Background/Aims: Hybrid endoscopic submucosal dissection (ESD), in which an incision is made around a lesion and snaring is performed after submucosal dissection, has some advantages in colorectal surgery, including shorter procedure time and preventing perforation. However, its value for rescue resection in difficult colorectal ESD cases remains unclear. This study evaluated the utility of rescue hybrid ESD (RH-ESD). Methods: We divided 364 colorectal ESD procedures into the conventional ESD group (C-ESD, n=260), scheduled hybrid ESD group (SH-ESD, n=69), and RH-ESD group (n=35) and compared their clinical outcomes. Results: Resection time was significantly shorter in the following order: RH-ESD (149 [90–197] minutes) >C-ESD (90 [60–140] minutes) >SH-ESD (52 [29–80] minutes). The en bloc resection rate increased significantly in the following order: RH-ESD (48.6%), SH-ESD (78.3%), and C-ESD (97.7%). An analysis of factors related to piecemeal resection of RH-ESD revealed that the submucosal dissection rate was significantly lower in the piecemeal resection group (25% [20%–30%]) than in the en bloc resection group (40% [20%–60%]). Conclusions RH-ESD was ineffective in terms of curative resection because of the low en bloc resection rate, but was useful for avoiding surgery.

Background/Aims: The frequency and details of nonalcoholic fatty liver disease (NAFLD) complications in patients with inflammatory bowel disease (IBD) remain unclear. This study aimed to clarify characteristics of NAFLD in patients with IBD. Methods: We retrospectively identified and enrolled patients with IBD diagnosed with or without NAFLD by undergoing abdominal computed tomography (CT) at our institution between 2005 and 2020. The primary endpoint was the complication rate of NAFLD in patients with IBD. Secondary endpoints were the clinical characteristics of nonobese patients with IBD and comorbid NAFLD and their association with nutritional and inflammatory parameters. Results: Twenty-one (21.9%) of 96 eligible patients with IBD also had NAFLD. In nonobese patients (defined as patients with a body mass index <25 kg/m2), C-reactive protein (CRP; P<0.001) and alanine aminotransferase (P=0.018) levels were higher and the albumin level (P=0.005) and prognostic nutritional index (PNI; P=0.002) values were lower in patients with NAFLD than in those without NAFLD. The PNI value was positively correlated (P<0.001) and the CRP level was negatively correlated (P=0.001) with the hepatosplenic ratio. However, in the NAFLD combined group, PNI (P<0.05) and CRP values (P<0.001) were improved over time after CT imaging by continuing IBD treatment. Conclusions Worsening nutritional and inflammatory status in IBD patients is associated with complications of NAFLD. Diagnosis of NAFLD in IBD patients using CT imaging might be useful not only for early detection of NAFLD but also in assessing the need for therapeutic intervention for IBD.

A 57-year-old man complained of dyspnea, and his echocardiography showed diffuse severe left ventricular dysfunction. Five days after admission and starting the treatment for congestive heart failure, a computed tomography pointed out DeBakey type 1 aortic dissection with a patent false lumen incidentally. The ostium of the left coronary artery was compressed with the false lumen, and this finding was thought to be a cause of development of left ventricular dysfunction. A modified Bentall procedure with bioprosthesis and total arch replacement were performed. The patient was discharged on the 28th postoperative day without any complications.

BACKGROUND/AIMS: Tacrolimus is effective for refractory ulcerative colitis in adults, while data for children is sparse. We aimed to evaluate the effectiveness and safety of tacrolimus for induction and maintenance therapy in Japanese children with ulcerative colitis.METHODS: We retrospectively reviewed the multicenter survey data of 67 patients with ulcerative colitis aged < 17 years treated with tacrolimus between 2000 and 2012. Patients’ characteristics, disease activity, Pediatric Ulcerative Colitis Activity Index (PUCAI) score, initial oral tacrolimus dose, short-term (2-week) and long-term (1-year) outcomes, steroid-sparing effects, and adverse events were evaluated. Clinical remission was defined as a PUCAI score < 10; treatment response was defined as a PUCAI score reduction of ≥ 20 points compared with baseline.RESULTS: Patients included 35 boys and 32 girls (median [interquartile range] at admission: 13 [11–15] years). Thirty-nine patients were steroid-dependent and 26 were steroidrefractory; 20 had severe colitis and 43 had moderate colitis. The initial tacrolimus dose was 0.09 mg/kg/day (range, 0.05–0.12 mg/kg/day). The short-term clinical remission rate was 47.8%, and the clinical response rate was 37.3%. The mean prednisolone dose was reduced from 19.2 mg/day at tacrolimus initiation to 5.7 mg/day at week 8 (P< 0.001). The adverse event rate was 53.7%; 6 patients required discontinuation of tacrolimus therapy.CONCLUSIONS: Tacrolimus was a safe and effective second-line induction therapy for steroid-dependent and steroid-refractory ulcerative colitis in Japanese children.
Adult ; Asian Continental Ancestry Group ; Biological Factors ; Child ; Colectomy ; Colitis ; Colitis, Ulcerative ; Female ; Humans ; Immunologic Factors ; Japan ; Prednisolone ; Remission Induction ; Retrospective Studies ; Tacrolimus ; Ulcer

Sources of research funding: We gratefully acknowledge the support of the 17th Congress of the Japanese Society for Emergency Medicine support of this program.
Ethical considerations: The program was conducted after receiving approval from the Institutional Animal Experiment Committee of the Jichi Medical University, and in accordance with the Institutional Regulation for Animal Experiments and Fundamental Guideline for Proper Conduction of Animal Experiment and Related Activities in Academic Research Institutions under the jurisdiction of the Ministry of Education, Culture, Sports, Science and Technology of Japan. It was approved on April 9th, 2014. The approval number is 14-225.
Disclosure of conflicts of interests: We gratefully acknowledge the contributions of personnel from Panasonic Corp. who enabled the interactive communication system.
Abstract
Introduction: Live surgery demonstrations have been widely used in surgical education. However, they cannot be used to demonstrate trauma surgery due to the emergency situation and lack of informed consent. The aim of this study was to conduct a live demonstration of trauma surgery with a porcine model to increase educational opportunities in trauma surgery.
Methods: Live demonstration was conducted at the Center for Development of Advanced Medical Technology (CDAMtec) , Jichi Medical University, Japan. An experienced trauma surgeon instructed three trainees during a live demonstration using pre-planned injuries in a porcine model. A six-point Likert Scale was used on a written survey to determine the value of the program to the viewers. Free-form written comments were also obtained from the participants. Live images of the surgical field were transmitted to a lecture room by a closed wireless LAN with interactive bidirectional audio capability.
Results: Eighty-three participants viewed this live demonstration and completed the questionnaire. Participants were highly satisfied with the live demonstration (mean survey scores: 4.6-5.1/6) , and gave very positive feedback concerning the educational value of this program. Nine free-form comments were submitted, which revealed that the participants felt they could acquire concrete skills for trauma surgery.
Discussion: Live demonstrations for trauma surgery using a porcine model are a feasible and effective educational tool to demonstrate technical procedures and non-technical skills, with possible added advantages regarding the ethical considerations of performing a live surgery demonstration.

Background: The pathogeneses of fibromyalgia syndrome (FMS) are related with the living way of a patient, that holds biopsychosocial-existential problems. Especially existential problems are more essential; such patients are sometimes in existential vacuum. It is impossible to care the patients by onlharmacotherapy; that needs psychotherapy and physical therapy. Logotherapy and existential analysis (LTEA) was established by Prof. Viktor Frankl to save such patients, that is one of the experimental psychotherapy. Balneotherapy (BT) is popular all around the world to cure stressful patients. Objective: We have developed Balneo-logotherapy (BLT) for patients with FMS by adding LTEA to the BT, which mainly consists of treatment carried out by taking bathes at a hot spring, a non-ordinary place. We also determined the prognosis one year after the therapy. Method of BLT: After enough motivation and the informed consent, a patient begins BLT program. The mean duration of the therapy was 4.5±1.2 weeks. During the period from the start of the BLT until the time the patient was relieved of Yuatari phenomenon (thermal crisis, bath reaction, YP), the patient was directed to do nothing. Therapist should pay attention to help the patient to overcome YP. After this period, the patient was given free time to do things such as taking a walk. Throughout the period of BLT, patients should write in the simple diary every day and record what they became aware concerning the body and the mind. Subjects and methods: Subjects were 65 patients with FMS (42.0 yrs±11.5, Male: Female = 24:41). Based on pathogenesis, FMS patients were classified into two groups: psychosomatic (PSD) Type (n=30) and PTSD Type (n=35). PSD type was mainly caused by loss of bodily sense (alexithymia) and hyper-adaptation. PTSD Type was mainly caused by trauma such as ill-treatment and war experience. The relationship between having YP or not and the prognosis was also determined. Results: Overall recurrence rate was 30.8%. Recurrence rates for each type were: 23.3% for PSD Type FMS, and 37.1% for PTSD Type. Incidence of YP occurrence was: 80.0% for all cases, 86.7% for PSD Type and 74.3% for PTSD Type. The more severe YP, the better the prognosis (p<0.05). One year after the therapy, cases without recurrence accounted for 69.2% of all the cases. In PSD Type, recurrence was not seen in 73.3%. In PTSD Type, recurrence was not seen in 65.7%. Recurrence rate was lower for the group of patients with development of YP. Discussion: Therapeutic self is most important; to create interpersonal communication to tune in the patient to get aware of intrapersonal communication (according to biopsychosocial-existential model) of the patient. Patient’s psychological movements were; Dependency ⇒ Awareness ⇒ Autonomy ⇒ Reset of the mind (through YP and ASC) ⇒ Intervention by the therapist to make change in behavior through the awareness of his own meaning of life. In this process, occurrence of YP is meaningful. A hot spa is a very suitable place to perform psychotherapy like logotherapy.

OBJECTIVEWe investigated relationship between job stress and self-rated health among Japanese nese full-time occupational physicians (OPs).

METHODSIn 2000, we mailed self-administrated questionnaires to 716 OPs. Of these OPs, 349 (49%) returned sufficiently completed questionnaires for analyses. oblique-rotated principal factor analysis of the job stress questionnaire extracted three components; low understanding of occupational health services in companies (low understanding), conflicts between occupational physicians and their coworkers (conflicts), and discrepancies between occupational physicians' routine work and occupational health services (discrepancies).

RESULTSThe model, in which low understanding contributed to self-rated health through job satisfaction and self-rated health was influenced by job satisfaction and discrepancies, provided a good fit to the data.

CONCLUSIONSWe found that a potential relationship between job stress and self-rated health among Japanese full-time OPs. The present results implied that among full-time OPs, low understanding contributed negatively to self-rated health through job satisfaction, and that self-rated health was influenced positively by job satisfaction and negatively by discrepancies.

OBJECTIVEThe present study investigated the relationship between coping skills and job satisfaction among Japanese full-time occupational physicians (OPs).

METHODSIn 2000 we mailed self-administered questionnaires to 716 full-time OPs who were members of "Sanyu-kai", the only Japanese association of full-time OPs. The questionnaires included age, gender, marital status, main type of company's work, the number of full-time OPs, the number of employees, working years as an OP, tenure in the present company, job stress, and coping skills question. The coping skills questions consisted of 11 items which were decided after discussion among several experienced full-time OPs. In total, 351 (49%) of the OPs returned suitable questionnaires for analyses.

RESULTSConsidering age, gender, marital status, and coping skills, multiple regression analysis (stepwise method) found that age, simplification of work, obvious roles for staff, consultations, and communication in the community and company were factors which contributed significantly to job satisfaction. Structural equation modeling showed that age and coping skills such as work system improvements, consultations, and communication in the community and company influenced job satisfaction.

DISCUSSIONOur results indicated that the age and coping skills influenced job satisfaction among full-time OPs. Our results are also considered to support the training of OPs in the future.

We reported a case of left atrial myxoma with renal infarction as an initial clinical symptom. A 65-year-old man had severe right lumbago. A chest CT demonstrated right renal artery embolism. On emergency operation a right renal embolus was removed. Preoperative echocardiography and transesophageal echo showed a tumor in his left atrium which was close to the mitral valve. The tumor was resected one week after the first operation. Embolectomy of the right renal artery could not restore renal function. To the best of our knowledge, this type of cardiac myxoma with renal infarction as an initial clinical symptom is rare.