[Brain Metastasis Following Conversion Surgery for Sigmoid Colon Cancer-A Case Report].

A 64-year-old man was diagnosed with KRAS-mutant type sigmoid colon cancer with metastasis in the lung, liver, left adrenal gland, and para-aortic lymph node(T3N1M1b, Stage ⅣB[Union for International Cancer Control 8th edition]). Laparoscopic transverse colostomy was performed to treat colonic obstruction. Subsequently, a combination regimen of capecitabine plus oxaliplatin plus bevacizumab was administered. After 5 courses of chemotherapy, the S8 liver tumor disappeared completely. Sigmoidectomy, para-aortic lymph node dissection, and left adrenal gland resection were performed. After 3 months, right S3 segmental pneumonectomy and right S8 and S10 partial pneumonectomy were performed. R0 resection for the primary lesion and metastatic lesions of the chest and abdomen was achieved. Following the conversion surgery, he was administered the adjuvant chemotherapy regimen of uracil-tegafur plus Leucovorin. After 2 courses of chemotherapy, he presented to our hospital complaining of vomiting and dizziness. Contrast-enhanced magnetic resonance imaging revealed multiple brain metastases. Thus, we should be mindful of the possibility of brain metastasis in cases of unresectable colon cancer showing satisfactory response to chemotherapy with an indication of conversion surgery.

Celiac Artery Dissection and Retroperitoneal Hemorrhage in Median Arcuate Ligament Syndrome Treated With a Stent and Transcatheter Arterial Embolization: Preprocedural 4-Dimensional Computed Tomography Angiography Assessment.

A 61-year-old man presented with retroperitoneal hemorrhage caused by an aneurysm rupture of the pancreaticoduodenal arcade (PDA), and acute celiac artery dissection distal to celiac axis stenosis. Owing to the gradual growth of the false lumen, we planned to deploy a stent to the celiac artery dissection and embolize the PDA aneurysm. Prior to stent placement, we assessed the acute celiac artery dissection distal to the stenosis using four-dimensional computed tomography (CT) angiography through expiration/inspiration/expiration cycle. We diagnosed median arcuate ligament syndrome considering that the celiac axis showed a hooked narrowing at end-expiration, and the compression decreased at end-inspiration. Additionally, the true lumen distal to the stretched axis dilated in the inspiration phase. Therefore, we could advance a catheter into the true lumen during inspiration and successfully deploy a stent. Subsequently, laparoscopic median arcuate ligament release was performed after the stent deployment. A postoperative CT scan showed good patency in the stent, with disappearance of the blood filling the false lumen and with reduced celiac axis stenosis.

[Rectal Neuroendocrine Tumor G2 of Measuring Less Than 1 cm in Diameter with Lymph Node Metastases-A Case Report].

A 40-year-old man visited our hospital with rectal submucosal tumors measuring 5 mm and the 7 mm as detected by colonoscopy, following which an endoscopic submucosal resection was performed. Pathological examination revealed that the tumors was neuroendocrine tumor(NET); the tumor measuring 5 mm was NET G1 without lymphatic and venous invasion, while the 7 mm size was NET G2 with venous invasion but without lymphatic invasion. Lymph node and distant metastasis were not observed by computed tomography. Informed consent was obtained and he agreed to undergo additional rectal resection. Laparoscopic low anterior resection was performed and pathological examination enabled a diagnosis of rectal neuroendocrine tumor with regional lymph node metastases(T1a, N1, M0, Stage ⅢB[Union for International Cancer Control 8th edition]). Post-surgery, he was followed up for 3 years, without recurrence. This report suggests that the determination of treatment plan for rectal neuroendocrine tumor measuring less than 1 cm in diameter should be done carefully.

Identification of B.1.346 Lineage of SARS-CoV-2 in Japan: Genomic Evidence of Re-entry of Clade 20C.

SARS-CoV-2 whole-genome sequencing of samples from COVID-19 patients is useful for informing infection control. Datasets of these genomes assembled from multiple hospitals can give critical clues to regional or national trends in infection. Herein, we report a lineage summary based on data collected from hospitals located in the Tokyo metropolitan area. We performed SARS-CoV-2 whole-genome sequencing of specimens from 198 patients with COVID-19 at 13 collaborating hospitals located in the Kanto region. Phylogenetic analysis and fingerprinting of the nucleotide substitutions were performed to differentiate and classify the viral lineages. More than 90% of the identified strains belonged to Clade 20B, which has been prevalent in European countries since March 2020. Only two lineages (B.1.1.284 and B.1.1.214) were found to be predominant in Japan. However, one sample from a COVID-19 patient admitted to a hospital in the Kanto region in November 2020 belonged to the B.1.346 lineage of Clade 20C, which has been prevalent in the western United States since November 2020. The patient had no history of overseas travel or any known contact with anyone who had travelled abroad. Consequently, the Clade 20C strain belonging to the B.1.346 lineage appeared likely to have been imported from the western United States to Japan across the strict quarantine barrier. B.1.1.284 and B.1.1.214 lineages were found to be predominant in the Kanto region, but a single case of the B.1.346 lineage of clade 20C, probably imported from the western United States, was also identified. These results illustrate that a decentralized network of hospitals offers significant advantages as a highly responsive system for monitoring regional molecular epidemiologic trends.

Identification of B.1.346 lineage of SARS-CoV-2 in Japan: Genomic evidence of re-entry of Clade 20C

ObjectivesWhole SARS-CoV-2 genome sequencing from COVID-19 patients is useful for infection control and regional trends evaluation. We report a lineage data collected from hospitals in the Kanto region of Japan. MethodsWe performed whole genome sequencing in specimens of 198 COVID-19 patients at 13 collaborating hospitals in the Kanto region. Phylogenetic analysis and fingerprinting of the nucleotide substitutions underwent to differentiate and classify the viral lineages. ResultsMore than 90% of the strains belonged to Clade 20B and two lineages (B.1.1.284 and B.1.1.214) have been detected predominantly in the Kanto region. However, one sample from a COVID-19 patient in November 2020, belonged to the B.1.346 lineage of Clade 20C, which has been prevalent in western United States. The patient had no history of overseas travel and no contact with anyone who had travelled abroad, suggesting that this strain appeared likely to have been imported from western United States, across the strict quarantine barrier. ConclusionB.1.1.284 and B.1.1.214 have been identified predominantly in the Kanto region and B.1.346 of clade 20C in one patient was probably imported from western United States. These results illustrate that a decentralized network of hospitals can be significantly advantageous for monitoring regional molecular epidemiologic trends. Highlights{middle dot} Whole SARS-CoV-2 genome sequencing is useful for infection control {middle dot} B.1.1.284 and B.1.1.214 have been identified predominantly in the Kanto region {middle dot} B.1.346 of Clade 20C was detected in one COVID-19 patient in November {middle dot} Molecular genomic data sharing provides benefits to public health against COVID-19

[R0 Resection following Chemotherapy for Colon Cancer Liver Metastasis Close to the Inferior Vena Cava and Hepatic Vein Confluence-A Case Report].

A 78-year-old man was diagnosed with sigmoid colon cancer, and laparoscopic sigmoidectomy was performed. On pathological examination, he was diagnosed with RAS-wild type sigmoid colon cancer with regional lymph node metastasis (T3, N1, M0, Stage ⅢB[Union for International Cancer Control 8th edition]). Computed tomography revealed S8 and S7 liver metastasis, 3 months after the initial surgery. The location of the S8 tumor was close to the inferior vena cava(IVC), right hepatic vein(RHV)and segment Ⅷ hepatic vein(V8). He was administered cetuximab plus modified FOLFOX6. After 6 courses of chemotherapy, the S8 and S7 liver tumor shrank. S8 plus 4 plus 1 and S7 partial hepatectomy was performed and R0 resection was achieved. The RHV and V8 were resected, while right superficial and middle hepatic veins were preserved. An IVC invasion was not observed. He was administered 12 courses of adjuvant modified FOLFOX6. After the partial hepatectomy, he has been followed up for 1.5 years with no recurrence.

[A Case of Adenocarcinoma Arising from an Ectopic Pancreas of the Stomach Presenting as Pyloric Stenosis].

The patient was a 37-year-old man who visited a neighborhood clinic complaining of nausea and upper abdominal pain. Since examination revealed abdominal distention, he was referred to our hospital. Abdominal computed tomography at our hospital revealed retention of gastric contents and contrast-enhancing wall thickening localized to the pyloric region. Upper gastrointestinal endoscopy showed stenosis involving the entire circumference of the pylorus. However, multiple biopsies failed to reveal any evidence of malignancy. Four dilatations were performed, with no improvement. Therefore, the patient was referred to the Department of Surgery. Since malignant disease could not be ruled out, laparoscopic distal gastrectomy with D2 lymph node dissection was performed. Histopathological examination of the resected specimen revealed the presence of ectopic pancreatic tissue in the proper muscle layer of the pylorus. Adenocarcinoma invading and proliferating into the surrounding ectopic mucosal lesion was observed. Therefore, the patient was diagnosed with adenocarcinoma arising from ectopic pancreas. The possibility of ectopic pancreatic cancer may need to be considered in patients with pyloric stenosis caused by a submucosal tumor-like lesion.

Impacts of chemically different surfaces of implants on a biological activity of fibroblast growth factor-2-apatite composite layers formed on the implants.

BACKGROUND: Implants coated with fibroblast growth factor-2 (FGF-2)-apatite composite layers were previously reported to enhance soft-tissue formation, bone formation, and angiogenesis around the implants owing to the biological activity of FGF-2. However, it is unclear whether the chemistries of the material and surface of implants have some impact on the retention of the biological activity of FGF-2 in FGF-2-apatite composite layers on them. Since magnitude of the impact should be evaluated for extensive application of the composite layer to coat various implants, following items were examined; (1) surface chemistries of six implants, (2) mitogenic activities of FGF-2 in FGF-2-apatite composite layers on the implants, and (3) improved synthesis method of the composite layer for retention of the mitogenic activity of FGF-2. HYPOTHESIS: The biological activity of FGF-2 in the composite layer is affected by the chemistries of the material and surface of implants. MATERIALS AND METHODS: Six commercial products of pins and screws having different surface chemistries were coated with FGF-2-apatite composite layers. The composite layers were quantitatively analyzed for calcium (Ca), phosphorus (P) and FGF-2, and also evaluated the mitogenic activities of FGF-2. Improvement of the synthesis method was then attempted using two pin products. RESULTS: Each commercial product had a chemically and morphologically characteristic surface. FGF-2-apatite composite layers were formed on all the commercial products. Although the Ca, P, and FGF-2 contents (4.7±0.9µg/mm, 2.2±0.4µg/mm, and 21.1±3.7ng/mm, respectively) and the Ca/P molar ratios (1.69±0.01) of the composite layers were almost the same, rate of retention of the mitogenic activity of FGF-2 in the composite layers significantly decreased on some pin products (3/12-4/12). The decrease in rate of retention of the mitogenic activity of FGF-2 was prevented by a two-step synthesis method to form a composite layer on a precoating with calcium phosphate (9/12-12/12). DISCUSSION: The chemistries of the implant surfaces had a significant impact on the retention of the mitogenic activity of FGF-2 in the composite layers formed on the implant. The two-step synthesis method was useful to retain mitogenic activity of FGF-2 regardless of the surface chemistries of the implants. The two-step synthesis method has potential to expand the applicability of FGF-2-apatite composite layers to a wider range of implants. LEVEL OF EVIDENCE: III, Case control in vitro study.

Ru3(CO)12-Catalyzed Reaction of 1,6-Diynes, Carbon Monoxide, and Water via the Reductive Coupling of Carbon Monoxide.

We report the ruthenium-catalyzed cyclization of 1,6-diynes with two molecules of carbon monoxide and water to give a variety of catechols. This reaction likely proceeds through the intermediacy of the water-gas shift reaction to generate an yne-diol-type intermediate followed by a [4 + 2] cycloaddition with 1,6-diynes. The reaction requires no external reductants or hydride sources and provides a novel and valuable method for the synthesis of a variety of catechols.

[Long-Term Disease Control with Capecitabine plus Bevacizumab Therapy for an Elderly Patient with Unresectable Colon Cancer-A Case Report].

An 83-year-old man visited our hospital with liver tumors detected by abdominal ultrasonography. On investigation, he was diagnosed with sigmoid colon cancer with metastasis in the supraclavicular lymph node, liver, and para-aortic lymph node(T3N1M1b, Stage ⅣB[Union for International Cancer Control 8th edition]). He was administered combination therapy with capecitabine and bevacizumab owing to the increased age and Eastern Cooperative Oncology Group performance status score of 1. After 8 courses of chemotherapy, the primary tumor and liver metastases shrank. As he developed Grade 2 hand-foot syndrome, the dose of capecitabine was decreased to 75%(1,500 mg/m2)from the 11th course and to 50% (1,000 mg/m2)from the 31st course. Until 2 years after initiation of the chemotherapy, the patient showed progression-free survival. Heparinoid-containing moisturizer and steroid ointment were administered for treatment of hand-foot syndrome. This report suggests that capecitabine plus bevacizumab therapy can maintain the quality of life and is safe with dose reduction and treatment of adverse reactions for elderly patients with colon cancer.

[A Case of Small Bowel Perforation Caused by Malignant Lymphoma after Methotrexate Therapy for Rheumatoid Arthritis].

A 73-year-old woman had a history of medication, including methotrexate for rheumatoid arthritis, for 5 years. She had chronic epigastralgia for 2 weeks and found to have multiple submucosal tumors on upper gastrointestinal endoscopy in another hospital. She had a strong abdominal pain thereafter and diagnosed as having gastrointestinal perforation on the basis of CT scans. Abdominal examination revealed disseminated peritonitis, and emergency laparoscopic surgery was performed on the day of admission. A 1 cm perforation of the ileum was identified, and a 5 cm mass of the mesentery near the perforation was also identified. Small bowel partial resection, including both lesions, was performed. From the intraoperative findings, methotrexate-associated lymphoproliferative disorders(MTX-LPD)was suspected, and methotrexate was discontinued after the surgery. At a later date, the pathological result from both the surgical specimen and upper gastrointestinal endoscopy was diffuse large B cell lymphoma(DLBCL). CT scan, PET-CT scan, and upper gastrointestinal endoscopy were performed 1-2 months after surgery, and no tumor was identified. Currently, 6 months after the surgery, the patient is still alive without any progression of the lymphoma.

[Trastuzumab Combination Chemotherapy Followed by R0 Resection for Locally Advanced Human Epidermal Growth Factor Receptor 2-Positive Gastric Cancer-A Case Report].

A man in the 60s visited our hospital with the complaints of epigastralgia and weight loss. Following an investigation, he was diagnosed with human epidermal growth factor receptor 2(HER2)-positive gastric cancer with invasion to the pancreas (T4b[pancreas], N2, M0, Stage ⅣA[Union for International Cancer Control 8th edition]). Preoperatively, he was administered a chemotherapeutic regimen of S-1 and cisplatin plus trastuzumab. After 2 courses of chemotherapy, computed tomography revealed invasion to the abdominal wall and pyloric stenosis; however, invasion to the pancreas was obscured, and the lymph node metastases had shrunk. He underwent laparoscopic gastro-jejunostomy. After 4 courses of chemotherapy, his condition was considered stable. A laparoscopic distal gastrectomy was performed together with resection of the abdominal wall invasion. The pathological stage was pT4b(abdominal wall), pN0, M0, Stage ⅢA, and R0 resection was achieved. The patient was administered 4 courses of adjuvant capecitabine plus oxaliplatin therapy and 4 courses of capecitabine monotherapy. He has been followed-up for 1.5 years since the curative resection and has not developed recurrences. This case suggests the usefulness of multimodal therapy for locally advanced gastric cancer.

Initial clinical trial of pins coated with fibroblast growth factor-2-apatite composite layer in external fixation of distal radius fractures.

BACKGROUND: Pin tract infection and loosening are major complications and challenges in the treatment of fractures by external fixation. To address this issue, we developed titanium pins coated with a fibroblast growth factor 2 (FGF-2)-apatite composite layer. The purpose of this initial clinical trial is to clarify the safety and feasibility of using these pins for the external fixation of distal radius fractures. METHODS: Unstable, displaced fractures of the distal radius that were medically suitable for external fixation were treated using external fixation pins coated and uncoated with an FGF-2-apatite composite layer. The coated pin group (n = 5) comprised 5 women (average age, 70.4 ±â€¯5.9 years), whereas the uncoated pin group (n = 10) comprised 8 women and 2 men (average age, 64.4 ±â€¯11.7 years). The average duration of external fixation was 40.8 ±â€¯1.3 and 41.6 ±â€¯2.1 days for the coated and uncoated pin groups, respectively. RESULTS: All patients achieved fracture union. One patient in the uncoated group had severe pin tract infection on the day of pin extraction. No pin loosening or difficulty in pin removal was observed in either group. Bacterial growth was present in 5% and 25% of the pin sites in the coated and uncoated groups, respectively (p = 0.059). No adverse events such as tumor formation were observed for more than 2 years after surgery in the coated pin group. CONCLUSIONS: This study clarified the safety and feasibility of using pins coated with an FGF-2-apatite composite layer for the external fixation of distal radius fractures.

For how long do denervated muscles in children retain the ability to regenerate?: Restoration of elbow flexion and shoulder function by partial nerve transfer in a child with long-standing poliomyelitis-like paralysis.

BACKGROUND: In infant poliomyelitis or poliomyelitis-like paresis, there has been no means of treating residual paralysis and the policy has been to wait until an affected infant has grown sufficiently to enable tendon transfer or arthrodesis. However, recent reports have described relatively good results for early surgical intervention in the form of nerve transfer. METHODS: In a 4-year and 6-month-old child we transferred a partial ulnar nerve for elbow flexor reconstruction even 3 years and 10 months after the onset of poliomyelitis-like palsy and also transferred partial accessory and radial nerves for shoulder function restoration 6 months after the first operation. RESULTS: Elbow flexor restored M4 on the British Medical Research Council scale. The shoulder subluxation resolved, however, the strengths of the deltoid and infraspinatus remained almost M1. At the most recent clinical examination, the patient was 18 years old and the active range of motion of patient's left elbow was 0°-125°, and those of the whole shoulder girdle were abduction 35°, flexion 60°, extension 30° and external rotation 0°. CONCLUSIONS: The outcomes we achieved may support partial nerve transfer techniques as viable treatment options for persistent long-standing motor deficits following poliomyelitis-like palsy in children. However, we recommend performing partial nerve transfer as early as possible after recovery from flaccid paralysis and also use of nerves that derive from narrow spinal cord segments. After denervation, children's neuromuscular systems seem to have the ability to regenerate after a much longer period than has generally been believed. This speculation is based on only a single case report; thus, more experience is needed before this generalization can confidently be made.

[A Case of Extrahepatic Bile Duct Carcinoid Tumor Involving Diagnostic Difficulties].

A patient in his 60s had undergone laparoscopic anterior resection for the treatment of carcinoma of the rectum in February 2016. Histopathologic examination revealed the lesion as a pT2(MP)n(-)M0, fStage Ⅰrectal cancer. One year post-surgery, contrast-enhanced computed tomography(CT)revealed enhancement of parts of the intrapancreatic distal bile ducts. Magnetic resonance cholangiopancreatography(MRCP)showed filling defects at the same site. Magnetic resonance imaging( MRI)with an endorectal coil(ERC)was then performed to identify reproducible bile duct filling defects. Neither cytology nor biopsy yielded any findings that definitely indicated malignancy. Intraductal ultrasonography(IDUS)led to the suspicion of a nonepithelial tumor or an enlarged lymph node. Repeated biopsies via ERC were performed based on the absence of evidence of malignancy and revealed the presence of some atypical cells within the lesions. Although no definitive diagnosis could be made, the patient was scheduled for surgery in June 2017 after obtaining his consent. Upon taping of the common bile duct during surgery, a tumor was palpable on the dorsal aspect of the pancreas. The bile duct tumor was completely excised and submitted for intraoperative diagnosis; the pancreatic dorsal aspect appeared to be totally split. There was no evidence of atypia in the neoplasm, which was therefore considered to be benign; however, malignancy could not be completely ruled out because the patient had presented with elevated serum levels of carbohydrate antigen(CA)19-9 once before the operation. After intraoperative consultation with the patient's family members, who were reluctant to provide consent for pancreaticoduodenectomy, we completed the operation with resection of the bile duct tumor, followed by choledochojejunostomy. The tumor was found to be chromogranin A(+), cluster of differentiation(CD)56(+/-), CA19-9(+, solely ductal structure), carcinoembryonic antigen(CEA)(+, solely ductal structure), and intranuclear p53(-), with an MIB- 1 index of<2%. With regard to neuroendocrine markers, a region that could potentially have been a carcinoid tumor, based on the findings on hematoxylin and eosin(HE)staining, and a lumenized superficial region showed positivity in toto. Therefore, the lesion as a whole was diagnosed as a G1 carcinoid neuroendocrine tumor(NET). However, the superficial lumenized layer was positive for both CA19-9 and CEA; therefore, the tumor was thought to concurrently have epithelial characteristics. The lateral stumpwas negative, while the status of the ablated region remained unclear. After discussing the histopathologic examination results with the patient and his family members, the patient's follow-upwas decided to consist of periodic checkups without any further surgical intervention. The patient has since remained free of recurrence. Carcinoid tumor of the bile duct is extremely rare but should be considered in cases involving bile duct tumors that show enhancement on imaging prior to surgery and for which no definitive diagnosis can be established despite repeated biopsy explorations.

[Pathological Complete Response Following Chemotherapy for Sigmoid Colon Cancer with Para-Aortic Lymph Node Metastasis-A Case Report].

A man in his 50s visitedour hospital with complaints of frequent urination, painful micturition, macrohematuria, and weight loss. On examination, he was diagnosed with RAS-wild-type sigmoid colon cancer invading the urinary bladder, ureter, andexternal iliac artery, with para-aortic lymph node metastasis(T4b, NX, M1a, Stage ⅣA according to the Union for International Cancer Control 8th edition guidelines)andsigmoid -vesical fistula. Thus, sigmoidcolostomy was performed. Postoperatively, S-1 plus oxaliplatin was administered. After 3 courses of chemotherapy, the primary tumor and para-aortic lymph node metastases shrunk. Moreover, after 8 courses of chemotherapy, further shrinkage of the primary tumor and paraaortic lymph node metastases was confirmed; however, tumor markers in the blood increased. Therefore, the patient received 3 additional courses of S-1 plus oxaliplatin plus cetuximab, which resultedin complete response. Sigmoidectomy, partial cystectomy, ureterectomy, resection of the external iliac artery, andreconstruction using a prosthetic vascular graft were performed. Subsequent pathological examination revealed no viable cancer cells(pathological response), achieving R0 resection. The patient has been followedup for 2.5 years after the curative resection, with no recurrence.

[A Case of Complete Response to Computed Tomography-Guided Celiac Plexus Neurolysis of Pain Associated with Postoperative Recurrence of Colon Cancer].

The patient was a man in his 40s, who had undergone laparoscopic ileocecal resection with lymph node dissection(D3)for cecal cancer in January 2012. Histopathological examination of the resected specimens had revealed StageⅡ primary tumor with subserosal invasion and positive metastasis in 1-3 regional lymph nodes(pT2[SS]n1[+]). The pathological stage was Ⅲa(fStage Ⅲa), and the tumor showed RAS gene mutation. The patient was administered 5 cycles of postoperative adjuvant chemotherapy with oral tegafur/uracil(UFT)in combination with calcium folinate(UZEL). Abdominal computed tomography( CT)performed 1.5 years postoperatively revealed liver metastasis, and a laparoscopic partial hepatectomy was performed in August 2015. In addition, a node in the greater omentum, located in the inferior surface of the liver, was also resected. Histopathological examination of the resected specimens revealed peritoneal metastasis, based on the identification of the same type of adenocarcinoma as the colon cancer. The patient was given 8 cycles of adjuvant chemotherapy with capecitabine and oxaliplatin(CapeOX). Then, he presented with colonic ileus, caused by recurrent dissemination, and underwent a laparoscopic transverse colectomy in October 2015. Multiple perineal disseminations were found intraoperatively, and chemotherapy was initiated with irinotecan plus tegafur/gimeracil/oteracil(S-1)plus bevacizumab(IRIS/BV)for the recurrent and unresectable disease. After 27 cycles of this regimen, lung metastasis was detected; in addition, progression of the para-aortic node metastasis around the celiac plexus was also observed, and the patient was considered as having pro- gressive disease(PD). Treatment with trifluridine/tipiracil(TAS102)was started in September 2017. Prior to the initiation of this regimen, the dose of opioid rescue medication previously started for back and abdominal pain was rapidly increased. Accordingly, the base dose was increased, but the pain could not be controlled, and the major pain was consistently located along the area of innervation in the celiac plexus. Therefore, celiac plexus neurolysis(CPN)was performed as a local therapy. A CT-guided injection technique was used to administer urografin, bupivacaine, and absolute ethanol to complete the procedure. The patient was discharged without major complications, and the base opioid dose was gradually reduced. Since the patient did not require any rescue medication during daytime on some days, the reduction of the base opioid dose was significantly effective in improving the patient's quality of life(QOL). In patients with pain possibly caused by metastasis to the para-aortic nodes, this local therapy technique may be considered.

The relationship between preoperative needle electromyography findings and muscle power restoration after surgery in severe carpal tunnel syndrome patients.

PURPOSE: Needle electromyography provides essential information about the functional aspects of the muscle. But little attention has been given in the literature to needle electromyography examinations in carpal tunnel syndrome. We examined the relationship between preoperative needle electromyography findings and functional recovery of the abductor pollicis brevis (APB) muscle in severe carpal tunnel syndrome patients. METHODS: The subjects of this study were 49 patients, 58 hands, who fit the following 5 criteria: (1) idiopathic carpal tunnel syndrome; (2) pre-op MMT grade of the APB muscle was M0 or M1; (3) APB-CMAP (compound muscle action potential) was not evoked in a median nerve conduction study; (4) needle electromyography of the APB muscle had been done; (5) underwent carpal tunnel release only. The patients were divided into two groups according to the results of pre-op needle electromyography: voluntary motor unit potential of the APB muscle was evoked [MUP(+) group]or not [MUP(-) group]. We evaluated APB muscle strength at one year after surgery, and patient satisfaction and functional evaluations (CTSI-FS) at more than one year after. RESULTS: The APB muscle recovery rate to M3 or higher was 100% in the MUP(+) group, and 57% in the MUP(-) group. Patient satisfaction was also high and functional recovery was sufficient in the MUP(+) group. No patients requested a second opponensplasty. CONCLUSION: Our findings suggest that post-op restoration of thumb function relates to whether or not the MUP ofthe APB muscle is evoked. Single-stage opponensplasty may be unnecessary if the MUP of the APB muscle is; evoked. Needle electromyography is therefore useful in consideration for opponensplasty. LEVEL OF EVIDENCE: Level Ⅲ, case-control study.

Reducing the risk of impaired bone apposition to titanium screws with the use of fibroblast growth factor-2-apatite composite layer coating.

BACKGROUND: Loosening of screws is a common problem in orthopedic and maxillofacial surgery. Modifying the implant surface to improve the mechanical strength of screws has been tried and reported. We developed screws coated with fibroblast growth factor-2 (FGF-2)-apatite composite layers. We then showed, in a percutaneous external fixation model, that this composite layer had the ability to hold and release FGF-2 slowly, thereby reducing the risk of pin tract infection of the percutaneous external fixation. The objective of the current study was to clarify the effect of FGF-2-apatite composite layers on titanium screws on bone formation around the screw. METHODS: We analyzed samples of previously performed animal experiments. The screws were coated with FGF-2-apatite composite layers by immersing them in supersaturated calcium phosphate solutions containing FGF-2. Then, the uncoated, apatite-coated, and FGF-2-apatite composite layer-coated screws were implanted percutaneously in rabbits. Finally, using inflammation-free histological sections, we histomorphometrically assessed them for the presence of bone formation. Weibull plot analysis was then applied to the data. RESULTS: On average, screws coated with FGF-2-apatite composite layers showed a significantly higher bone apposition rate than the uncoated or apatite-coated screws. Although the difference in the average bone apposition rate was small, the FGF-2-apatite composite layers produced a significant, marked reduction in the incidence of impaired bone formation around the screw compared with the incidence in the absence of FGF-2 (uncoated and apatite-coated screws). The probability of resulting in a bone apposition rate equal to or less than 63.75%, for example, is 3.5 × 10-4 for screws coated with the FGF-2-apatite composite layers versus 0.05 for screws in the absence of FGF-2. CONCLUSIONS: FGF-2-apatite composite layer coating significantly reduced the risk of impaired bone apposition to the screw. Thus, it is feasible to use titanium screws coated with FGF-2-apatite composite layers as internal fixation screws to decrease the risk of loosening.

[A Case of Phrenic Nerve Paralysis During Adjuvant Chemotherapy for Rectal Cancer].

A man aged 66 years presented with pneumaturia as a major complaint. Cancer of the sigmoid colon with infiltration to the urinary bladder was diagnosed and the patient underwent colectomy of the sigmoid colon and partial cystectomy of the bladder in May 2015. Histopathologic examinations revealed pT4b, Si(bladder), pN(-), cM0, fStage II . Because intestinal sub-obstruction and lymphatic invasion were present, CapeOX was administered as an adjunctive chemotherapy for the high-risk Stage II cancer. Because Grade 2 peripheral neuropathy appeared as a side effect, the dose was decreased to 80% from the 3 cycle. After the 7 cycle, cough and disturbed breathing appeared. The chest CT scans did not reveal drug-induced interstitial pneumonia, but indicated an elevated right diaphragm and zosteroid changes in the medial lobe of the right lung due to discoid atelectatic condition. The Grade 1 respiratory symptoms were mild, and the lung field was considered to exhibit no problems. Thus, the 8 cycle was administered. The symptoms disappeared after about 2 weeks following completion of oral administration of capecitabine. The diaphragm also recovered to its original height. In the attached document, the frequency is unknown and "dyspnea" is written for L-OHP and capecitabine, respectively. It is unknown whether phrenic nerve paralysis occurs. However, because other organic lesions were absent and the symptoms appeared during chemotherapy, the possibility is not deniable. At present, 2 years postoperatively, recurrent lesions in the mediastinum and recurrent respiratory difficulties are absent. Generally, although phrenic nerve paralysis is not considered to be a specific side effect, it was considered that for respiratory difficulties, CT reveals not only the affected condition in the lung fields, but is also useful for detection.