An 89-year-old female was referred to her local doctor with persistent chest pain. She was rushed to our hospital because acute coronary syndrome was suspected. Emergency catheterization revealed a severe stenosis in left main trunk. An intra-aortic balloon pump (IABP) was placed, and we planned urgent surgery. During off-pump coronary artery bypass grafting, mitral valve regurgitation due to systolic anterior motion (SAM) occurred, her hemodynamics remained unstable after the operation. We performed tapering of catecholamine, and gave intravenous fluids and use of β-blocker to her. But what most improved her hemodynamics was that we removed the IABP.

A woman in her 50s underwent abdominal total hysterectomy for uterine myoma. She was discharged from the hospital on postoperative day (POD) 6 following an uneventful postoperative course but returned to the outpatient clinic on POD 11 with chief complaints of fever and abdominal pain. Blood tests at presentation showed a C-reactive protein level of 22.95 mg/dL and a white blood cell count of 21300/μL, indicating an increased inflammatory response. Transvaginal ultrasonography and contrast-enhanced computed tomography (CT) revealed a small amount of ascites and a thickened pelvic peritoneum. Based on these findings, pelvic peritonitis was diagnosed and the patient was readmitted to the hospital. After admission, antimicrobial treatment with cefmetazole 3 g/day was started, but transvaginal ultrasonography on POD 13 (3 days after readmission) revealed an intra-pelvic abscess. The abscess was punctured under transvaginal ultrasonographic guidance and the puncture fluid was submitted for microbiological examination, followed by CT-guided drainage. At the same time, the antimicrobial regimen was changed to sulbactam/ampicillin 9 g/day and doxycycline (DOXY) 200 mg/day (100 mg/day from the following day). On POD 18 (8 days after readmission), Mycoplasma hominis was detected in the abscess culture, leading to the decision to increase the dose of DOXY to 200 mg. Subsequently, with improvement of subjective and objective symptoms and reduction of the abscess cavity, the patient was discharged from the hospital on POD 21 (11 days after readmission). Although M. hominis is a common urogenital commensal, it can be a potential pathogen in a patient with a pelvic abscess that occurs as a late postoperative complication and does not respond to beta-lactam antibiotics, so treatment decisions should be made with this organism kept in mind.

The patient was a 36-year-old primipara with no comorbidities such as diabetes or hypertension. At 35 weeks and 3 days of pregnancy, she was admitted for rupture of membranes. She vomited often during the expulsive stage of labor, so a vacuum extraction was performed. Her vital signs were normal throughout the delivery. She vomited repeatedly after the delivery but did not complain of headache or arm weakness and her level of consciousness was Japan Coma Scale I-1. Head CT revealed right caudate hemorrhage and cerebral ventricular rupture. Head MRI showed no obvious cerebrovascular abnormality, so she was followed up with symptomatic treatment. Recovery was uneventful, without neurological sequelae, and she was discharged on postpartum day 27. Cerebral hemorrhage during pregnancy is caused in many cases by comorbidities such as cerebral aneurysm, cerebral artery malformation, and pregnancyinduced hypertension syndrome. Cerebral hemorrhage may occur in pregnant women with no risk factors, even when their vital signs are stable. It is necessary to pay attention to the appearance of new symptoms, such as vomiting, around the time of delivery.

A 71-year-old woman underwent gastrostomy due to malnutrition resulting from impaired esophageal peristalsis due to scleroderma. However, the gastrostomy tube was removed due to worsening of difficult-to-treat dermatitis around the gastrostomy. An intractable gastrocutaneous fistula with persistent gastric juice leakage and peri-gastrostomy dermatitis was treated with fistulotomy and local negative pressure closure therapy under local anesthesia. Spontaneous closure of an intractable fistula after gastrostomy removal can be difficult due to underlying malnutrition and exposure to leaking gastric juice, among other factors. The present case suggests that fistulectomy followed by local negative pressure closure therapy for an intractable fistula after gastrostomy removal can enable oral intake in the early postoperative period and also facilitate wound management.

In infectious enteritis, the affected site differs depending on the organism causing the disease, and based on this feature, it is possible to estimate the causative organisms of infectious enteritis. However, there have been few reports of infectious enteritis mainly affecting the duodenum. This report describes a case of duodenal enteritis that was suspected to be associated with Legionella infection. The patient was a 66-year-old man. He was febrile for 5 days and had watery diarrhea for 3 days before admission, and he presented to our hospital when the symptoms did not improve. He was hypoxemic at presentation, and a CT scan on admission revealed nonsegmental ground-glass opacities in both lung fields and thickening of the intestinal wall, mainly in the duodenum. Blood tests and chest imaging findings led to suspicion of Legionella pneumonia. Urine specimens were submitted for Legionella antigen testing and were found to be positive, confirming the diagnosis. Subsequent antimicrobial therapy resulted in improvement of the diarrhea symptoms and duodenal wall thickening, and the patient was discharged on hospital day 19. This case shows that Legionella pneumonia can manifest as abdominal symptoms. The possibility of Legionella pneumonia should thus be considered in patients with duodenitis.

Introduction: We experienced a case of lung cancer in which arthrocentesis and radiation were effective in treating pain caused by malignant joint fluid. Case: An 80-year-old man was referred to our hospital because of right shoulder pain and difficulty in raising his right hand. Whole body computed tomography (CT) showed right lung tumor, multiple liver metastases and multiple bone metastases. There were also bone metastases in the right scapula and joint fluid accumulation in the right shoulder joint. He was irradiated for bone metastases in the right scapula, but the pain remained, although it had not worsened. Therefore, an arthrocentesis of the right shoulder joint was performed and pain was alleviated. In addition, the diagnosis of non-small cell carcinoma was made by joint fluid cytology. A biopsy was also taken from the right lung tumor, and as the histological diagnosis was similar to that of the joint fluid, chemotherapy was started. CT after the start of treatment showed a decrease in the right shoulder joint fluid and no progression of right scapular metastases. Conclusion: In case of malignant joint fluid associated with bone metastases, a severe prognosis is expected, but arthrocentesis and irradiation can reduce pain.

Objective: Pharmacists deliver medicines that require refrigeration directly to patients’ homes for home medical care or due to supply shortages. However, there are no investigations into the delivery of medicines under appropriate temperature control. Therefore, we conducted a questionnaire survey regarding the delivery of cold-stored pharmaceuticals and considered packaging methods for medicines that would enable appropriate temperature control based on the results. Methods: A questionnaire survey was conducted at 86 pharmacies between January 25 and March 31, 2019. Subsequently, we measured the surface temperature of the medicine (InnoLet® 30R Injection) using a cold bag and ice pack. Results: We received responses from 79 pharmacies. The questionnaire survey revealed that 44% (35 pharmacies) delivered medicines needing refrigeration directly to patients’ homes, and of those, 43% (15 pharmacies) expressing concerns about temperature control during delivery. Additionally, based on a reproduction experiment using the packaging method confirmed in the questionnaire survey (using a cold bag, 0 to 4 ice packs, and an outside temperature of 28℃), the lowest storage temperature (mean±SD) of InnoLet® was 18.8±0.3℃ for zero ice packs, 18.0±0.3℃ for one ice pack, 12.7±0.1℃ for two ice packs, and −0.2±0.3℃ for four ice packs. Thus, the storage temperature of InnoLet® was outside the range of 2-8℃. Therefore, we improved the packaging method to maintain the proper storage temperature by using bubble wrap and paper wiper (Kim Towels®) in 10-45℃ weather conditions. Conclusion: In this study, we discovered the packaging method of medicines to maintain the proper storage temperature (2-8℃) in 10-45℃ weather conditions. Applying the temperature-based packaging method studied in this paper to actual pharmacy operations will ensure the quality of pharmaceuticals that require refrigeration, contribute to ensuring their efficacy and safety, and help ensure delivery. This is expected to alleviate pharmacists’ concerns regarding temperature control of medicines.

Congenital fetal abnormalities, typically structural abnormalities, are found about 3-5% of all pregnancies. The prenatal detection of these abnormalities are especially important in providing optimal perinatal management for neonates. In many obstetric hospitals and clinics in Japan, fetal ultrasound screening is provided by obstetricians at regular pregnancy checkups. There were few reports on fetal ultrasound performed by medical technologists. Therefore, we conducted a retrospective investigation to determine the efficacy and accuracy of fetal ultrasound performed by medical technologists in our hospital. In total, 2,289 pregnancy women underwent fetal ultrasound screening. We excluded cases that were a second or subsequent scan, had gestational age of <22 weeks at the time of ultrasound screening, or had missing perinatal and neonatal outcomes. The remaining of 2,186 cases, including 65 cases of twins, were investigated. Abnormal findings were noted in 79 cases (3.6%): 31 for the heart, 14 for head, and 11 for urogenital organs. In those cases, congenital abnormalities were found in 39 neonates (1.8%). There were 95 cases (4.3%) in which abnormal finding were absent in fetal ultrasound screening but congenital abnormalities were diagnosed in neonates, including ventricular aneurysm, interruption of the vena cava, cerebellar medulloblastoma, atrial septal defect, and cleft palate. In conclusion, for detecting structural abnormalities, fetal ultrasound screening performed by medical technologists is an important alternative to ultrasound screenings performed by obstetricians. To increase the accuracy of fetal ultrasound screening, continuous improvement of fetal ultrasound skills is important.

Objective: Spine surgeons are often at risk of radiation exposure due to intraoperative fluoroscopy, leading to health concerns such as carcinogenesis. This is due to the increasing use of percutaneous pedicle screw (PPS) in spinal surgeries, resulting from the widespread adoption of minimally invasive spine stabilization. This study aimed to elucidate the effectiveness of smart glasses (SG) in PPS insertion under fluoroscopy. Methods: SG were used as an alternative screen for fluoroscopic images. Operators A (2-year experience in spine surgery) and B (9-year experience) inserted the PPS into the bilateral L1–5 pedicles of the lumbar model bone under fluoroscopic guidance, repeating this procedure twice with and without SG (groups SG and N-SG, respectively). Each vertebral body’s insertion time, radiation dose, and radiation exposure time were measured, and the deviation in screw trajectories was evaluated. Results: The groups SG and N-SG showed no significant difference in insertion time for the overall procedure and each operator. However, group SG had a significantly shorter radiation exposure time than group N-SG for the overall procedure (109.1 ± 43.5 seconds vs. 150.9 ± 38.7 seconds; p = 0.003) and operator A (100.0 ± 29.0 seconds vs. 157.9 ± 42.8 seconds; p = 0.003). The radiation dose was also significantly lower in group SG than in group N-SG for the overall procedure (1.3 ± 0.6 mGy vs. 1.7 ± 0.5 mGy; p = 0.023) and operator A (1.2 ± 0.4 mGy vs. 1.8 ± 0.5 mGy; p = 0.013). The 2 groups showed no significant difference in screw deviation. Conclusion The application of SG in fluoroscopic imaging for PPS insertion holds potential as a useful method for reducing radiation exposure.

Objective: To elucidate the patient characteristics and outcomes of emergency surgery for spinal metastases and identify risk factors for emergency surgery. Methods: We prospectively analyzed 216 patients with spinal metastases who underwent palliative surgery from 2015 to 2020. The Eastern Cooperative Oncology Group performance status, Barthel index, EuroQol-5 dimension (EQ5D), and neurological function were assessed at surgery and at 1, 3, and 6 months postoperatively. Multivariate analysis was performed to identify risk factors for emergency surgery. Results: In total, 146 patients underwent nonemergency surgery and 70 patients underwent emergency surgery within 48 hours of diagnosis of a surgical indication. After propensity score matching, we compared 61 patients each who underwent nonemergency and emergency surgery. Regardless of matching, the median performance status and the mean Barthel index and EQ5D score showed a tendency toward worse outcomes in the emergency than nonemergency group both preoperatively and 1 month postoperatively, although the surgery greatly improved these values in both groups. The median survival time tended to be shorter in the emergency than nonemergency group. The multivariate analysis showed that lesions located at T3–10 (p = 0.002; odds ratio [OR], 2.92; 95% confidence interval [CI], 1.48–5.75) and Frankel grades A–C (p < 0.001; OR, 4.91; 95% CI, 2.45–9.86) were independent risk factors for emergency surgery. Conclusion Among patients with spinal metastases, preoperative and postoperative subjective health values and postoperative survival are poorer in emergency than nonemergency surgery. Close attention to patients with T3–10 metastases is required to avoid poor outcomes after emergency surgery.