Objective: In comparison with laparoscopic transperitoneal para-aortic lymphadenectomy, the advantages of laparoscopic extraperitoneal para-aortic lymphadenectomy (ePAL) are that the operative field is not obstructed by bowel and the Trendelenburg position is not required [1]. The ePAL technique has been adopted to the robotic surgery with the da Vinci Xi. There are only a few reports demonstrating the technical feasibility of robot-assisted ePAL (RAePAL) [2,3]. This report describes the new surgical technique of RAePAL with the bipolar cutting method. Methods: The patient was a 53-year-old woman diagnosed as ovarian clear cell carcinoma (CCC) after left salpingo-oophorectomy. As the re-staging surgery, robot-assisted right salpingo-oophorectomy, hysterectomy, omentectomy, and pelvic lymphadenectomy were planned following ePAL. The patient was placed in the supine position and tilted 5 degrees to the right. Three da Vinci arms were docked at the patient's left side (Fig. 1). The bipolar cutting method was performed by with the surgeon's right hand. An AirSeal® port (ConMed, Utica, NY, USA) was placed on the side near the assistant. After the para-aortic space was expanded, lymphadenectomy was performed up to the renal veins with the bipolar cutting method. Results: The PAL operative time was 155 minutes, estimated blood loss was 25 mL. The patient developed no perioperative complications, and the postoperative diagnosis was stage IC1 ovarian CCC with no pelvic (n=0/42) and para-aortic lymph nodes (n=0/59) metastasis. Conclusion RAePAL with the bipolar cutting method was technically feasible. Performing lymphadenectomy between the aorta and the vena cava was facilitated by the articulated robotic arm.

To clarify characteristics of home care in rural areas in Japan, we investigated the actual status of home care in a rural area (Asuke town, Asahi town, Inabu town, northern part of Toyota city and Shimoyama village) in Aichi prefecture. The subjects were 149 patients who were under medical care and nursing supervision at home for the last 2 years and a half. Age, sex, ADL, prognosis, principal care-givers of the patients and distance from patients' houses to our hospital were compared with the average data of all the nurse stations in Japan (1996). The percentage of patients over 90 years old was 23.4% in this area as against 13.5% of the national average. Sex and ADL levels were similar to the average. The proportion of females as principal care-givers of patients was 80%, which is about average. However, the proportion ofdaughters-in-law was 51.7%, double of the national average. In 48 cases (32%), the time required to get to the hospital by car was over 31 min. This ratio was 3 times higher than that of the average data, and it took 50 min from farthest patient's house (35km). In prognosis, 66 patients died-44 cases (67%) in hospital and 22 cases (23%) at home.
Our questionnaire survey regarding patients' and care-givers' wishes was responded to by 38 of 47 principal care-givers who utilized our home care and nursing survice program. One half of care-givers were over 60 yearsold and had taken care of a patient for over 5 years. Mental stress, feeding and toileting were major problems most principal care-givers cited. However, they required services at a day-care institution for elderly patients and recovery of used paper diapers. Death at home was wished by 23 (61%) patients and care-givers, if they received enough medial care and welfare services.
These findings revealed that elderly people take care of elderly patients, their houses are far from the hospital and they wish to die at home. More collaboration among all providers of medical care and health and welfare services, and the establishment of an information network are necessary to improve these problems, resulting in safe, acceptable and satisfied home care for patients and care-givers.

OBJECTIVESThe present study investigated the involvement of oxidative stress in the degeneration of the cerebellum during methylmercury (MeHg) intoxication and the protective effect of α-tocopherol (Vit E) against MeHg toxicity.

METHODSAfter 5 mg/kg of MeHg was administered to Wistar rats for 12 consecutive days, the cerebellum were examined histopathologically. In addition, the same amount of MeHg was administered to 3 different groups of Wistar rats: rats with a Vit E-deficient diet, rats fed 150 mg/kg of Vit E for 20 consecutive days after initial MeHg administration, and rats with an ordinary diet.

RESULTSPositive immunoreactivity against anti-hydroxynonenal (HNE), a marker of lipid peroxidation, was observed in the cerebellum after MeHg administration. Levels of thiobarbituric acid reactive substance (TBARS), another marker of lipid peroxidation, and those of protein carbonyl, a biomarker for protein oxidation, increased after MeHg administration. In the rats with MeHg and a Vit E-deficient diet, mortality and prevalence of piloerection significantly increased, and in the rats with MeHg and Vit E, mortality, piloerection, retracted and crossed hind leg, and ataxic gait significantly decreased, compared with the rats with MeHg alone. The levels of NO(2) (-) and NO(3) (-) in the serum significantly increased in the rats with MeHg alone 14 days after the initial MeHg administration, but were significantly suppressed by Vit E administration.

CONCLUSIONSOxidative stress, especially lipid peroxidation, may play an important role in the cerebellar degeneration process during MeHg intoxication and Vit E may play a protective role against MeHg toxicity as an effective antioxidant.

Methods: The study included 100 patients with cervical myelopathy who underwent surgery at the National Center for Geriatrics and Gerontology in Obu, Japan from June 2010 to March 2013. Before the surgery, neck pain was evaluated using a Visual Analog Scale (a score ≥50 indicated neck pain and a score <50 indicated no neck pain). The preoperative cross-sectional areas of the trapezius muscles were measured with cervical magnetic resonance imaging sagittal T2-weighted images. Cranial stimulation under general anesthesia was used to derive the MEPs, enabling the measurement of latency and amplitude, using preoperative MEPs of the trapezius muscles. Results: The MEP of the trapezius muscle in patients with neck pain had significantly shorter latencies than those in patients who did not have neck pain. However, there was no significant difference in the amplitude between patients with and without neck pain. However, this tended to be greater in patients with neck pain as compared to that in those without neck pain. The cross-sectional area of the trapezius muscle in patients with neck pain was significantly smaller than that in those who did not have neck pain. Conclusions MEPs revealed electrophysiological abnormalities of the trapezius muscles in patients with neck pain, supporting a relationship of neck pain with the trapezius muscles.

Methods: A total of 79 patients with cervical myelopathy who underwent cervical laminoplasty at our facility between June 2010 and March 2013 were included in this study. Intraoperative control and final waveform were evaluated based on the trapezius muscle MEPs by measuring the latency and amplitude. A neck pain group comprised patients with higher neck pain Visual Analog Scale scores from preoperative value to 1 year postoperatively. The cross-sectional areas of the trapezius muscles and the MEP latencies and amplitudes were compared between patients with and without neck pain. Results: The latency and amplitude of the control waveforms were not significantly different between groups. The neck pain group had a significantly shorter final waveform latency (neck pain: 23.6±2.5, no neck pain: 25.8±4.5; p =0.019) and significantly larger amplitude (neck pain: 2,125±1,077, no neck pain: 1,630±966; p =0.041) than the no neck pain group. Conclusions Postoperative neck pain was associated with the final waveform latency and amplitude of the trapezius muscle MEPs during cervical laminoplasty. Intraoperative electrophysiological trapezius muscle abnormalities could cause postoperative neck pain.

Results: The study included 101 patients (84 females) with a median follow-up period of 23.6±14.2 months. The persistence rate declined to 85.3%, 78.3%, 74.1%, 71.3%, and 69.3% at 12, 24, 36, 48, and 60 months, respectively. Age at the initiation of denosumab therapy differed significantly between non-persistent (n=31) and persistent (n=70) patients (81.3 vs. 72.8 years, p <0.01). Persistence was significantly lower in patients aged ≥80 years than in those aged <60 and 60–79 years (both p <0.01). The reasons for non-persistence of denosumab therapy were transfer to another hospital (n=13), interruption of outpatient visits (n=11), dental treatment (n=4), adverse events (n=2), and patient request (n=1). Conclusions Persistence was significantly lower in patients aged ≥80 years than in patients of other ages, and strategies promoting persistence are needed for these elderly patients.

Methods: The subjects were 23 children with LLD ≥20 mm (range, 27–65 mm) treated at Nagoya University Hospital between 2007 and 2017. Whole spine posteroanterior standing radiographs and whole lower limb radiographs in a supine position were recorded. Data were collected for demographics, LLD, Cobb angle, pelvic obliquity, and Nash/Moe index. Scoliosis was defined as a Cobb angle ≥10°. Leg length was measured from the top of the femoral head to the middle of the tibial plafond, and LLD was defined as the difference between the left and right leg lengths. Results: The patients (nine males and 14 females) had a mean age of 14.0 years (range, 5–18 years). The average LLD was 44.3±17.2 mm, with LLDs of 20 to 39 mm, 40 to 59 mm, and ≥60 mm in 13, five, and five subjects, respectively. The average Cobb angle was 13.0°±7.0°, and 15 subjects (65%) had scoliosis. Convexity of the scoliosis was to the short leg side in all cases. The Cobb angle was significantly related to the severity of the LLD (R=0.736, p<0.01), pelvic obliquity (R=0.966, p<0.01), and Nash/Moe index (p<0.05). Conclusions LLD is a common pediatric condition that can cause scoliosis of the spine. Severe scoliosis may develop if the LLD is ≥30 mm. Long-term studies are needed to examine the effect of LLD resolution on the elimination of scoliosis.