Ischemic peripheral circulatory disorders have been observed more and more frequently in maintenance hemodialysis patients in recent years. This tendency is associated with the progression of arteriosclerosis characteristic of such patients. In the present study, we made inquiries about the presence or absence of subjective symptoms of ischemic peripheral circulatory disorders in maintenance hemodialysis patients and examined pulsation of dorsal artery and cyanosis of foot to make early diagnosis of the circulatory disorders possible. Furthermore, we measured the ankle brachial pressure index (API) and examined the calcification in thoracic and abdominal aortae on X-rays. According to clinical symptoms, the subjects were classified into no clinical symptom, sensory disorder, and motor disorder. Of the participants in the present study, 31.0% had API below 1.0. The mean age and hemodialysis period of the patients with API below 1.0 were more than those of the patients with API 1.0 or over. However, the differences were not significant. Of the patients with no clinical symptom, 21.2% had API below 1.0. We found a patient with no clinical symtom who had no pulsation of dorsal artery and cyanosis of foot. Of the patients who complained sensory and motor disorders, 35.0% and 45.5%, respectively, had API below 1.0. In the examination of calcification of thoracic and abdominal aortae, 23.8% of the patients with no calcification, 22.2% of the patients with the calcification in thoracic aorta alone, 27.8% of the patients with the calcification in abdominal aorta alone, and 29.6% of the patients with the calcification in both thoracic and abdominal aortae had API below 1.0. We believe that these results will make for early diagnosis and care treatment of ischemic peripheral circulatory disorders in hemodialysis patients.

Objective: The aims of this study are to investigate the working mechanism, the characteristics, the clinical application and the suggested modification of the Quad Helix appliance. Methods: A 7-year-old, female patient with Pierre-Rokin syndrome, who was preformed with palatorrhaphy at 21-month-old treated by using a Quad Helix appliance for one year. Results: After one-year treatment, the wide between the maxillary first molars increased 9.65mm, and the wide between maxillary canines increased 5.20mm. The wide between the mandibular first molars also increased 3.60mm, however the wide between mandibular canines decreased 5.20mm. Conclusion: The Quad-helix appears to be a successful Orthodontic appliance to expand the narrow maxillary or mandibular arches.

Dialysis hypotension is one of the most common complications observed during hemodialysis. As it may be due to vasodilatation, vasoconstrictors are usually given to patients to control blood pressure. Howerver, there are some patients who are resistant to the medication with vasoconstrictors. Recently, it has been reported that as one of the treatments of dialysis hypotension, the cooling of dialysate is effective in inducing vasoconstriction via stimulating the sympathetic nerve system. Also, the application of the interaction of citrus juices with some kinds of drugs to the treatment of dialysis hypotension has been reported effective. In the present study, we examined the effectiveness of those two methods in nine hemodialysis patients in whom dialysis hypotension had not been improved with vasoconstrictors. Dialysate temperatures were lowered from 36.0 to 35.0 C during hemodialysis and/or 100m1 of citrus juice (grapefruit juice) were given to the patients before hemodialysis in addition to vasoconstrictors. Lowering dialysate temperaturse reduced the incidence of intradialytic hypotension and helped improve the patients' quality of life after hemodialysis therapy. Body temperature remained unchanged between before and after hemodialysis. However, we observed cramps in two patients and an impairment of consciousness in one patient during hemodialysis. Thus, we concluded due caution should be exercise against the side effects during hemodialysis when dialysate temperatures are lowered. Meanwhile, the intake of grapefruit juice before hemodialysis was not effective for the improvement of intradialytic hypotension and the patients' quality of life.

A 36-year-old female with a high-grade fever and epigastric abdominal pain was prescribed antibiotics, but developed hypoxia and dyspnea. An echocardiography revealed diffuse hypokinesis and massive pericardial effusion, after which diagnostic cardiac catheterization and an endomyocardial biopsy (EMB) were peformed to reveal fibrosis and infiltration of inflammation cells composed primarily of neutrophils. Clinical manifestation of a spiking fever, leukocytosis, elevated ferritin levels, skin rash and EMB findings led to a diagnosis of adult-onset Still's disease (AOSD) with acute myocarditis. Pulse therapy of intravenous methylprednisolone was performed for three days, followed by a daily dose of prednisone (60 mg). After a course of steroid therapy for fever and pericardial effusion, and conducting a left ventricular ejection fraction, the patient showed improvement and was discharged asymptomatic within 32 days of admission. This study is the first to report on a case of myocarditis in AOSD diagnosed by neutrophil infiltration in the myocardium.
Abdominal Pain ; Adult ; Anoxia ; Anti-Bacterial Agents ; Biopsy* ; Cardiac Catheterization ; Cardiac Catheters ; Diagnosis ; Dyspnea ; Echocardiography ; Exanthema ; Female ; Ferritins ; Fever ; Fibrosis ; Heart Failure ; Humans ; Inflammation ; Leukocytosis ; Magnetic Resonance Imaging* ; Methylprednisolone ; Myocarditis* ; Myocardium ; Neutrophil Infiltration ; Neutrophils ; Pericardial Effusion ; Prednisone ; Still's Disease, Adult-Onset* ; Stroke Volume

Purposes: We prospectively examined the effects of “instruction for near death” by doctors to improve communication and difficulty in end-of-life care in acute general wards. Methods: A non-randomized controlled trial was conducted to evaluate the communication between pre-treatment group and the group with and without the “instruction for near death” in the end-of-life period by Japanese version of Support Team Assessment Schedule (STAS-J). We also compared the difficulty of end-of-life care before and after the trial. Results: The “communication between professionals” in STAS-J was 0.46±0.53 in pre-treatment group (n=71), 0.18±0.39 in the instruction group (n=34) and 0.66±0.48 in the non-instruction group (n=44) (p<0.001). The “family anxiety”, the “family insight”, “communication between patient and family” and “communication professional to patient and family” in STAS-J were not significantly different between the groups. The questionnaire of difficulty of end-of-life care showed no change in both doctors and nurses. Conclusions: The “communication between professionals” was improved in the group with the “instruction for near death”. The difficulty of end-of-life care was not reduced, and it did not contribute to family anxiety and communications.

Introduction: Intravascular large B-cell lymphoma (IVLBCL) is a rare disease entity of non-Hodgkin lymphoma. Patients with IVLBCL frequently have neurological symptoms associated with cerebrovascular infarction or central nervous system involvement of malignant lymphoma. Case: A 67-year-old man consulted the Department of Hematology at our hospital because of fever of unknown origin, anemia and increased serum lactate dehydrogenase. Although IVLBCL was strongly suspected, no lymphoma cells were found by multiple bone marrow aspirations and skin biopsies. Two months later, he developed hyperactive delirium, which was difficult to manage using antipsychotic agents. Brain MRI revealed multiple hyper-intense infarct-like lesions on diffusion-weighted images. After assessment of bone marrow aspiration and skin biopsies, he was administered an enough dose of prednisolone to manage malignant lymphoma. Hyperactive delirium rapidly improved. Discussion: In patients with IVLBCL, corticosteroids may be useful to manage hyperactive delirium due to cerebrovascular infarction or central nervous system involvement of IVLBCL.