We report two cases in which insomnia successfully treated with sansoninto alone or in combination and the effectiveness could be objectively evaluated with the portable sleep test. Case 1 was 40-year-old man who had suffered from arousal during sleep and daytime fatigue for several years. After taking sansoninto with ninjinto, his symptoms improved. Case 2 was 60-year-old woman who had suffered from a lack of deep sleep and daytime sleepiness. After taking sansoninto, she could get a deep sleep and could have less daytime sleepiness. In this report, we present that portable sleep test conducted before and after treatment confirmed that sleep quality improved. Sansoninto is one of the curative medicines for insomnia, but we believe this is the first report showing objective therapeutic effects using portable sleep test.

We report a case of obstructive sleep apnea improved with the treatment both of Kampo medicine and Western medicine. The patient aged 52 years old was struggling with daytime drowsiness. Through the sleep test, he was diagnosed as severe obstructive sleep apnea (OSA) and was received a continuous positive airway pressure therapy (CPAP). Generally, positive air from CPAP applies through the nose and usage reports were recorded in the device. If having nasal congestion, it may be hard to continue CPAP. In this case he had a severe nasal congestion, and he nearly became CPAP failure. It was clear from the poor usage reports. Using Eppikajutsuto for nasal congestion, he felt decrease of nasal congestion. By switching to Shoseiryuto or kakkontokasenkyusin’i from Eppikajutsuto with reference to CPAP usage and nasal CT images, CPAP was continued effectively. Eventually, his daytime sleepiness disappeared.To continue CPAP, which is one of Western medicine, Kampo medicine was useful. On the other hand, to evaluate the effectiveness of Kampo medicine, Western medicine was necessary. CPAP reports and nasal CT images, which are Western medicine, contributed to the switch to Kampo medicine. This case showed the worth of the combined therapy of Kampo medicine with Western medicine.

We report a case of sleep terrors complicated with sleepwalking. The patient was 9-year-old boy who suddenly woke up, walked, or screamed in his sleep. These symptoms were sometimes induced by such as fever elevation or school events. In order to prevent injury while sleeping, he was suggested taking medicine to suppress the nocturnal behavior. After taking shokenchuto based on his findings of qi deficiency, the episodes gradually disappeared and the frequency of fever elevation decreased. In this report, we present the improvements of sleep parameters provided by overnight polysomnography, performed before and after treatment. Shokenchuto is known as one of the curative medicines for sleep terrors, but this is the first report showing objective therapeutic effects using overnight polysomnography.

We have previously reported that the thoracolumbar posterior nerve root shows a tortuous epidural course, based on studies of human fetuses near term. For comparison with the cervical nerve, examinations were conducted using frontal, sagittal and horizontal sections of cervical vertebrae from 22 fetuses at 30–38 weeks of gestation. The cervical nerve root showed a short, straight and lateral course near the zygapophysial joint. Multiple rather than single bundles of the cervical posterior root seemed to account for the majority of sensory nerve fibers innervating the upper extremity. Fasciculation of rootlets was evident near the thoracolumbar spinal cord, whereas it was seen in the dural pocket at the nerve exit from the dural sac although both sites were subdural. As in the thoracolumbar region, the nerve sheath was continuous with the dura mater and independently surrounded each of the anterior and posterior roots. Radicular arteries were few in the cervical region. In 2 of the 22 fetuses (31 weeks and 33 weeks), there was a segmental, unilateral abnormality of nerve rootlet fasciculation where the dorsal root ganglion was located lateral or peripheral to the intervertebral region. Long nerve roots running inferiorly are a necessary adaptation to the delayed and marked growth of the thoracolumbar vertebral column.In children, the cervical nerve roots are likely to be affected by movement or dislocation of the vertebrae. The segmental abnormality of the cervical nerve root may be linked to rare variations in the brachial plexus.

In the palliative setting, the necessity of biliary drainage of both liver lobes for malignant hilar biliary obstruction remains controversial. However, bilateral biliary drainage is a reasonable option to prevent cholangitis of the undrained lobe and to preserve liver function during the course of chemotherapy. Bilateral biliary drainage can be accomplished by the percutaneous or endoscopic placement of multiple self-expandable metallic stents (SEMS). Although SEMS placement via bilateral (multiple) percutaneous routes is technically simple, multiple percutaneous transhepatic biliary drainage (PTBD) may lead to additional morbidity. SEMS placement via a single percutaneous route is a useful method; however, negotiation of a guidewire into the contralateral bile duct is occasionally impossible if the hilar angle between the right hepatic duct and left hepatic duct is acute. Percutaneous dual SEMS placement is generally performed using the stent-in-stent technique (T configuration or Y configuration) or the side-by-side technique. In addition, the crisscross technique has been reported as being a useful method for trisegmental drainage. The side-to-end technique is also useful for multiple SEMS placement. In the future, the combination of percutaneous intervention and endoscopic ultrasonography-guided procedures may be effective in the management of malignant hilar biliary obstruction.
Bile Ducts ; Biliary Tract Neoplasms ; Cholangitis ; Drainage ; Drug Therapy ; Hepatic Duct, Common ; Liver ; Methods ; Negotiating ; Stents*

Congenital syphilis (CS) is a public health burden in both developing and developed countries. We report two cases of CS in premature neonates with severe clinical manifestations; Patient 1 (gestational age 31 weeks, birth weight 1423 g) had disseminated idiopathic coagulation (DIC) while Patient 2 (gestational age 34 weeks and 6 days, birth weight 2299 g) had refractory syphilitic meningitis. Their mothers were single and had neither received antenatal care nor undergone syphilis screening. Both neonates were delivered via an emergency cesarean section and had birth asphyxia and transient tachypnea of newborn. Physical examination revealed massive hepatosplenomegaly. Laboratory testing of maternal and neonatal blood showed increased rapid plasma reagin (RPR) titer and positive Treponema pallidum hemagglutination assay. Diagnosis of CS was further supported by a positive IgM fluorescent treponemal antibody absorption test and large amounts of T. pallidum spirochetes detected in the placenta. Each neonate was initially treated with ampicillin and cefotaxime for early bacterial sepsis/meningitis that coexisted with CS. Patient 1 received fresh frozen plasma and antithrombin III to treat DIC. Patient 2 experienced a relapse of CS during initial antibiotic treatment, necessitating parenteral penicillin G. Treatment was effective in both neonates, as shown by reductions in RPR. Monitoring of growth and neurological development through to age 4 showed no evidence of apparent delay or complications. Without adequate antenatal care and maternal screening tests for infection, CS is difficult for non-specialists to diagnose at birth, because the clinical manifestations are similar to those of neonatal sepsis and meningitis. Ampicillin was insufficient for treating CS and penicillin G was necessary.

Congenital syphilis (CS) is a public health burden in both developing and developed countries. We report two cases of CS in premature neonates with severe clinical manifestations; Patient 1 (gestational age 31 weeks, birth weight 1423 g) had disseminated idiopathic coagulation (DIC) while Patient 2 (gestational age 34 weeks and 6 days, birth weight 2299 g) had refractory syphilitic meningitis. Their mothers were single and had neither received antenatal care nor undergone syphilis screening. Both neonates were delivered via an emergency cesarean section and had birth asphyxia and transient tachypnea of newborn. Physical examination revealed massive hepatosplenomegaly. Laboratory testing of maternal and neonatal blood showed increased rapid plasma reagin (RPR) titer and positive Treponema pallidum hemagglutination assay. Diagnosis of CS was further supported by a positive IgM fluorescent treponemal antibody absorption test and large amounts of T. pallidum spirochetes detected in the placenta. Each neonate was initially treated with ampicillin and cefotaxime for early bacterial sepsis/meningitis that coexisted with CS. Patient 1 received fresh frozen plasma and antithrombin III to treat DIC. Patient 2 experienced a relapse of CS during initial antibiotic treatment, necessitating parenteral penicillin G. Treatment was effective in both neonates, as shown by reductions in RPR. Monitoring of growth and neurological development through to age 4 showed no evidence of apparent delay or complications. Without adequate antenatal care and maternal screening tests for infection, CS is difficult for non-specialists to diagnose at birth, because the clinical manifestations are similar to those of neonatal sepsis and meningitis. Ampicillin was insufficient for treating CS and penicillin G was necessary.