The purpose of this study was to examine factors related to the occurrence of enthesis pain by long-term longitudinal investigation and measurement in junior high school soccer players, while intervening for its prevention. The subjects were 107 male junior high school soccer club members. The presence or absence of enthesis pain, the height growth velocity, muscle tightness, and alignment were longitudinally investigated, and stretching was instructed periodically. The time of enthesis pain occurrence was consistent with phase II of the height growth velocity curve in many cases. On comparison between before and after the appearance/disappearance of enthesis pain, no association was noted between the muscle tightness and occurrence of enthesis pain. But, on comparison of changes with time in muscle tightness, the tightness of the right quadriceps significantly increased, being useful for the prediction of enthesis pain. A significant increase in the Q-angle was also noted when enthesis pain appeared. Furthermore, the tightness of the bilateral iliopsoas, hamstrings, hip adductors, and gastrocnemius had significantly improved on the final measurement, showing that instruction in stretching was effective. This study showed the necessity of the long-term longitudinal evaluation of muscle tightness, suggesting that there is a possibility of intervention for prevention, as well as physical therapy for sporting injuries in the growth period.

　　We report a case of subcutaneous port-site hematoma developed on day 6 after laparoscopic left-sided salpingooophorectomy. To start the procedure, three ports were placed in the umbilicus and in each lower quadrant using bladeless trocars. No bleeding was observed at the trocar sites after insertion or withdrawal. The patient was discharged on postoperative day (POD) 3, but returned to the emergency outpatient department with acute left lower abdominal pain on POD 6. Dynamic CT revealed a port-site hematoma with active bleeding from a subcutaneous artery. Hemostasis was achieved easily by opening the trocar wound. Dynamic CT was useful to locate the bleeding vessel and enabled use of a minimally invasive procedure to control bleeding.

　　This retrospective study was carried out to clarify the preventive effect of neutral positioning of both arms on upper extremity neuropathy after gynecological laparoscopic surgery compared with right arm abduction positioning. In 93 cases of right arm abduction positioning >90°, with the left arm tucked in at the side, postoperative right hand numbness occurred in 6 cases (6.5%). In these 6 cases, symptoms disappeared in 4 cases after postoperative day (POD) 1, in 1 case after POD 21, and in the remaining case after POD 41. In 81 cases where both arms were in the neutral position tucked in at the sides with shoulder braces applied, upper extremity numbness was not experienced in any cases; however, shoulder pain developed in 4 cases (4.9%) and was thought to be related to using the shoulder braces. The pain disappeared in 2 cases after POD 1, in 1 case after POD 2, and in the remaining case after POD 3. In right arm abduction positioning without the use of shoulder braces, shoulder pain was not experienced in any cases. Neutral positioning of both arms in gynecological laparoscopic surgical patients was effective for the prevention of upper extremity neuropathy, but measures to alleviate the onset of shoulder pain after change in positioning need to be addressed in the future.

　　We report a case of vaginal cuff dehiscence after total laparoscopic hysterectomy that was successfully managed by a newly developed vaginal double-layer circular incision-closure method through a transvaginal approach. The nulligravid postmenopausal patient with cervical cancer received a diagnosis of vaginal evisceration on postoperative day 24. The eviscerated small intestine was pushed back after vaginal douching with normal saline before the procedure. The vaginal mucosa was incised circularly in two layers at the levels of 10 mm and 15 mm from the vaginal stump, and the edges apposed with double-layer closures. She was discharged on postoperative day 3 and followed up for 5 years, with no recurrence of cancer or vaginal dehiscence. This operative method is especially useful for a nulligravida with a small vagina.

Pregnant women with renal disease are at high risk of perinatal complications and renal impairment. Here, we report the outcomes of 4 pregnancies complicated by renal disease diagnosed during pregnancy and the puerperal period. Case 1: Urine test had been positive for protein from 8 weeks of pregnancy, and chronic kidney disease stage G4 was diagnosed at 25 weeks of pregnancy. Renal impairment worsened over time, and cesarean section was performed due to non-reassuring fetal status at 32 weeks of pregnancy. Case 2: Urine test had been positive for protein since before pregnancy, and chronic glomerulonephritis was diagnosed at 15 weeks of pregnancy. Gradual impairment of renal function started at 31 weeks of pregnancy, and the patient had a vaginal delivery at 37 weeks of pregnancy. Case 3: Urine test had been positive for protein since before pregnancy, and hypertension and urine protein were observed since around 26 weeks of pregnancy. Cesarean section was performed due to acute renal failure at 36 weeks of pregnancy. Chronic glomerulonephritis was suspected after childbirth. Case 4: Blood pressure became uncontrollable beginning around 28 weeks of pregnancy, and cesarean section was performed due to sudden worsening of hepatic and renal functions at 31 weeks of pregnancy. Autosomal dominant polycystic kidney disease was diagnosed after childbirth. Pregnancies complicated by renal disease need to be managed carefully with monitoring of blood pressure and renal function. Cooperation with a renal specialist is crucial throughout the perinatal and puerperal periods.

Introduction: We report two cases of surgery under general anesthesia during cancer pain management of patients with methadone therapy. Case 1: A 57-year-old woman was started on methadone for pain from right breast cancer with multiple bone metastases, and right mastectomy was performed during the course of chemotherapy. There was no exacerbation of cancer pain due to methadone withdrawal, although analgesics were used temporarily for wound pain. Case 2: A 76-year-old man was placed on methadone for pain from lung cancer. There was concern that lower limb paralysis would develop from a compression fracture of the lumbar spine that had occurred during the course of treatment. Therefore, decompression and fixation surgery was performed. Ketamine was used to control intraoperative pain exacerbation, and fentanyl was used by continuous injection for re-exacerbation of pain after the patient had awakened from anesthesia. Conclusion: Since methadone is available only by mouth in Japan and the equianalgesic ratio between methadone and other opioids has not been established, caution is needed for perioperative pain control while oral methadone cannot be administered. Thus, pain and palliative care specialists prescribing methadone are expected to play an active role in adequate perioperative pain control.

At Anjo Kosei Hospital, all staff has been working concertedly on a project to establish a community hospital in line with our future vision. Hospital staff in charge of the Medical Affairs Division has been involved in measures aimed at achieving the slogan “health and happiness of local residents” as part of this project. To address this, three goals were set as follows: improvement of recoveries in accounts receivable management, a reduction of money held in trust, and a decrease in the number of outsourced transactions. To achieve the goals described above, the following specific measure were carried out: (1) collection of accounts receivable using convenience store settlement; (2) collection of high-cost medical expenses by wider use of Eligibility Certificates for Ceiling-Amount Applications and promotion of the Major Medical Cost Loan System for national health insurance holders; and (3) support in acquiring family registration for nonregistered family members and for health insurance benefits. Recoveries of accounts receivable through convenience store settlement was about 90,000 yen/month, and our support activities for family registration and health insurance benefits provided the recoveries of about 80,000 yen/month. Furthermore, the promoted use of the certificate and loan system resulted in recoveries of about 17 million yen/year. The average commission fee and number of outsourcing was 890,188 yen and 12 cases, respectively, from April to August 2016. However, in 2017, it was 305,615 yen and 10 cases, respectively. Our project aimed at achieving slogan-elicited patient voluntary payment of medical expenses, leading to improved recoveries, with reduced money held in trust and fewer outsourced transactions.

Coronavirus disease 2019 (COVID-19) has spread rapidly in Japan. The purpose of this study was to report the clinical experience of our COVID-19 patients early in the pandemic and lessons from our experience. An outpatient fever clinic was established on April 7. Admission of COVID-19 patients was started on July 23. Between April 7 and September 30, there were 364 walk-in outpatients and emergency patients with fever. Polymerase chain reaction test for SARS-CoV-2 RNA or COVID-19 antigen test were performed in all patients, and all results were negative. Twenty patients with COVID-19 were admitted to a newly established dedicated COVID-19 ward. They were discharged well. There were no cases of nosocomial infection at our hospital. Length of hospitalization was correlated with serum ferritin level at admission, serum CRP level at admission, and age. More than half the patients experienced psychological stress, and COVID-19 specialized nurses experienced some stress. It is essential to set up the medical system for COVID-19 according to the trends of the disease. Creation of our original database and our “problem notebook” were useful for treatment and care of COVID-19 patients as well as for mental care of nurses.

Placenta accreta spectrum (PAS) disorders may lead to massive postpartum hemorrhage but optimal treatment strategies have yet to be determined. This retrospective analysis involved 35 cases of PAS that occurred at our hospital between January 2014 and November 2021. Mean maternal age was 37 (21-43) years and 8 pregnancies were the result of assisted reproductive therapy. Fifteen patients had placenta previa, 12 had a history of cesarean delivery, and one had a history of PAS. Mean gestational age was 36 (26-41) weeks. Twenty deliveries were by cesarean section and 15 were vaginal deliveries. Mean blood loss was 2,970 (300-14,727) mL. Nine patients were treated by manual placenta removal, one of whom had a delayed hysterectomy because of bleeding. Eleven patients were treated by cesarean hysterectomy and 2 were treated by curettage. Thirteen patients were treated by conservative management, and in 3 of them, treatment was changed to curettage, abdominal placenta resection, or hysterectomy because of vaginal bleeding or intrauterine infection. Four patients thought to have PAS before delivery were treated by cesarean hysterectomy and the amount of bleeding was not severe. Conservative treatment for placenta accreta was successful in 10 patients (77%), and the uterus could be preserved in 12 women (92%). In cases thought to be PAS before delivery, if the placenta is not removed, cesarean hysterectomy should be selected. Conservative management tends to be selected in cases of PAS when the main part of the placenta can be removed. However, in cases of life-threatening hemorrhage or infection, clinicians might need to perform peripartum hysterectomy or uterine artery embolization when bleeding or infection occurs. Therefore, clinicians should obtain informed consent for such treatment in advance.

We report a case of ureteral endometriosis thought to have developed following relapse of pelvic peritoneal endometriosis after laparoscopic surgery. The patient was a woman in her late 40s who had undergone laparoscopic right adnexectomy for an endometrial cyst 5 years earlier. Electrocoagulation was performed for residual endometriosis of adherent cyst wall on the right sacrouterine ligament. The normal left ovary was preserved and she received no postoperative hormonal therapy. She developed right back pain during menstruation 5 years after the surgery. Pyeloureterography revealed stenosis of the ureter to the right of the uterus. Urinary cytology revealed endometrial cells with no atypia. Conservative management was opted for because malignant transformation of endometriosis was considered unlikely and she was expected to reach menopause within a few years. She is now doing well 24 months after initiation of progestin treatment with placement of a ureteral stent. Postoperative hormonal therapy is recommended for patients who are considered to have possible lesions of residual endometriosis and for whom ovarian function is preserved.