Background/Aims: To date, only thinner-diameter metal stents have been evaluated for unresectable malignant distal biliary obstruction (UR-MDBO). This study investigated the outcomes and optimal cohorts for a 6-mm-diameter fully covered self-expandable metal stent (FCSEMS) compared with those for a 10-mm-diameter FCSEMS. Methods: This single-center retrospective cohort study included patients who underwent initial transpapillary metal stenting for UR-MDBO. Propensity score matching (1:1) analysis was performed. Results: Of 133/68 patients who underwent 6-mm/10-mm-diameter FCSEMS deployment, 59 in each group were selected. The median time to recurrent biliary obstruction was not significantly different between the groups (p=0.46). In contrast, use of the 6-mm-diameter FCSEMS resulted in a significantly reduced incidence of stent-related adverse events (AEs) (p=0.016), especially cholecystitis (p=0.032), and patients aged <70 years were particularly affected by this significant reduction. Among the patients in the end-stage cohort who were unable to continue chemotherapy after FCSEMS deployment, the free rate of stent-related events, including recurrent biliary obstruction and stent-related AEs, was significantly higher in the 6-mm group (p=0.027). Conclusions For UR-MDBO, a 6-mm-diameter FCSEMS can be an optimal and safe option in the younger cohort with a relatively high risk of AEs and in the end-stage cohort requiring safer drainage without interference from stent-related events during times of poor prognosis.

Background/Aims: To date, only thinner-diameter metal stents have been evaluated for unresectable malignant distal biliary obstruction (UR-MDBO). This study investigated the outcomes and optimal cohorts for a 6-mm-diameter fully covered self-expandable metal stent (FCSEMS) compared with those for a 10-mm-diameter FCSEMS. Methods: This single-center retrospective cohort study included patients who underwent initial transpapillary metal stenting for UR-MDBO. Propensity score matching (1:1) analysis was performed. Results: Of 133/68 patients who underwent 6-mm/10-mm-diameter FCSEMS deployment, 59 in each group were selected. The median time to recurrent biliary obstruction was not significantly different between the groups (p=0.46). In contrast, use of the 6-mm-diameter FCSEMS resulted in a significantly reduced incidence of stent-related adverse events (AEs) (p=0.016), especially cholecystitis (p=0.032), and patients aged <70 years were particularly affected by this significant reduction. Among the patients in the end-stage cohort who were unable to continue chemotherapy after FCSEMS deployment, the free rate of stent-related events, including recurrent biliary obstruction and stent-related AEs, was significantly higher in the 6-mm group (p=0.027). Conclusions For UR-MDBO, a 6-mm-diameter FCSEMS can be an optimal and safe option in the younger cohort with a relatively high risk of AEs and in the end-stage cohort requiring safer drainage without interference from stent-related events during times of poor prognosis.

Background/Aims: To date, only thinner-diameter metal stents have been evaluated for unresectable malignant distal biliary obstruction (UR-MDBO). This study investigated the outcomes and optimal cohorts for a 6-mm-diameter fully covered self-expandable metal stent (FCSEMS) compared with those for a 10-mm-diameter FCSEMS. Methods: This single-center retrospective cohort study included patients who underwent initial transpapillary metal stenting for UR-MDBO. Propensity score matching (1:1) analysis was performed. Results: Of 133/68 patients who underwent 6-mm/10-mm-diameter FCSEMS deployment, 59 in each group were selected. The median time to recurrent biliary obstruction was not significantly different between the groups (p=0.46). In contrast, use of the 6-mm-diameter FCSEMS resulted in a significantly reduced incidence of stent-related adverse events (AEs) (p=0.016), especially cholecystitis (p=0.032), and patients aged <70 years were particularly affected by this significant reduction. Among the patients in the end-stage cohort who were unable to continue chemotherapy after FCSEMS deployment, the free rate of stent-related events, including recurrent biliary obstruction and stent-related AEs, was significantly higher in the 6-mm group (p=0.027). Conclusions For UR-MDBO, a 6-mm-diameter FCSEMS can be an optimal and safe option in the younger cohort with a relatively high risk of AEs and in the end-stage cohort requiring safer drainage without interference from stent-related events during times of poor prognosis.

We investigated the history and indications of Toenho, Kinseiho, and Cho-Sanshaku-Shinteiho, which are different formulae with the same name of seishoekkito. According to the description in “Futsugoyakushitsuhokankuketsu” written by Sohaku Asada, Kinseiho exhibits an immediate effect, while Toenho has preventive effects. However, according to the original text, Kinseiho was formulated such that it could be administered regularly in the summer for prophylaxis. Furthermore, Kinseiho is regarded as a simplified formula with the central structure of Toenho. This implies that Kinseiho is composed of selected crude drugs used in Toenho that are responsible for the main effects of Toenho, such as invigorating spleen energy, clearing fever and generating body fluids. Moreover, there is an instruction to arrange Kinseiho to fit each patient’s condition. In this study, it was found that Cho-Sanshaku-Shinteiho described in “Futsugoyakushitsuhokankuketsu” is a modification of Kinseiho prescribed by Katsuki Gyuzan for patients with fever, consistent with the concept of personalized medicine. The medical extract preparation seishoekkito, which is currently widely used, is Kinseiho. We may use it with heat-clearing formula, fluid-regulating formula or some modifications to make the appropriate formulation based on the patient's symptoms.

We conducted a fact­finding survey about the difficulties of handling the telephone consultations at a Kampo medicine outpatient clinic. We extracted the details of consultations that could not be handled by an outpatient nurse alone from the descriptive data of the telephone responses described by the nurses in the sur­vey. We, then, identified the factors that were involved in the difficulties encountered in these consultations, and countermeasures were established and implemented. One year later, we compared and examined the status of telephone consultations between before and after the fact-­finding survey. We classified the telephone con­sultations that were difficult for the outpatient nurses to handle alone into four categories : (1) consultation about a physical disorder, (2) questions about prescribed Kampo medicines, (3) reports and questions based on the patient's own judgment, and (4) questions about treatment and hospitalization. Some of the questions about Kampo medicines included the continued use of the medicine and drug interactions, and the main topics of the survey's nurse self-­judgment reports were dose reductions and changes in Kampo medicine regimens. As a re­sult of the introduction of guidelines prepared by the nurses together with physicians at the clinics, the outpa­tient nurses became able to handle telephone consultations about frequently asked questions (FAQs). At 1 year after the survey, the number of cases of difficulties in handling telephone consultations decreased to less than half the original value, and no telephone consultations were made within 1 week after the patients' first visits to the outpatient clinic.

We investigated the number of drugs and pharmaceutical cost among 159 patients prescribed Western medicine and hospitalized from August 2006 to August 2015 in the Department of Oriental (Kampo) Medicine at Chiba University Hospital. The number of drugs used in Western medicine among improved patients significantly decreased from 5.6 ± 3.6 at hospitalization to 5.3 ± 3.5 at discharge, but the number of Kampo medicine drugs was not changed. The total number of drugs including both Western medicine and Kampo medicine significantly decreased from 7.0 ± 3.8 to 6.7 ± 3.6. The number of drugs used in Western medicine among nochanged patients decreased from 5.1 ± 3.4 at hospitalization to 5.0 ± 3.7 at discharge, but the number of Kampo medicine drugs significantly increased from 1.0 ± 0.0 at hospitalization to 1.3 ± 0.5. The total number of drugs including both Western medicine and Kampo medicine increased from 6.1 ± 3.4 to 6.3 ± 3.9. We thus conclude that a combination of Kampo medicine with Western medicine can be useful for reducing the number of drugs related to polypharmacy. To achieve these results, it is essential to use the concept of sho (a way of pattern recognition of a patient's symptoms in Kampo medicine).

We experienced 8 cases of children who presented with somatic complaints and found it difficult to attend school successfully treated with Kampo medicine. We evaluated them objectively by using the evaluation scale in the guideline for medical care of school refusal. Four cases were orthostatic dysregulation, 2 cases were migraine, 1 case was involuntary movement in upper abdomen and the other case was autonomic dysfunction. Kampo medicines were selected according to conventional method, so-called sho. Among 8 cases, 5 cases had a major response, 2 cases had a minor response and one case had no beneficial response. These results suggest that Kampo therapy can be effective therapeutic means. Kampo therapy is quite personalized and beneficial especially for children who find it difficult to attend school and need individualized care. This is the first report evaluating many cases objectively by using the evaluation scale and there have been no reports similar to ours. We have to continue to enlighten general pediatricians about the effectiveness of Kampo therapy.

Soshikokito has long been used to treat cough in frail patients with cold sensation in their feet, based on the Japanese traditional Kampo textbook “Iryo-Shuhou-Kiku”. In many old documents including “Wazai-Kyokuho,” where soshikokito was first described, it is suggested that airways obstructed by a large quantity of watery expectoration should be the proper indication for the use of this formula. However, in the five cases that we successfully treated, the quantity of sputum was relatively small. To determine the practical indications for this, we examined their abdominal strength and the presence or absence of “cold feet” sensation. In addition, we investigated the nature of sputum in the past clinical reports in which successful treatment using soshikokito was described. It has become clear that we can prescribe soshikokito as an antitussive regardless of the patients' physical fitness as deduced from the abdominal strength. The “cold feet” sensation was not an essential symptom and was regarded as one of the symptoms of qi counterflow. Regarding the properties of sputum, it was viscous and small in quantity. In the cases where soshikokito was effective, it was speculated that viscous sputum would result in airway obstruction, coughing, and wheezing. These conditions will be ameliorated by the antitussive and expectorant effect of this formula, which improves qi counterflow and mildly tonifies water. In the treatment of cough with respiratory distress, “sputum with high viscosity and hard to discharge” is considered to be the targeted symptom in the practical usage of soshikokito.

We report a case of prolonged lumbago with severe cold intolerance successfully treated with keppuchikuoto and uzushakusekishigan. The patient was a 71-year-old female with lumbar spinal canal stenosis which was refractory to several nerve and intervertebral disc block therapies and oral medications. She had been also suffering from constipation, leg cramps, intermittent chest pains, and severe cold intolerance. We prescribed keppuchikuoto for chronic blood stagnation and deficiency and uzushakusekishigan for intermittent chest pains in order to improve those symptoms all together. The severity of her lumbago and severe cold intolerance were remarkably reduced after the administration of the two formulas. This case suggests that the two formulas exerted their effectiveness by ameliorating chronic severe cold intolerance, blood stagnation, and blood deficiency and resulted in remarkable improvement in lumbago.

Enterovaginal fistula, which causes uncontrollable symptoms such as gas release, vaginal defecation, perineal erosion, and vaginitis, markedly reduces patients' quality of life. In this report, we present a case of successful treatment for enterovaginal fistula with Kampo medicine.
A 62 year-old female who had ileoanal canal anastomosis for ulcerative colitis developed symptoms of gas release and defecation from the vagina. Although these symptoms had disappeared with conventional medicine previously, they recurred 7 years later. There was no medical indication for surgery because the fistula could not be located by barium enema or endoscopic examination. She, therefore, visited our outpatient clinic 1 and a half years after all conventional management had ended in vain.
Her symptoms were slightly improved by the administration of ifutokaogi, a Kampo formula, although they persisted. Three months after switching her prescription to another Kampo formula, goreisan, her symptoms completely disappeared.
In recent years, there has been no report on goreisan for the successful treatment of enterovaginal fistulae. Our case suggests that Kampo medicine can be an option for the treatment of enterovaginal fistula refractory to conventional treatments.