonstrated ST segment depression with increasing heartbeat. Exercise ²⁰¹Tl myocardial scintigram also demonstrated ischemia of the anterior LV wall. Multi-slice coronary computed tomography (CT) demonstrated hypoplasia of the left main coronary artery. The syncope on exertion was ascribed to myocardial ischemia due to hypoplasia of the left main coronary artery. We performed off-pump coronary artery bypass graft (CABG) (left internal thoracic artery-left descending artery). The postoperative course was uneventful and postoperative stress ²⁰¹Tl myocardial scintigram demonstrated the absence of myocardial ischemia. Coronary CT demonstrated good graft patency. To date, there has not been any recurrence of syncope on exertion. We herein report a successful off-pump CABG for a patient with syncope due to hypoplasia of the left main coronary artery. Syncope on exertion due to hypoplasia of the left main coronary artery is very rare. However, certain forms of congenital coronary anomalies are associated with adverse cardiac events, including sudden cardiac death. The diagnosis, therefore, can be important and CABG is indicated, especially when there is repetitive syncope due to myocardial ischemia.

The activated clotting time (ACT) is used to assess adequacy of anticoagulation during cardiopulmonary bypass (CPB). However, ACT values during CPB do not correlate with heparin concentration and are affected by variations of such factors as hypothermia and hemodilution. ACT is also used to estimate protamine doses, because excess protamine may result in hypotension and an increase in bleeding after CPB. This study was designed to evaluate the effect of heparin and protamine administration that were administered based on whole blood heparin concentration using Hepcon/HMS (HC group) on the incidence of bleeding and blood transfusion after CPB. We treated 32 of adult cases and 36 pediatric cases. For the control group (NC group), an initial fixed dose of 300U/kg heparin was administered and if the ACT was less than 400s an additional fixed dose of 100U/kg heparin was administered. Heparin was neutralized with an initial fixed dose of protamine. For the HC group, the initial dose of heparin and the additional dose of heparin were based on an automated heparin dose response assay. The initial dose of protamine was based on the residual heparin concentration. The patients in the HC group received greater doses of heparin and lower doses of protamine than the patients in the NC group. In the pediatric HC group, the amount of TAT, FTC and D-dimer post CPB were smaller than those in the NC group. Operative time and closure time were similar the two groups. Operative bleeding, mediastinal chest tube drainage in the postoperative period were similar in the two groups. The volume of total blood transfusion was also comparable in the two groups. In conclusion, the monitoring of heparin concentration during CPB in children was effective for the maintenance of coagulation factors.

Purpose: Re-irradiation is a treatment option for recurrent esophageal cancer patients with a history of radiotherapy, but there is a risk of severe late adverse effects. This study focused on the efficacy and safety of re-irradiation using hyperfractionated radiotherapy. Materials and Methods: Twenty-six patients who underwent re-irradiation by the hyperfraction technique using twice-daily irradiation of 1.2 Gy per fraction for recurrent esophageal cancer were retrospectively included in this study. The overall survival period after the start of secondary radiotherapy and the occurrence of late adverse effects were investigated. Results: Of 26 patients, 21 (81%) received re-irradiation with definitive intention and 21 (81%) underwent concurrent chemotherapy. The median re-irradiation dose was 60 Gy in 50 fractions in 25 treatment days, and the median accumulated irradiation dose in equivalent dose in 2 Gy per fraction was 85.4 Gy with an α/β value of 3. The median interval between two courses of radiotherapy was 21.0 months. The median overall survival period was 15.8 months and the 1-year and 3-year overall survival rates were 64.3% and 28.3%, respectively. Higher dose of re-irradiation and concurrent chemotherapy significantly improved survival (p < 0.001 and p = 0.019, respectively). Severe late adverse effects with the Common Terminology Criteria for Adverse Events grade 3 or higher were observed in 5 (19.2%) patients, and 2 (7.7%) of them developed a grade 5 late adverse effect. Conclusion High-dose re-irradiation using a hyperfractionated schedule with concurrent chemotherapy might be related to good prognosis, while the rate of late severe adverse effects is not high compared with the rates in past reports.

Methods: In total, 155 consecutive patients who underwent muscle-preserving consecutive double laminectomies for cervical spondylotic myelopathy from 2005 to 2013 were included in this study. The imaging parameters included the C2–C7 angle, range of motion, C2–C7 sagittal vertical axis (SVA), C7 slope, C2–C5 angle, C5-C7 angle, local disk angle caudal to the decompression level, and the disk height between C2/C3 and C7/Th1. Results: The caudal disk angle of the decompression level decreased after consecutive double laminectomies, thus suggesting that the extension unit maintained the local lordosis at the lower disk of the decompression level. Postoperatively, in the C3–4 decompression cases, the C2–C7 angle decreased by 7.3°, and the C2–C7 SVA increased by 8.6 mm, thus indicating the appearance of an alignment disorder. Multivariate logistic regression analysis showed that cephalad laminectomy was a risk factor for C2–C7 angle decreases >10°. However, the postoperative recovery rate of Japanese Orthopedic Association scores after consecutive double laminectomies was reasonable, and the overall cervical alignment was well maintained in all decompression levels except C3–C4. Conclusions The cervical extension unit maintained lordosis at the disk caudal to it. The extension unit was found to contribute more to the maintenance of lordosis of the entire cervical spine at the cephalad side.

Methods: The images of 83 patients with cervical single-level spondylolisthesis were studied. We looked at 52 slipped levels for anterior slippage and 31 for posterior slippage. The imaging parameters included slippage in the neutral, flexed, and extended positions, axial facet joint orientation, sagittal facet slope, global cervical alignment, C2–C7 angle, C2–C7 sagittal vertical axis, range of motion (ROM), and slipped disc angle ROM. Results: With the narrowing of the intervertebral disc height, slippage in the flexed position of both anterior and posterior spondylolisthesis increased. However, in both anterior and posterior spondylolisthesis, disc height narrowing did not show stability. The narrowing of the intervertebral disc height was found to be a risk factor for a translation of slippage of 1.8 mm or more in flexionextension motion in anterior spondylolisthesis in multivariate regression analysis. Conclusions Narrowing the intervertebral disc height did not stabilize the translation of slippage in flexion-extension motion in cervical spondylolisthesis. Instead, narrowing of the disc height was associated with a translation of slippage of 1.8 mm or more in flexion-extension motion in cases of anterior slippage. Therefore, we discovered that degenerative cascade stabilization for cervical spondylolisthesis was difficult to achieve.

Purpose: Gastric neoplasia is a common manifestation of familial adenomatous polyposis (FAP). This study aimed to elucidate the clinical characteristics, endoscopic features including fundic gland polyposis (FGPsis), and treatment outcomes of gastric neoplasms (GNs) in patients with FAP. Materials and Methods: A total of 35 patients diagnosed with FAP, including nine patients from four pedigrees who underwent esophagogastroduodenoscopy (EGD), were investigated regarding patient characteristics, GN morphology, and treatment outcomes. Results: Twenty-one patients (60.0%) had 38 GNs; 33 (86.8%) and 5 (13.2%) were histologically diagnosed with adenocarcinoma and adenoma, respectively. There were no specific patient characteristics related to GNs.Nodule-type GNs were more prevalent in patients with FGP than without (52.2% vs. 0.0%, P=0.002) in the upper body of the stomach. Conversely, depressed-type GNs were fewer in patients with FGPsis than in those without (13.0% vs. 73.3%, P<0.001). Slightly elevated-type GNs were observed in both groups (34.8% vs. 20.0%, P=0.538). Even within pedigrees, the background gastric mucosa and types of GNs varied. In total, 24 GNs were treated with endoscopic submucosal dissection (ESD) and eight with endoscopic mucosal resection (EMR). EMR was selected for GNs with FGPsis because of the technical difficulty of ESD, resulting in a lower en bloc resection rate (62.5% vs. 100%, P=0.014). Conclusions Our study indicates the necessity of routine EGD surveillance in patients diagnosed with FAP. Notably, the morphology and location of GNs differed between patients with and without FGPsis. Endoscopic treatment and outcomes require more attention in cases of FGPsis.

Objective: To examine the efficacy and safety of an innovative, device-driven abdominal trunk muscle strengthening program, with the ability to measure muscle strength, to treat chronic low back pain (LBP) in elderly participants. Methods: Seven women with non-specific chronic LBP, lasting at least 3 months, were enrolled and treated with the prescribed exercise regimen. Patients participated in a 12-week device-driven exercise program which included abdominal trunk muscle strengthening and 4 types of stretches for the trunk and lower extremities. Primary outcomes were adverse events associated with the exercise program, improvement in abdominal trunk muscle strength, as measured by the device, and improvement in the numerical rating scale (NRS) scores of LBP with the exercise. Secondary outcomes were improvement in the Roland-Morris Disability Questionnaire (RDQ) score and the results of the locomotive syndrome risk test, including the stand-up and two-step tests. Results: There were no reports of increased back pain or new-onset abdominal pain or discomfort during or after the device-driven exercise program. The mean abdominal trunk muscle strength, NRS, RDQ scores, and the stand-up and two-step test scores were significantly improved at the end of the trial compared to baseline. Conclusion No participants experienced adverse events during the 12-week strengthening program, which involved the use of our device and stretching, indicating the program was safe. Further, the program significantly improved various measures of LBP and physical function in elderly participants.

Methods: This study analyzed 143 patients who underwent decompression surgery between 2012 and 2014, who had symptomatic cervical disorders and MRI evidence of spinal cord or nerve compression but had no history of cervical spine surgery. Patient demographics, disease type, Japanese Orthopedic Association score, and follow-up periods were recorded. Spinal surgeons conducted radiological evaluations to determine stenosis levels using computed tomography myelography or MRI in neutral and extended positions. Measurements such as dural tube and spinal cord diameters, cervical alignment, range of motion, and various angles and distances were also analyzed. The residual space available for the spinal cord (SAC) was also calculated. Results: During extension, new stenosis frequently appeared caudal to the stenosis site in a neutral position, particularly at C5/C6 and C6/C7. A low SAC was identified as a significant risk factor for the development of new stenosis in both the upper and lower adjacent disc levels. Each 1-mm decrease in SAC resulted in an 8.9- and 2.7-fold increased risk of new stenosis development in the upper and lower adjacent disc levels, respectively. A practical SAC cutoff of 1.0 mm was established as the threshold for new stenosis development. Conclusions The study identified SAC narrowing as the primary risk factor for new stenosis, with a clinically relevant cutoff of 1 mm. This study highlights the importance of local factors in stenosis development, advocating for further research to improve outcomes in patient with cervical spine disorders.

Objective: To keep medical costs down, it is important to promote the use of generic drugs at pharmacies, where prescription volumes are high. However, many parents do not opt for generic drugs. This study examines the effectiveness of pharmacists’ explanations to parents, with the aim of promoting the use of generic drugs among young patients under the age of 20.Method: A questionnaire-based survey was conducted from November 25 to December 1, 2019, at 129 pharmacies.Results: During the survey period, 91 pharmacies received 4,491 prescriptions from young patients. The percentage of generic drugs dispensed per prescription was lower for the young patients than for adult patients (65.4% vs. 70.4%; p < 0.001). Statistically, the percentage of prescriptions dispensed using generic drugs was higher in pharmacies that explained costs, equivalence of quality and efficacy, safety, side effects, and the trial system (divided dispensing), compared to pharmacies that did not use these explanations. Conversely, the percentage of prescriptions dispensed using generic drugs was lower at pharmacies that explained dosage form and ease of swallowing. Many pharmacies explained the equivalence of quality and efficacy (85.7%), with many questions from parents (82.4%). However, only a few pharmacies explained the trial system (divided dispensing) (1.1%), with no questions raised by parents (0.0%).Conclusion: This study found that pharmacists’ explanations are effective in promoting the use generic drugs for young patients. However, there is a lack of awareness among parents about the trial system (divided dispensing), and public institutions and pharmacists are not responding appropriately. To promote generic drug usage among young patients, it is important to develop educational tools regarding the trial system (divided dispensing), create awareness campaigns for parents, and revise medical fee. Furthermore, to ensure safe drug therapy, pharmacists should also provide information on the appearance and taste of generic drugs.

Objective: The proportion of young patients in Japan in whom generic drugs are used is lower than that of other age groups. To promote the use of generic drugs in young patients, we need to change the parents’ attitude toward generic drugs. Therefore, we aimed to contribute to the maintenance and reform of the Japanese social security system by investigating the effects of parent’s sex, patient’s age, and use of the children’s medical expense subsidy system on the selection of generic drugs. Method: We surveyed parents of young patients (<20 years) whose prescriptions were filed at pharmacies from November 25 to December 1, 2019. Results: Of the 712 valid questionnaires retrieved, 74.3% of parents reported using generic drugs for young patients. Approximately 92.2% of the parents reported using the children’s medical expense subsidy system. The highest (51.4%) reason for switching to generics was “recommendation from a pharmacist, etc.” Cognitive methods using online content were higher among male parents than among female parents (28.0% vs. 11.5% ; P<0.001). Regarding catchphrases that make them want to hear, female parents were more likely to hear about generic drugs than male parents were if the catchphrases quality and safety were used (38.1% vs. 23.8% ; P＝0.007). Compared to parents of 7-19-year old children (6.8%), parents of 0-6-year old children (13.1%) reportedly switched to generic drugs because they were easier to ingest (P＝0.022). Conclusion: Recommendations from medical professionals such as pharmacists are effective in convincing parents of young patients to switch to generic drug use. To promote the use of generic drugs in young patients, in addition to explaining and publicizing its financial benefits, pharmacists need to explain the added value of generic drugs such as the ingenuity of its dosage form. In addition, it is essential to adopt a multifaceted approach that considers the parents’ background including (1) publicity using the internet for male parents, (2) reaching out to female parents with preschool children, (3) increasing publicity using tickets for children’s medical expenses subsidy system, and (4) drug education that matches the growth of children.