The patient was a female in her 60's with Parkinson's disease. She had lateral trunk flexion, which was suspected to be caused by drug-induced dystonia with Pramipexole. Even one month after withdrawal of the drug, the condition didn't improve. Therefore, physical therapy was initiated. Chief complaints were pain of the left trapezius and erector spine, and inability to walk for a long time. Dystonia of oblique muscles caused lateral trunk flexion. Lateral trunk flexion caused the secondary pain of left trapezius and erector spine for compensation. Physical therapy using a sling was carried out to practice relaxation of the right oblique muscles and contraction of the right erector spine without conpensation of the left side. Standing position and gait training were done shoe height on the right side. After 7 months, pain of the left trapezius and erector spine dissapeared during rest and housework. Gait duration increased to over 1 hour. QOL (SF-36) was improved on all of 8 scores.

Objective: For safe use of drugs, it is indispensable to carry out proper and continuous risk management throughout preclinical to post-marketing phases.  In Japan, denosumab, a novel anti-RANKL antibody for treatment of bone metastasis, was approved in April 2012.  Since beginning of clinical use, severe hypocalcemia has been reported as adverse drug reactions.  In this study, the role of pharmacists in minimization of risks of newly introduced drugs was examined using denosumab as an example.
Methods: Firstly, the description on prevention of hypocalcemia in approval review report and different versions of drug package inserts of denosumab were compared.  Secondly, the differences in ratio of hypocalcemia in patients using denosumab with or without concomitant use of Ca and vitamin D preparations in Kobe City Medical Center General Hospital between April 2012 and July 2013 were examined.
Results: During the few months after beginning of clinical use of denosumab, many cases on the onset of severe hypocalcemia induced by denosumab had been reported.  Therefore, drug package insert was revised to enhance and recommend Ca and vitamin D supplementation.  Before the in-house enforcement in our hospital, of 26 patients, 6 patients were administered with denosumab without Ca and vitamin D preparations and 2 of them developed hypocalcemia over Grade 3.  After the in-house enforcement, no significant changed in serum Ca level in the 20 patients with Ca and vitamin D preparations were observed.
Discussion: Severe side effects can be avoided if hospital pharmacists take appropriate measures based on rational evaluation of proper information.
Conclusions: For risk minimization, pharmacists must evaluate and manage the risks of newly introduced drugs.

A 74-year-old man had been taking warfarin for atrial fibrillation, but warfarin was discontinued due to upper gastrointestinal bleeding. One week later, left hemiplegia occurred, and cranial magnetic resonance imaging revealed multiple cerebral infarctions. Systemic examination revealed thrombi in both atria as well as duodenal cancer. Because all of the thrombi in both atria were larger than 30 mm in diameter, the risk of embolism or sudden death was assumed to be high. Although the use of cardiopulmonary bypass for cancer patients is controversial, bilateral atrial thrombectomy was performed 4 weeks after cerebral infarction onset because reasonable survival duration was expected with surgery for duodenal cancer after thrombectomy and further treatment. The timing of and indications for surgery in this case are discussed.

A typical feature of mid-ventricular obstructive hypertrophic cardiomyopathy (MVO-HCM), is obvious hypertrophy of the mid-ventricular muscle and ventricle with transformation into the shape of an hourglass. We report a 60-year-old woman who had been given a diagnosis of apical type hypertrophic cardiomyopathy 12 years previously, but it changed to MVO-HCM with apical left ventricular aneurysm. We considered the impending rupture of the aneurysm because its wall was thin and pericardial effusion was detected by UCG (ultrasonic cardiograph). Urgent surgery was performed consisting of ventricular aneurysmectomy and patch reconstruction. After the surgery, a pseudoaneurysm was found in cardiac apex, so we performed surgery again. A residual shunt in the trabeculation caused the pseudoaneurysm, but its origin was not clear. She has been fine for 18 months without complications such as recurrence of aneurysm, ventricular arrhythmia or left ventricular dysfunction since the last surgery.

Between January 1994 and October 2004, 87 patients underwent emergency thoracic aortic surgery. Of these, 11 patients were more than 80 years old (O-group) and 76 were less than 80 years old (Y-group). A total of 58 patients (6 in O-group and 52 in Y-group) were treated for acute type-A aortic dissection, 5 (0 in O-group and 5 in Y-group) for acute type-B aortic dissection and 21 (4 in O-group and 17 in Y-group) for the involved rupture of a thoracic aortic aneurysm. The operative procedures consisted of the replacement of either the ascending, or the ascending and transverse aorta in 71 patients (8 in O-group and 63 in Y-group), and the replacement of the distal descending aorta in 15 patients (3 in O-group and 12 in Y-group). The operative mortality rates were 27.2% (3 patients) and 19.7% (15 patients) in the O- and Y-groups, respectively, with no significant difference between the groups. The rate of early complications, including circulatory failure, respiratory failure and cerebral infarction, did not statistically differ between the 2 groups. The overall 2-year survival rates of the patients who survived the operation were 83.3% in the O-group and 95.1% in the Y-group. Moreorer, 75% of the patients (6 of 8) who survived the surgery regained normal activities of daily life after the surgery, at a level similar to before the surgery. The present data indicates that emergency thoracic aortic surgery can be justified in selected in octogenarian patients.

The collagen gel droplet-embedded culture drug sensitivity test (CD-DST) identifies effective anticancer drug using resected tumor specimen, enabling tailor-made chemotherapy for a rare tumor. We report a case of the patient with leiomyosarcoma originating in the inferior vena cava, to which CD-DST was applied. This application has not been previously reported to the best of our knowledge. A 61-year-old woman consulted a nearby hospital because of abdominal pain. Computed tomography revealed an inferior vena cava tumor. The tumor was resected with the inferior vena cava, which was reconstructed with a 16 mm ePTFE graft. The tumor was diagnosed as leiomyosarcoma histopathologically. CDDP, VP-16, ADR, and VDS were CD-DST showed the tumor to be sensitive. Her postoperative course has been good without recurrence of tumor for 6 months, and the results of CD-DST may be helpful for chemotherapy strategy in case of recurrence.

Constipation is one of the most common symptoms seen in elderly people, and is sometimes difficult to treat. Daikenchuto is a well-known Kampo formulation for treating ileus. Here, we report a case in which daikenchuto was not effective and constipation was effectively treated with kobokushokyohangeninjinkanzoto. The patient was an 81-year-old woman who had been hospitalized for treatment of a thighbone fracture. She was originally constipated, and her constipation had worsened over the course of hospitalization. Colonoscopy examination and abdominal computerized tomography showed no structural lesions. Her constipation improved after the administration of daikenchuto, but the improvement was transient. Since the constipation and abdominal distension worsened after she began eating again, we administered kobokushokyohangeninjinkanzoto. Subsequently, her condition improved remarkably. Eight days later, we changed the initial kobokushokyohangeninjinkanzoto to ninjinto and hangekobokuto. Her complaint did not recur, and she was discharged 17 days later. In case of deficiency pattern ileus, kobokushokyohangeninjinkanzoto may be considered as an alternative to daikenchuto. Furthermore, we believe that the combination of ninjinto and hangekobokuto is an effective alternative to kobokushokyohangeninjinkanzoto.

We describe two cases of cardiac failure in elderly patients successfully treated with shimbuto. Case 1 was that of an 84-year-old man with severe aortic stenosis and liver cancer. His cardiac failure led to repeated hospitalization. After taking shimbuto, his pleural effusion decreased and cardio thoracic ratio improved. Case 2 was that of an 84-year-old man who was hospitalized because of cardiac failure and aspiration pneumonia after undergoing an operation for lung cancer. After taking shimbuto, his urine volume increased and cardiac failure improved. No notable adverse events were observed in any of the abovementioned cases. It is important that kanzo is not included in shimbuto to demonstrate risui action, hence the use of other “ho” formulations should be avoided. These cases suggest that shimbuto is indicated for elderly patients with cardiac failure under terminal care.

We present a case of aortic valve replacement after retrosternal gastric tube reconstruction for esophageal cancer. A 84-year-old man with a history of esophageal resection with retrosternal reconstruction by gastric tube for esophageal cancer required aortic valve replacement for aortic stenosis. The aortic valve was approached through an 8-cm right parasternal incision over the third and fourth costal cartilages. Cardiopulmonary bypass was initiated through cannulas in the ascending aorta and the right atrium and the aortic valve was replaced with a bioprosthetic valve. The postoperative course was uneventful. In the literature, there are only 7 reports on such cases so far, in which aortic valve relplacement was performed through left thoracotomy, right parasternal approach or median sternotomy. We recommend the right parasternal approach in cases of aortic valve replacement in patients with retrosternal gastric tube, because it does not only avoids injury of gastric tube, but also offers an excellent operative view.

A 10-year-old girl with heart murmur immediately after birth was found to have a ventricular septal defect (VSD). Although she had been followed up for an insignificant shunt, funnel chest became apparent and was referred to our hostpital at the age of 10. She was 133 cm in height, 25.7 kg in weight with a body surface area of 0.99 m². The VSD was the muscular outflow type with a Qp/Qs of 1.1, defect of 2.5 mm in diameter, and pulmonary artery pressure of 24/10/15 mmHg. Pectus excavatum was apparent with a CT index of 2.99. The preceding surgery for one was likely to interfere with the subsequent surgery for the other. Therefore we decided on concomitant surgery for both. Under median sternotomy, cardiopulmonary bypass was established and the VSD was closed with a patch. After the pericardium was sutured and closed, a tape was carefully passed through the chest wall under the guidance of direct vision and digital palpation. A metal bar was inserted guided by the tape, reversed with a rotator, appropriately shaped with a hand bender, and was fixed to the chest wall with the stabilizer bars at both ends. The sternum was sutured with 1-0 polyester sutures and two sternum pins made of particulate hydroxyapatite and poly-L lactide. The postoperative course was uneventful. After 2 years, the excavatum was adequately corrected and the bar was successfully removed under general anesthesia. Although the comorbidity of VSD and funnel chest is rare, concomitant surgery for both can be safely carried out and may be considered as an option for treatment.