Purpose: We report two patients receiving high doses of systemic opioids in whom gradual switching of the opioid administration route from systemic to intrathecal provided satisfactory pain relief without excessive sedation or withdrawal symptoms. Case reports: In one of the patients, who was already receiving 500mg morphine intravenously but still suffered from right upper quadrant pain, it was difficult to increase the opioid dosage according to the WHO guidelines because of intolerable side effects. The other patient, in spite of taking a combination of systemic opioids equivalent to 760mg oral morphine, had inadequate pain relief and could not continue receiving home medical care. In both cases we could successfully change from systemic to intrathecal opioid administration in a step-wise manner without deterioration of pain control, adverse effects due to over dosage, or withdrawal symptoms. Intrathecal opioid administration also reduced drowsiness and improved daily activity. Conclusion: Currently, there are no guidelines for change of route of opioid administration from systemic to intrathecal administration and few published reports have concretely documented opioid route switching in Japan. A carefully planned, step-wise switching of opioid administration route from systemic to intrathecal should be considered in patients who are already taking high doses of systemic opioids. Palliat Care Res 2009; 4(1): 317-320

We report a patient with candidemia, and remote organ infection, who underwent surgical treatment of aortic valvular stenosis. The patient was a 77-year-old man. Candida glabrata was detected in a blood culture during pharmacological treatment for pyelonephritis associated with vesicoureteral transition stenosis. A ureteral stent had been placed to preserve urine outflow, and vesicoureteral surgery had been scheduled. However, the urological surgery had to be performed first because of severe aortic valvular stenosis. After long-term (5 months) of antifungal treatment, Candida was no longer detected in the urine or blood cultures, but the serum β-D-glucan level did not fall below the reference value (21.6 pg/ml at the last measurement). It was difficult to control the infection further, and we decided to perform aortic valve replacement. There was no evidence of endocarditis at surgery, but pathological examination revealed traces of the fungus in the tissue of the aortic valve. The post-operative course was uneventful, and urological surgery was carried out 45 days later. Infection recurred when the antifungal medication was temporarily discontinued. The infection was then controlled by resumption of the antifungal medication. The patient has been free of recurrence for the past year since the aortic valve replacement. In the present case, in which a mycosis from a remote source was not readily eradicated prior to valve replacement, we were able to obtain good results by first administering long-term antifungal medication to quell the inflammation as much as possible.

The laxity of shoulder is one of main factors affecting shoulder lesions in athletes.
To measure the anterior-posterior laxity of shoulder, a stress machine was arranged because the ordinary rentogenographic measurement is not suitable. The measurement of the anterior-posterior laxity was done with athletes in several kinds of sports in which shoulder joints are mainly used. The result was compared with those from clinical examinations and stress rentogenography. Conclusions :
1. The anterior-posterior displacements of the affected side in baseball, volleyball and javelin players were significantly larger than that of the control side.
2. For the anterior-posterior displacement of the shoulder joint, baseball, volleyball and javelin players showed significantly larger values than truck runners as the control whereas significantly smaller values were found in water polo players.
3. There was no correlation between the anterior-posterior laxity and the inferior laxity.

We surveyed the working environment, the degree of satisfaction and the educational methods targeting under forty congenital cardiac surgeons in Japan. We herein report the results of this survey. Summary of this work was presented at the 2018 CHSS Japan Congress, Tokyo, Japan.

Aim To investigate the molecular mecha-nism of mTORC1/2 inhibitor PP242, which inhibiting cholangiocyte cell preliferation and cystic diliatation via inducing apoptosis and autophagy in the polycystic kid-ney ( PCK ) rats. Methods The expression of p-mTOR and p-Akt in the bile duct epithelial cells was examined by immunohistochemistry. The inhibiting effect of rapamycin and PP242 on cell proliferation ac-tivity on bile duct epithelial cells, the effect of gene si-lence on LC3, Beclin-1 and the effect of the authoph-agy-specific inhibitor 3-methyladenine (3-MA) on cell proliferation were respectively analyzed by WST-1 as-say. The expression of PI3K/Akt signaling pathway re-lated proteins, autophagy-related proteins LC3, Bec-lin-1 and clevead caspase-3, which were treated by PP242 were determined by Western blot. The effect of PP242 on apoptosis was detected by Annexin V/PI double staining and ELISA. The expression of LC3 in cytoplasm was detected by immunofluorescence. The a-bility of rat bile duct epithelial cells spheroid formation was detected by 3D cell culture method, and the cells were treated by single applied with rapamycin and ap- plied rapamycin combined with Rictor gene silencing respectively. Results The protein levels of p-Akt and p-mTOR markedly increased in the bile duct epitheli-um of PCK rats. PP242 inhibited the proliferation of bile duct epithelial cells more effectively than rapamy-cin and showed a dose-and time-dependent manner ( P<0.05 ) . PP242 significantly reduced the levels of PI3K/Akt signaling pathway-related proteins in PCK rat cholangiocytes. PP242 induced apoptosis and auto-phagy, up-regulated the levels of cleaved caspase-3, Beclin-1 and increased the ratio of LC3-II/LC3-I. The combination of Rictor gene silencing and rapamycin was more effective than rapamycin alone in inhibiting cholangiocytes in PCK rats. The inhibitory effect of PP242 on the cell viability was significantly weakened by treatment with 3-MA and knockdown of LC3 and Beclin-1 ( P <0.05 ) . Conclusions PP242 inhibits the proliferation of PCK rat cholangiocytes through PI3K/Akt/mTOR signaling pathway, and the mecha-nism is closely related with autophagy and apoptosis.