Background: and Purpose To assess the long-term outcomes of intracranial dural arteriovenous fistula (DAVF) treated with stereotactic radiosurgery (SRS) alone or embolization and SRS (Emb-SRS) and to develop a grading system for predicting DAVF obliteration. Methods: This multi-institutional retrospective study included 200 patients with DAVF treated with SRS or Emb-SRS. We investigated the long-term obliteration rate and obliteration-associated factors. We developed a new grading system to estimate the obliteration rate. Additionally, we compared the outcomes of SRS and Emb-SRS by using propensity score matching. Results: The 3- and 4-year obliteration rates were 66.3% and 78.8%, respectively. The post-SRS hemorrhage rate was 2%. In the matched cohort, the SRS and Emb-SRS groups did not differ in the rates of obliteration (P=0.54) or post-SRS hemorrhage (P=0.50). In multivariable analysis, DAVF location and cortical venous reflux (CVR) were independently associated with obliteration. The new grading system assigned 2, 1, and 0 points to DAVFs in the anterior skull base or middle fossa, DAVFs with CVR or DAVFs in the superior sagittal sinus or tentorium, and DAVFs without these factors, respectively. Using the total points, patients were stratified into the highest (0 points), intermediate (1 point), or lowest (≥2 points) obliteration rate groups that exhibited 4-year obliteration rates of 94.4%, 71.3%, and 60.4%, respectively (P<0.01). Conclusions SRS-based therapy achieved DAVF obliteration in more than three-quarters of the patients at 4 years of age. Our grading system can stratify the obliteration rate and may guide physicians in treatment selection.

Endoscopic papillectomy (EP) for ampullary adenomas achieves cure rates ranging from 76% to 90%, and recurrence rates are as high as 33%. If remnant or recurrent lesions after prior EP are endoscopically visible and are not suspected of intraductal extension into the biliary or pancreatic duct, repeated snaring and cutting can be performed until all visible lesions are completely resected. However, endoscopic ablative therapies, particularly argon plasma coagulation, can be attempted for tiny or uncertain remnant and recurrent lesions. In addition, intraductal radiofrequency ablation has recently been attempted for residual intraductal lesions after EP at several institutions. Although still under investigation, it has shown some promise. It might be offered as an alternative to surgery, particularly in patients who are unfit for surgery or those who refuse to undergo surgery.

In Japan, cost-effectiveness evaluations for medicines and medical devices are scheduled to be introduced in April, 2019 in a full-scale mode, following 2-year trial. The whole process of the “Cost-Effectiveness Evaluation (Japanese HTA：Health Technology Assessment)” is divided into three steps that are “Assessment” , “Appraisal” , and “Decision” . In the process of the “Appraisal”, the results of cost-effectiveness analysis (CEA) are evaluated along with the several factors other than CEA, such as social and ethical elements. The Special Committee on Cost-Effectiveness Evaluation (SCCEE) of Central Social Insurance Medical Council (CSIMC) has determined four factors that should be considered during the “Appraisal” process, as follows. 1) Benefit from the standpoint of public health (e.g. measures for infectious diseases), 2) Additional costs which are not included in public health insurance (e.g. long-term care costs, productivity costs), 3) Life-prolonging therapy for long-standing severe diseases, 4) Treatment for the diseases in which alternative treatment is not sufficiently present. Special attention for ‘Innovation’ used to be discussed in SCCEE, however, they decided not to employ it as a considerable factor for the “Appraisal” , since it had already received ‘Innovation premium’ at an initial pricing process. It is controversial whether the Japanese HTA agency should ask the pharmaceutical companies to present another CEA model that includes public health view or indirect costs, or just consider 1) and/or 2) factors as qualitative or semi-quantitative ones during “Appraisal” process. As for 3), they should pay attention for the special situation of the patients with end of life stage. SCCEE has declared that they will use the results of HTA just for adjusting the price of medicines or devices, not for insurance covering decision, while UK uses it for the latter purpose. It will be necessary further discussion on problems regarding “Appraisal” process, considering the difference of purpose for utilizing HTA results between Japan and UK.

Colorectal endoscopic submucosal dissection (ESD) is now a well-established endoscopic treatment for early-stage colorectal neoplasms, especially in Asian countries, including Japan. Despite the spread of colorectal ESD, there are still situations in which achieving successful submucosal dissection is difficult. Various novel techniques and devices have been developed to overcome these difficulties, and past reports have shown that some of these strategies can be applied to colorectal ESD. We review several recent developments in the field. The techniques reviewed include the pocket creation method and traction methods and the devices reviewed include the overtube with balloon and electrosurgical knives with water-jet function. These improved techniques and devices can facilitate safer, more reliable ESDs and expand its applicability and acceptability all over the world.
Asian Continental Ancestry Group ; Colorectal Neoplasms ; Humans ; Japan ; Methods ; Traction

Endoscopic submucosal dissection (ESD) for early gastric cancer is a well-established procedure with the advantage of resection in an en bloc fashion, regardless of the size, shape, coexisting ulcer, and location of the lesion. However, gastric ESD is a more difficult and meticulous technique, and also requires a longer procedure time, than conventional endoscopic mucosal resection. These factors naturally increase the risk of various complications. The two most common complications accompanying gastric ESD are bleeding and perforation. These complications are known to occur both intraoperatively and postoperatively. However, there are other rare but serious complications related to gastric ESD, including aspiration pneumonia, stenosis, venous thromboembolism, and air embolism. Endoscopists should have sufficient knowledge about such complications and be prepared to deal with them appropriately, as successful management of complications is necessary for the successful completion of the entire ESD procedure.
Constriction, Pathologic ; Embolism, Air ; Hemorrhage ; Pneumonia, Aspiration ; Stomach Neoplasms ; Ulcer ; Venous Thromboembolism

Purpose: Our previous study compared the characteristics of middle-aged persons who regularly take hot bathtub baths with those who do not and found taking hot bathtub baths helped to have good sleep and increase self-rated health. However, few studies have focused on this habit among young people. This study therefore compared the characteristics of young persons who regularly take hot bathtub baths with those who do not and clarify the potential effects of habitual bathtub bathing on their health. Methods: In this cross-sectional study, a self-reported questionnaire on bathtub bathing habits and general health and lifestyle was distributed to 483 university students between May and June 2013. Respondents were divided into two groups: those who took 3 or more bathtub baths per week (high-frequency group) and those who took 2 or fewer bathtub baths per week (low-frequency group). Differences between the groups were determined for sex, age, living with or apart from one’s family, quality of sleep, sense of fatigue, and self-rated health. Prior to conducting the study, the study protocol was approved by the Institutional Review Board of Daito Bunka University. Results: We obtained 394 responses (response rate: 81.6%) and analyzed 376 valid responses. Those who answered the question on bathtub bathing habits were divided into a high-frequency group (176 persons, 47%) and a low-frequency group (200 persons, 53%). The high-frequency group (52% men, 43% women, 5% sex was unknown) had a slightly greater proportion of men than in the low-frequency group (p=0.07). The two bathing frequency groups did not significantly differ by age group(p=0.43), and the age distribution in the high-frequency group age was 51% among 18 year olds, 45% among 19 year olds, 39% among 20 year olds, 48% among 21 year olds, and 61% among 22 year olds and older. Significantly more of the high-frequency group lived with their family (70% versus 23% living alone) than the low-frequency group (p<0.001). In terms of quality of sleep, 62% of the high-frequency group and 60% of the low-frequency group reported having good sleep (p=0.72). For sense of fatigue, 27% of the high-frequency group and 23% of the low-frequency group reported they did not experience fatigue (p=0.36), and for self-rated health, 81% of the high frequency group and 76% of the low-frequency group reported they were healthy (p=0.30). While there were no significant differences between the two groups, the findings suggest that those in the high-frequency group experienced good health. Results of logistic regression analysis adjusted for living with or apart from family showed the following odds ratios (95% confidence intervals) in the high-frequency group: good quality of sleep 1.02 (0.63-1.66), no fatigue 1.37 (0.76-2.46), and self-rated health 1.61 (0.90-2.89). Conclusion: Among university students in this study, men and persons living with their families were highly likely to take hot bathtub baths regularly. While there were no significant differences between the high and low frequency bathers, taking hot bathtub baths may marginally help to reduce fatigue and increase self-rated health. Competing interests: The authors declare no conflicts of interest.

Objective: In the intensive care unit (ICU), drugs are administered in sequence as the conditions of the patient change rapidly, and there are often cases where many injections are administered simultaneously.  For this reason, it is important to quickly select the appropriate administration route.  In this study, we prepared a quick reference table for incompatibilities of frequently used and highly important injections in the ICU (referred to as the “quick reference table”) that will enable selection of the appropriate administration route, and we investigated the status of use and usefulness of this quick reference table.
Methods: The drugs included in the quick reference table were extracted from prescription records from May to October 2009, and these were finalized by discussions with the nurses in the ICU.  Three reference materials were used: Manual on the Supervision of Injection Preparation (3rd Edition), Data Search on Injection Incompatibilities 2009, and MICROMEDEX®.  The survey was conducted with all 12 nurses in the ICU after 4 months of distributing the quick reference table.
Results: The quick reference table included 57 pharmaceutical items, and compatibility was classified into 10 categories.  The quick reference table was prepared as one A3 page for convenience.  The retrieval rate of the survey was 100%.  The average number of years of practical experience as a nurse was 12.2 years, and 11 out of 12 nurses used the quick reference table.  Of the 11 nurses who used the table, 6 answered that it was “very useful,” while 4 answered that it was “useful.”  All 11 nurses who used the quick reference table answered that they “consulted the pharmacists less frequently.”
Conclusion: Satisfactory evaluations were obtained with regard to the details included in the quick reference table, and the table was estimated to be highly useful and important even for ICU nurses with many years of experience.  Furthermore, it was suggested that the quick reference table was also useful in reducing the workloads of the pharmacists.

Purpose: In Japan, only a few studies reported self-management systems of narcotic drugs among hospitalized patients. Our purpose was to develop a self-management system for patients and assess its effectiveness. Methods: Based on the results of a questionnaire administered to our hospital medical staff, methods of selecting eligible patients and methods of self-management of narcotic drugs were determined by a multi-professional team. Selection criteria for eligible patients were: 1) satisfactory results on assessment of the patient's ability to self-manage orally-administered drugs; 2) satisfactory results on assessment of the patient's ability to self-manage narcotic drugs; 3) physician's consent was obtained; and 4) the patient wanted to participate in this program. After the period of self-management of drug administration, questionnaires were distributed to the patients and medical staff in the general ward. Results: One hundred hospitalized patients used narcotic drugs between April 2008 and March 2009. Among them, 26 patients met the criteria for self-management of narcotic drugs, and 20 voluntarily participated in the program. There were no reports of missing or stolen drugs. There were no reports of administration of incorrect dose of the drug during the self-management period (average 15.0 days). Ninety-four percent of the self-managing patients provided positive feedback about self-management of narcotic drugs, such as mental stability by having drugs on hand and no problems in self-management. Seventy-five percent of staff members answered that the self-management system of narcotic drugs should be continued. Conclusion: Our results suggest that this system of narcotic drug self-management is safe and appropriate. Palliat Care Res 2010; 5(1): 114-126