With advances in cancer treatment, such as cytotoxic chemotherapy and radiotherapy, grave new sequelae of treatment have emerged for young cancer survivors. One sequela that cannot be overlooked is male infertility, with reportedly 15% to 30% of cancer survivors losing their fertility potential. Cytotoxic therapy influences spermatogenesis at least temporarily, and in some cases, permanently. The degree of spermatogenesis impairment depends on the combination of drugs used, their cumulative dose, and the level of radiation. The American Society of Clinical Oncology has created an index to classify the risks to fertility based on treatment. Medical professionals currently use this risk classification in fertility preservation (FP) programs. FP programs are currently being promoted to prevent spermatogenesis failure resulting from cancer treatment. For patients who are able to ejaculate and whose semen contains sperm, the semen (sperm) is cryopreserved. Moreover, for patients who lack the ability to ejaculate, those with azoospermia or severe oligozoospermia, and those who have not attained puberty (i.e., spermatogenesis has not begun), testicular biopsy is performed to collect the sperm or germ cells and cryopreserve them. This method of culturing germ cells to differentiate the sperm has been successful in some animal models, but not in humans. FP has recently gained popularity; however, some oncologists and medical professionals involved in cancer treatment still lack adequate knowledge of these procedures. This hinders the dissemination of information to patients and the execution of FP. Information sharing and collaboration between reproductive medicine specialists and oncologists is extremely important for the development of FP. In Japan, the network of clinics and hospitals that support FP is expanding across prefectures.

Azoospermia ; Cysts ; Humans ; Male ; Prostate ; Prostatic Diseases ; Saccule and Utricle ; Urethra

BACKGROUNDDespite an increasing awareness of the risk of medical errors, few data sources are available to highlight the characteristics and patterns of medical errors in the clinical management of rheumatoid arthritis (RA). The present study aimed to evaluate medical malpractice claims associated with the management of RA and other autoimmune connective tissue diseases (ACTDs).

METHODSWe analyzed 38 ACTD-associated closed claims extracted from a total of 8530 claims processed between July 2004 and June 2014 by the Tokyo headquarters office of Sompo Japan Nipponkoa Incorporated, a leading malpractice insurer in Japan.

RESULTSRA was the most common ACTD assessed in this study, accounting for 20 cases. Although the male-to-female ratio among these cases was 5:15, in accordance with the general demographic distribution of RA, the proportion of patients older than 60 years (77.8%) was relatively high as the general range of RA susceptibility is 30-50 years. The analysis of allegation types among RA cases revealed statistically significant differences from non-RA cases (Fisher's exact test) as well as the following key findings: diagnosis-related allegations were absent (P < 0.01), whereas medication-related allegations were distinctively common (P = 0.02). Clinical processes related to the assessment process were most vulnerable to breakdown and leading to negligence identified with subsequent medication-related allegations, particularly among RA cases.

CONCLUSIONSThe characteristics of malpractice claims associated with RA management, including the high frequency of medication-related allegations, breakdowns in the assessment process, and high claim numbers among patients older than 60 years, suggest the importance of caution exercised by physicians when administering immunosuppressants for the clinical treatment of RA.

　　A 48-year-old man with jaundice was referred to our hospital. Endoscopic retrograde cholangiography showed primary sclerosing cholangitis. Endoscopic biliary drainage was not successful because of highly viscous bile, so we performed percutaneous trans-gallbladder drainage (PTGBD), which was able to reduce the total serum bilirubin level from 8 to 10mg/ml. Subsequently, an indwelling drainage catheter was placed in the gallbladder for 13 months. However, liver atrophy worsened with the gradual progression of hepatic failure. Twelve months later, he complained of dyspnea. Computed abdominal tomography showed that the drainage catheter had perforated the diaphragm and become exposed to the chest cavity. In spite of intensive care, the patient died of liver failure while waiting for a liver transplant. Careful attention should be paid to the possibility of this serious complication in such patients.

The removal of aspiration objects is often required for aspiration, which takes place at the time of a video fluoroscopic examination of swallowing (VF) for the assessment of dysphagia rehabilitation. We report our approach against correspondence for aspiration at VF.　　As subjects for this report, we sampled 6 patients (average age: 78.3±3.0, four males and two females) from 19 patients, who had aspiration of barium sulfate or meal with barium contrast medium at the time of VF form October 1, 2009, to March 31, 2011. For the first step of correspondence for aspiration at VF, we dealt with coughing, huffing, suction and postural drainage under the guidance of a Speech-Language-Hearing Therapist and, depending on the case, a Physical Therapist who dealt with chest physical therapy. When expectoration was found impossible, we checked to see if it was necessary to perform biphasic cuirass ventilation with a clinical engineer. We assessed the chest X-ray films and existence or non-existence of expectoration immediately after aspiration, and fever, inflammatory response, respiratory symptoms and gastrointestinal symptoms one week after the examination, and retrospectively checked the influence of aspiration.　　As a result, three patients had residue as revealed on chest X-ray films, and the three remaining patients had none. For the former three patients, we intervened in a team approach and succeeded in removing the residue from two patients (one with initial correspondence, and the other with execution by the Physical Therapist). Though two patients had fever and inflammatory response one week later, It was hardly possible that aspiration at the time of VF became a direct cause. No patient had either the respiratory or gastrointestinal symptom.　　Correspondence for aspiration was attained by establishing a team approach system. Even if a patient had heavy aspiration, it was not reflected on chest X-ray films, depending on the case, and therefore deliberation was required for correspondence.

Objective: Macrolide therapy has been recommended as an effective treatment for pediatric otolaryngology patients with conditions such as chronic sinusitis and otitis media with effusion.  However, in many cases, a relapse may occur after cessation of treatment.  Therefore, patients are compelled to continue taking antibiotics.  In this paper, we examined the relationship between the duration of therapy and period to relapse on the basis of prescription information and literature research.
Methods: To evaluate the therapeutic doses, we investigated the clinical doses of erythromycin and clarithromycin used for pediatric patients in a community pharmacy from January 2009 to July 2009.  Further, we performed literature searches on the doses of both drugs using Igaku-Chuo-Zasshi databases (from 1983 to 2011) and compared the data obtained with the clinical doses.  Accordingly, the oral doses of macrolides were classified as a low dose or normal dose.  We analyzed the relationship between the administration period and the cessation period, which was defined as the period from the cessation of the treatment to relapse.
Results: Review of the 17 selected reports and the clinical doses showed that the maximum dose of erythromycin was 15 mg/kg/day and that of clarithromycin was 8 mg/kg/day during therapy.  When both cephem or penicillin antibiotics and low-dose macrolides were taken continuously during the administration period, a weak correlation was observed between the administration period and the cessation period.
Conclusion: These results may be useful for the appropriate use of antibiotics and for preventing relapse in pediatric otolaryngology patients.

INTRODUCTIONPulse oximetry (SpO2) measures oxygen saturation but not alveolar ventilation. Its failure to detect alveolar hypoventilation during sedated endoscopy under oxygen supplementation has been reported. The aim of this study was to measure the masking effect of oxygen supplementation in SpO2 when alveolar hypoventilation develops during sedated endoscopy.

METHODSA total of 70 patients undergoing sedated diagnostic colonoscopy were randomly divided into two groups - oxygen supplementation group (n = 35) and room air breathing group (n = 35). SpO2 and end-tidal carbon dioxide (etCO2) were measured by non-intubated capnography during the procedure for all the patients.

RESULTSThe rise of etCO2 caused by alveolar hypoventilation was comparable in the two groups after sedation. SpO2 was significantly higher in the oxygen supplementation group than in the room air breathing group (98.6% ± 1.4% vs. 93.1% ± 2.9%; p < 0.001) at peak etCO2, and oxygen supplementation caused SpO2 to be overestimated by greater than 5% when compared with room air. SpO2 at peak etCO2 was reduced from the baseline before sedation for the oxygen supplementation and room air breathing groups by 0.5% ± 1.1% and 4.1% ± 3.1%, respectively (p < 0.001).

CONCLUSIONSpO2 alone is not adequate for monitoring alveolar ventilation during sedated endoscopy under oxygen supplementation due to possible delays in detecting alveolar hypoventilation in patients. Even if SpO2 decreases by only 1% during the procedure and its level remains near 100%, physicians should consider the onset of severe alveolar hypoventilation, which requires immediate intervention.

Adult ; Aged ; Carbon Dioxide ; analysis ; Colonoscopy ; Conscious Sedation ; Endoscopy ; Female ; Humans ; Hypoventilation ; diagnosis ; Male ; Middle Aged ; Monitoring, Intraoperative ; methods ; Oximetry ; methods ; Oxygen ; administration & dosage ; Respiration, Artificial

Background: Although previous reports have shown a lower proportion of the ACTN3 XX genotype (R577X nonsense polymorphism) in sprint/power athletes compared with controls, possibly attributed to the importance of skeletal muscle function associated with alpha-actinin-3 deficiency, the findings on association between endurance athlete status and R577X genotype are equivocal. Purpose: The present study was undertaken to examine association of ACTN3 R577X genotype with elite Japanese endurance athlete status. Subjects and Methods: Subjects comprised 79 elite Japanese endurance runners (E) who participated in competition at national level and 96 Japanese controls (C). We divided endurance runners into two groups, i.e., 42 national level runners (E-N) and 37 international level runners (E-I) who had represented Japan in international competition. R577X genotype (rs1815739) was analyzed by direct sequencing. Frequency differences of polymorphisms between athletes and controls were examined by Chi-square tests. Result: The R allele frequency tended to be higher in E group than in C group (P=0.066). When we divided E into two groups, the R allele frequency in E-I group was significantly higher than that in C group (P=0.046); whereas there were no significant differences between E-N and C groups (p=0.316). Then, the three genetic models were tested. In the additive genetic model (RR>RX>XX), there were significantly differences between E-I and C (P=0.038), but not the dominant (RR vs. RX+XX) and the recessive (RR+RX vs. XX) genetic models. Conclusion: R allele of the R577X genotype in the ACTN3 gene was associated with elite Japanese endurance athlete status.

The aim of this study was to reveal the mechanism of exaggerated blood pressure rise during resistance exercise. Muscle sympathetic nerve activity (MSNA), heart rate (HR), blood pressure (BP) and grip force were measured during static handgrip exercise. After a 3-minute control period, intermittent static handgrip exercises (10 30-sec contractions with a 30-sec pause between contractions) at 30% of maximum voluntary contraction (HG 30) or with maximum voluntary effort (HGMX) were performed in nine healthy volunteers who gave their consent in advance to participate in this study. In the HG 30 study, MSNA did not increase compared with the control value until the fifth grip exercise, and BP rose during the third HG exercise. HR was elevated in the first grip exercise and remained elevated up to the 10th grip exercise. During HGMX, MSNA, HR and BP increased significantly during the first grip exercise compared to the control rest, and MSNA and BP rose even further as the contractions accumulated; while HR response remained almost constant throughout the contractions. Mean handgrip force decreased progressively with the increasing number of grip exercises.
These results indicate that exaggerated BP rise during static muscle contraction dose not seem to be muscle reflex, at least, during the first several contractions; but rather other factors such as central command or mechanical compression of vessels. However, muscle reflex, for instance metaboor mechanoreflex may contribute to elevated BP when the number of contractions accumulate or muscle fatigue develops.

A study was conducted to determine whether anticipation of exercise alters the responses of sympathetic nerve activity to muscle contraction. Sympathetic nerve activity leading to the skin (SSA) and muscle (MSA) was recorded from the tibial nerve in the left and right legs using tungsten microelectrodes. Heart rate and blood pressure (oscillometric method) were also measured during the experiment. Seven healthy subjects, who gave informed consent, participated in the experiment. They were asked to exert a static handgrip (SHG) for 2 min at a tension of 30% of maximal voluntary handgrip. Two different situations were set before the commencement of exercise. One was that after several minutes of controlled rest, a countdown was started 2 min before the exercise, and then the handgrip was applied (Cond. 1) . The other was that a preparation time of between 7 and 5 min was set prior to the handgrip exercise while no information regarding the starting time of exercise was given to the subjects (Cond. 2) . SSA for 30 s just before the exercise was increased in comparison with the control value at rest in Cond. 1, but not in Cond. 2. There was no difference in the SSA response patterns to SHG between the two conditions. Before the commencement of SHG, MSA did not alter from the control value at rest in either condition. The magnitudes of the increase in MSA during SHG were almost identical under both conditions. Heart rate for 30s before SHG in Cond. 1 was increased significantly from the control value, whereas there was no significant change in Cond. 2. The magnitude of the heart rate response to SHG was the same in both conditions. The mean blood pressure showed no significant change before SHG, but increased significantly during SHG in both conditions. The increases in SSA and heart rate prior to the commencement of exercise may be related to the anticipatory response to the exercise, although this response was not significant in MSA. These results confirm that anticipation of exercise increases sympathetic outflow to the skin. This may be advantageous in adapting the body to exercise.