The U-40 generation of surgeons are practicing through trial and error, and form various careers. At the 51st Annual Meeting of the Japanese Society of Cardiovascular Surgery, U-40 Special Project, we looked back on the U-40 generation and more senior doctors to see what kind of future visions, problems and careers they have had. We conducted a questionnaire for the purpose of visualizing the future prospects of the U-40 generation. In this article, we report the results.

Methods: Nineteen volunteers (16 men, three women) lifted a 60-kg doll from a seated position to a standing position. The first transfer was performed without the HAL for Care Support, and the second was performed with the HAL for Care Support assistive robot. We evaluated transfer performance, the visual analog scale (VAS) score for lumbar fatigue, and electromyogram analyses of the trunk and hip. Results: Four participants (two men, two women) succeeded with the HAL for Care Support even though they were unable to perform the task without it. The mean lumbar fatigue VAS score for all participants without the HAL for Care Support was 62 mm, while that with it was 43 mm. With lumbar assistance from the HAL for Care Support, subjective lumbar fatigue during the transfer decreased significantly. A power analysis indicated adequate statistical power to detect a difference in the VAS score for lumbar fatigue (0.99). The activity of the left gluteus maximus alone increased significantly during transfers with the HAL for Care Support. No adverse events occurred during use of the HAL for Care Support for transfers. Conclusions The HAL for Care Support was able to reduce lumbar load in a simulated patient transfer.

In the U-40 column, we conducted a questionnaire survey of the U-40 generation on the theme of the specialist system for cardiovascular surgery and reported on the present condition and problems in obtaining certification. With the introduction of a new system, off the job training and participatory training using extracorporeal circulation techniques were newly mandated. In this article, we report the results and discussion of the questionnaire survey regarding the present condition of extracorporeal circulation training for the U-40 generation and the pros and cons of training programs.

We investigated how cardiovascular surgeons get a day off.

Calcification of the ligamentum flavum (CLF), which is a rare disorder that can potentially cause myelopathy, occurs uncommonly in the thoracic spine. Here, we report a rare case of thoracic myelopathy caused by CLF in a 78-year-old man. Magnetic resonance imaging (MRI) showed posterior spinal cord compression by a hypo-signal intense mass, and computed tomography (CT) revealed CLF and vacuum disc phenomenon at T10/11. After undergoing posterior decompression and instrumented fusion (T9–T12), the patient’s gait difficulties improved. The pathogenesis of CLF is largely unknown; however, it involves accumulation of calcium pyrophosphate dehydrate crystals (CPPD), and CLF from CPPD deposition tends to occur within a thickened and hypertrophic ligament. CLF occurs predominantly in the cervical spine and less frequently in the lumbar spine, with few cases involving the thoraco-lumbar spine. The thoracic spine is characterized by hypomobility; however, the thoraco-lumbar spine has a mobile segment which may potentiate CLF formation. Decompression with fusion surgery can be useful for treating patients with thoraco-lumbar CLF.

Objective: Whether or not emergent decompression/fusion surgery for paralysis caused by metastatic spinal tumors of unknown origin improves patient neurological outcome and survival remains unclear. This study aimed to evaluate the clinical outcomes of emergent decompression/fusion surgery for paralysis caused by spinal tumors of unknown or not previously diagnosed origin.Patients and Methods: Data from the medical records of 11 patients with spinal tumors of unknown origin (study group) were compared with those of 15 patients with metastatic spinal tumors of known origin (control group). The outcome measures were postoperative performance status, motor function evaluated with the Frankel grade, and actual survival after surgery as compared with the estimated survival calculated using the Tokuhashi score. χ2 analyses were performed to evaluate differences between the groups.Results: The mean performance status was 3.6 preoperatively, which improved to 2.9 postoperatively (P<0.05), in the unknown origin group and 3.6 preoperatively, which improved to 2.7 postoperatively (P<0.05), in the control group. Seven patients (64%) in the unknown origin group showed improvement in paralysis by ≥1 Frankel grade. By contrast, only 4 patients (27%) in the control group showed improvement in paralysis. The unknown origin group tended to show better improvement (P=0.05). All the patients in the unknown origin group underwent adjuvant therapy after definitive diagnosis following surgery. The unknown origin group showed a slight tendency toward better survival than toward the estimated survival.Conclusion: Emergent decompression/fusion surgery for patients with paralysis caused by metastatic tumors of unknown origin is potentially useful for diagnosing tumor origin and improving neurological outcomes and performance status, and thus for extending survival.

Context: Delirium in cancer is often difficult to control and refractory when haloperidol is invalid which is considered standard therapy. We need second and subsequent-line therapy to reduce hyperactivity and not to over-sedation for refractory delirium. Objectives: To investigate the efficacy and safety of continuous subcutaneous infusion chlorpromazine on delirium refractory to first-line antipsychiatric medications in advanced cancer palliative care setting. Method: The study population consisted of patients who received continuous subcutaneous infusion chlorpromazine for delirium at two certified PCU. Primary endpoint was the proportion of patients who showed improvements in delirium severity by Delirium Rating Scale Revised 98 score of less than 13 or decrease from baseline and maintained the ability to communicate coherently by Communication Capacity Scale Item-4 score of 2 or less. Secondary outcome were the Nursing Delirium Screening Scale subscale score, and injection site reactions evaluated according to the Common Terminology Criteria for Adverse Events. These outcome measures were assessed at baseline, 48 hours and 7 days after the start of the study. Result: Among eighty-four patients, sixty were positive responders (71.4%, 95% CI [61–80]). The mean CCS Item-4 scores significantly decreased from the baseline value of 1.48 (range 0–3) to 1.03 (range 0–3) at post-treatment (p<0.001). Grade 2 or higher injection site reactions were observed in 1 patient (1.2%, 95% CI [0–7]). Conclusion: Our study suggested that continuous subcutaneous infusion chlorpromazine could improve refractory delirium symptoms and patients’ communication capabilities. Although most of the skin disorders observed in association with chlorpromazine were mild, their incidence rates were relatively high, suggesting the need for careful monitoring.

Objective: To treat vertebral fractures with posterior wall injury in the elderly, vertebral bone grafting is generally performed through a posterior transpedicular approach, combined with pedicle screw fixation. An autologous bone is ideal to treat this disorder. However, harvesting autologous bones from the elderly with osteoporosis is limited by the amount and quality of available autologous bone. Thus, we developed a bone-grafting substitute. The newly developed unidirectional porous β-tricalcium phosphate, with a porosity of 57% (UDPTCP; Affinos®, Kuraray Co., Ltd., Tokyo, Japan), is used in the bone-grafting procedure. This is the first report of UDPTCP used as an artificial bone graft in patients with an acute vertebral burst fracture.Materials and Methods: UDPTCP (mean: 4.2 g) was implanted through the pedicle, and posterior instrumentation was achieved with pedicle screws in five elderly patients. Resorption of UDPTCP and substitution with the autologous bone were evaluated on computed tomography (CT) and plain X-ray performed immediately and at 3, 6, and 12 months after the operation.Results: In case 1, the pedicle screws did not loosen, and UDPTCP was completely resorbed and replaced with the autologous bone at 3 postoperative months. In the other four cases, although the pedicle screws or the caudal part loosened because of osteoporosis, resorption of UDPTCP was observed at 3 postoperative months. At 6 postoperative months, progressive substitution with the autologous bone was confirmed, and at 12 postoperative months, formation of the good autologous bone was confirmed.Conclusion: This preliminary case series demonstrated that the newly developed UDPTCP shows good clinical potential as a bone-graft substitute for acute vertebral burst fractures in the elderly, including patients with osteoporosis.

Continuous subcutaneous injections of medication are effective in controlling symptoms of the terminal stage of cancer. Chlorpromazine and levomepromazine occasionally cause skin irritation. We examined all patients who underwent continuous subcutaneous administration of psychotropic drugs (chlorpromazine, levomepromazine, midazolam) at the palliative care unit of our hospital from April 2010 to March 2013, the frequency of adverse skin reactions of Common Terminology Criteria for Adverse Events (CTCAE) v4.0 grade 3 or above. Of the 603 hospitalized patients, 389 (64.5%) underwent continuous subcutaneous administration of one of the three drugs. The frequency of grade 3 or above (ulceration or necrosis) adverse skin reactions was 4 out of 345 chlorpromazine cases (1.2%; 95% CI: 0.0-2.3%), 2 out of 90 levomepromazine cases (2.2%; 95% CI: −0.8-5.2%), and 0 out of 210 midazolam cases (0.0%; 95% CI: 0.0-0.0%). The frequency of serious adverse skin reactions caused by continuous subcutaneous administration of psychotropic drugs was low, suggesting that this treatment is relatively safe for the skin.

Introduction: The use of methadone in Japan is limited to cases being switched from the preceding use of strong opioids; the stop-and-go strategy is recommended in which the previously used opioid analgesic is discontinued and methadone is initiated at its full estimated dosage. Case: Refractory cancer pain due to an iliolumbar syndrome was temporarily exacerbated by the stop-and-go switching to methadone from morphine along with ketamine. Pain relief was achieved upon readministration and concomitant use of morphine with methadone after approximately two weeks. Discussion: Through examining this case, we believe that a stepwise switching strategy, rather than the stop-and-go strategy, could be more useful. Considering that overdosage may cause side effects, it is safer to initiate methadone with a small dose. However, more studies need to be conducted to decide whether the establishment of the initial dosage and dosage adjustment should be made more flexible to avoid pain intensification. Further investigation is required on whether the concomitant use of adjuvant analgesics such as ketamine, which similar to methadone is an NMDA receptor antagonist, should be continued when switching to methadone.