Need for education of psychiatric evaluation of offenders with mental disorders:A questionnaire survey for Japanese designated psychiatrists

BACKGROUND The management of offenders with mental disorders has been a significant concern in forensic psychiatry.In Japan,the introduction of the Medical Treatment and Supervision Act in 2005 addressed the issue.However,numerous psychiatric patients at risk of violence still find themselves subject to the administrative involuntary hospitalization(AIH)scheme,which lacks clarity and updated standards.AIM To explore current as well as optimized learning strategies for risk assessment in AIH decision making.METHODS We conducted a questionnaire survey among designated psychiatrists to explore their experiences and expectations regarding training methods for psychiatric assessments of offenders with mental disorders.RESULTS The findings of this study’s survey suggest a prevalent reliance on traditional learning approaches such as oral education and on-the-job training.CONCLUSION This underscores the pressing need for structured training protocols in AIH consultations.Moreover,feedback derived from inpatient treatment experiences is identified as a crucial element for enhancing risk assessment skills.

Current role of ultrasound for the management of hepatocellular carcinoma

Hepatocellular carcinoma(HCC)has a decisive influence on the prognosis of cirrhotic patients.Although α-fetoprotein(AFP)is a known and specific tumor maker for HCC,it is not suitable for the screening and surveillance of HCC because of its poor predictive value and low sensitivity.The use of imaging modalities is essential for the screening,diagnosis and treatment of HCC.Ultrasound(US)plays a major role among them,because it provides realtime and non-invasive observation by a simple and easy technique.In addition, US-guided needle puncture methods are frequently required for the diagnosis and/or treatment process of HCC.The development of digital technology has led to the detection of blood flow by color Doppler US, and the sensitivity for detecting tumor vascularity has shown remarkable improvement with the introduction of microbubble contrast agents.Moreover,near real- time 3-dimensional US images are now available.As for the treatment of HCC,high intensity focused ultrasound (HIFU)was developed as a novel technology that provides a transcutaneous ablation effect without needle puncture.These advancements in the US field have led to rapid progress in HCC management,and continuing advances are expected.This article reviews the current application of US for HCC in clinical practice.

Successful resection of metachronous para-aortic, Virchow lymph node and liver metastatic recurrence of rectal cancer

A 66-year-old female presented with the main complaint of defecation trouble and abdominal distention. With diagnosis of rectal cancer, c SS, c N0, c H0, c P0, c M0 c Stage Ⅱ, Hartmann's operation with D3 lymph node dissection was performed and a para-aortic lymph node and a disseminated node near the primary tumor were resected. Histological examination showed moderately differentiated adenocarcinoma, p SS, p N3, p H0, p P1, p M1(para-aortic lymph node, dissemination) f Stage Ⅳ. After the operation, the patient received chemotherapy with FOLFIRI regimen. After 12 cycles of FOLFIRI regimen, computed tomography(CT) detected an 11 mm of liver metastasis in the posteroinferior segment of right hepatic lobe. With diagnosis of liver metastatic recurrence, we performed partial hepatectomy. Histological examination revealed moderately differentiated adenocarcinoma as a metastatic rectal cancer with cut end microscopically positive. After the second operation, the patient received chemotherapy with TS1 alone for 2 years. Ten months after the break, CT detected a 20 mm of paraaortic lymph node metastasis and a 10 mm of lymph node metastasis at the hepato-duodenal ligament. With diagnosis of lymph node metastatic recurrences, we performed lymph node dissection. Histological examination revealed moderately differentiated adenocarcinoma as metastatic rectal cancer in paraaortic and hepato-duodenal ligament areas. After the third operation, we started chemotherapy with modified FOLFOX6 regimen. After 2 cycles of modified FOLFOX6 regimen, due to the onset of neutropenia and liver dysfunction, we switched to capecitabine aloneand continued it for 6 mo and then stopped. Eleven months after the break, CT detected two swelling 12 mm of lymph nodes at the left supraclavicular region. With diagnosis of Virchow lymph node metastatic recurrence, we started chemotherapy with capecitabine plus bevacizumab regimen. Due to the onset of neutropenia and hand foot syndrome(Grade 3), we managed to continue capecitabine administration with extension of interval period and dose reduction. After 2 years and 2 mo from starting capecitabine plus bevacizumab regimen, Virchow lymph nodes had slowly grown up to 17 mm. Because no recurrence had been detected besides Virchow lymph nodes for this follow up period, considering the side effects and quality of life, surgical resection was selected. We performed left supraclavicular lymph node dissection. Histological examination revealed moderately differentiated adenocarcinoma as a metastatic rectal cancer. After the fourth operation, the patient selected follow up without chemotherapy. Now we follow up her without recurrence and keep her quality of life high.

Computed tomography perfusion imaging as a potential imaging biomarker of colorectal cancer

Neovascularization was reported to arise early in the adenoma-carcinoma sequence in colorectal cancer(CRC),and the importance of angiogenesis in cancer progression has been established.Computed tomography(CT)perfusion(CTP)based on high temporal resolution CT images enables evaluation of hemodynamics of tissue in vivo by modeling tracer kinetics.CTP has been reported to characterize tumor angiogenesis,and to be a sensitive marker for predicting recurrence or survival in CRC.In this review,we will discuss the biomarker value of CTP in the management of CRC patients.

Sofosbuvir treatment and hepatitis C virus infection

Hepatitis C virus(HCV) infection is a serious problem worldwide.The use of interferon-based therapy has made HCV eradication challenging.The recent appearance of direct-acting antiviral agents(DAAs) has changed HCV therapy.Combining the use of DAAs with peginterferon and ribavirin has improved treatment efficacy.Furthermore,the combination of different orally administered DAAs has enabled interferon-free therapy with much higher efficacy and safety.In particular,sofosbuvir,a nucleotide-based NS5 B inhibitor,prevents HCV RNA synthesis by acting as a "chain terminator".Treatment with sofosbuvir has attained an extremely high rate of sustained virologic response.The current review summarizes the efficacy and safety of sofosbuvir therapy.

Polysomnographic assessment of respiratory disturbance during deep propofol sedation for endoscopic submucosal dissection of gastric tumors

AIM To investigate that polysomnographic monitoring can accurately evaluate respiratory disturbance incidence during sedation for gastrointestinal endoscopy compare to pulse oximetry alone.METHODS This prospective observational study included 10 elderly patients with early gastric cancer undergoing endoscopic submucosal dissection(ESD) under propofol sedation. Apart from routine cardiorespiratory monitoring, polysomnography measurements were acquired. The primary hypothesis was tested by comparing the apnea hypopnea index(AHI), defined as the number of apnea and hypopnea instances per hour during sedation, with and without hypoxemia; hypoxemia was defined as the reduction in oxygen saturation by ≥ 3% from baseline.RESULTS Polysomnography(PSG) detected 207 respiratory disturbances in the 10 patients. PSG yielded a significantly greater AHI(10.44 ± 5.68/h) compared with pulse oximetry(1.54 ± 1.81/h, P < 0.001), thus supporting our hypothesis. Obstructive AHI(9.26 ± 5.44/h) was significantly greater than central AHI(1.19 ± 0.90/h, P < 0.001). Compared with pulse oximetry, PSG detected the 25 instances of respiratory disturbances with hypoxemia 107.4 s earlier on average.CONCLUSION Compared with pulse oximetry, PSG can better detect respiratory irregularities and thus provide superior AHI values, leading to avoidance of fatal respiratory complications during ESD under propofol-induced sedation.

Esophageal intramural pseudodiverticulosis of the residual esophagus after esophagectomy for esophageal cancer

A 91-year-old man was referred to our hospital with intermittent dysphagia. He had undergone esophagectomy for esophageal cancer(T3N2M0 Stage Ⅲ) 11 years earlier. Endoscopic examination revealed an anastomotic stricture; signs of inflammation,including redness,erosion,edema,bleeding,friability,and exudate with white plaques; and multiple depressions in the residual esophagus. Radiographical examination revealed numerous fine,gastrografinfilled projections and an anastomotic stricture. Biopsy specimens from the area of the anastomotic stricture revealed inflammatory changes without signs of malignancy. Candida glabrata was detected with a culture test of the biopsy specimens. The stricture was diagnosed as a benign stricture that was caused by esophageal intramural pseudodiverticulosis. Accordingly,endoscopic balloon dilatation was performed and antifungal therapy was started in the hospital. Seven weeks later,endoscopic examination revealed improvement in the mucosal inflammation; only the pseudodiverticulosis remained. Consequently,the patient was discharged. At the latest follow-up,the patient was symptomfree and the pseudodiverticulosis remained in the residual esophagus without any signs of stricture or inflammation.

Imaging biomarkers for the treatment of esophageal cancer

Esophageal cancer is known as one of the malignant cancers with poor prognosis.To improve the outcome,combined multimodality treatment is attempted.On the other hand,advances in genomics and other“omic”technologies are paving way to the patient-oriented treatment called“personalized”or“precision”medicine.Recent advancements of imaging techniques such as functional imaging make it possible to use imaging features as biomarker for diagnosis,treatment response,and prognosis in cancer treatment.In this review,we will discuss how we can use imaging derived tumor features as biomarker for the treatment of esophageal cancer.

Signaling pathway of insulin-like growth factor-Ⅱ as a target of molecular therapy for hepatoblastoma

AIM: To address the possibility that insulin-like growth factor (IGF)-Ⅱ is a growth factor and its signaling pathway so as to develop a molecular therapy for hepatoblastoma. METHODS: Huh-6 and HepG2, human hepatoblastoma cell lines, were used. IGF-Ⅱ was added to the medium deprived of serum. Western blot analysis was performed to clarify the expression of IGF-I receptor (IGF-IR). Inhibitors of IGF-IR (piclopodophyllin, PPP), phosphatidyl-inositol (PI) 3-kinase (LY294002 and Wortmannin), or mitogen-activated protein (MAP) kinase (PD98059) were added to unveil the signaling pathway of IGF-Ⅱ. Cells were analyzed morphologically with hematoxylin-eosin staining to reveal the mechanism of suppression of cell proliferation.RESULTS: IGF-Ⅱ stimulated cells proliferated to 2.7 (269% ± 76%) (mean ± SD) (Huh-6) and 2.1 (211% ± 85%) times (HepG2). IGF-IR was expressed in Huh-6 and HepG2. PPP suppressed the cell number to 44% ± 11% (Huh-6) and 39% ± 5% (HepG2). LY294002 and Wortmannin suppressed the cell number to 30% ± 5% (Huh-6), 44% ± 0.4% (HepG2), 49% ± 1.0% (Huh-6) and 46% ± 1.1% (HepG2), respectively. PD98059 suppressed the cell number to 33% ± 11% for HepG2 but not for Huh-6. When cell proliferation was prohibited, many Huh-6 and HepG2 cells were dead with pyknotic or fragmented nuclei, suggesting apoptosis.CONCLUSION: IGF-Ⅱ was shown to be a growth factor of hepatoblastoma via IGF-I receptor and PI3 kinase which were good candidates for target of molecular therapy.

Endoscopic occlusion with silicone spigots for the closure of refractory esophago-bronchiole fistula after esophagectomy

A 65-year-old man with c T1 b N0M0 stage Ⅰ middle thoracic esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the posterior mediastinal route after preoperative carbon-ion radiotherapy and chemotherapy in a clinical trial. Anastomotic leakage occurred,but it spontaneously improved. At six months after the operation,he was rehospitalized with a cough and dysphagia. An esophago-bronchiole fistula and stenosis of the gastric tube were observed. He first underwent stent placement in the gastric tube. Two weeks later,the syringeal epithelium was burned by argon plasma coagulation after stent removal. Endoscopic occlusion was then performed for the fistula with two guidewire-assisted silicone spigots. Two weeks later,he was discharged on an oral diet,and he has not developed recurrence of the fistula or cancer for three years. This is the first report of endoscopic occlusion with a guidewire-assisted silicone spigot through the esophagus.

Is the use of IL28B genotype justified in the era of interferon-free treatments for hepatitis C?

In 2009, several groups reported that interleukin-28B(IL28B) genotypes are associated with the response to peginterferon plus ribavirin therapy for chronic hepatitis C virus(HCV) infection in a genome-wide association study, although the mechanism of this association is not yet well understood. However, in recent years, tremendous progress has been made in the treatment of HCV infection. In Japan, some patients infected with HCV have the IL28 B major genotype, which may indicate a favorable response to interferon-including regimens; however, certain patients within this group are also interferon-intolerant or ineligible. In Japan, interferonfree 24-wk regimens of asunaprevir and daclatasvir are now available for HCV genotype 1b-infected patients who are interferon-intolerant or ineligible or previous treatment null-responders. The treatment response to interferon-free regimens appears better, regardless of IL28 B genotype. Maybe other interferon-free regimens will widely be available soon. In conclusion, although some HCV-infected individuals have IL28 B favorable alleles, importance of IL28 B will be reduced with availability of oral interferon free regimen.

The Relationship between Neck and Shoulder Pain and the Sagittal Alignment of the Spine in Standing in Younger Generation

Background: The relationship between chronic neck and shoulder pain and posture remains controversial. The purpose of this study was to investigate the relationship between chronic neck and shoulder pain and spinal sagittal alignment in standing posture in younger generation. Methods: Subjects included 57 females and 32 males (average age, 29.9 ± 5.7 years). All subjects were 20s or 30s. Spinal curvature was assessed using SpinalMouse. The subjects were also divided into a normal group (VAS zero group) and a pain group by VAS results. Statistical analysis was performed by Student’s t-test. Significance was defined as p < 0.05. Results: The normal group and pain group included 29 and 60 subjects, respectively. In terms of location of pain, thirty-one subjects felt neck pain, 50 felt pain above the scapula, and 17 felt pain between the thoracic spine and scapula. Thoracic kyphosis and lumbar lordosis in the pain group were significantly higher than those in the normal group (p = 0.013 and p = 0.020, respectively). Thoracic kyphosis in subjects with neck pain or pain above scapula was significantly higher than that in subjects without pain (p = 0.0075 and p = 0.025, respectively). Lumbar lordosis in subjects with pain above the scapula or interscapula was significantly higher than that in subjects without pain (p = 0.016).

Predictor of respiratory disturbances during gastric endoscopic submucosal dissection under deep sedation

BACKGROUND Sedation is commonly performed for the endoscopic submucosal dissection(ESD)of early gastric cancer.Severe hypoxemia occasionally occurs due to the respiratory depression during sedation.AIM To establish predictive models for respiratory depression during sedation for ESD.METHODS Thirty-five adult patients undergoing sedation using propofol and pentazocine for gastric ESDs participated in this prospective observational study.Preoperatively,a portable sleep monitor and STOP questionnaires,which are the established screening tools for sleep apnea syndrome,were utilized.Respiration during sedation was assessed by a standard polysomnography technique including the pulse oximeter,nasal pressure sensor,nasal thermistor sensor,and chest and abdominal respiratory motion sensors.The apnea-hypopnea index(AHI)was obtained using a preoperative portable sleep monitor and polysomnography during ESD.A predictive model for the AHI during sedation was developed using either the preoperative AHI or STOP questionnaire score.RESULTS All ESDs were completed successfully and without complications.Seventeen patients(49%)had a preoperative AHI greater than 5/h.The intraoperative AHI was significantly greater than the preoperative AHI(12.8±7.6 events/h vs 9.35±11.0 events/h,P=0.049).Among the potential predictive variables,age,body mass index,STOP questionnaire score,and preoperative AHI were significantly correlated with AHI during sedation.Multiple linear regression analysis determined either STOP questionnaire score or preoperative AHI as independent predictors for intraoperative AHI≥30/h(area under the curve[AUC]:0.707 and 0.833,respectively)and AHI between 15 and 30/h(AUC:0.761 and 0.778,respectively).CONCLUSION The cost-effective STOP questionnaire shows performance for predicting abnormal breathing during sedation for ESD that was equivalent to that of preoperative portable sleep monitoring.

Postoperative recurrence of an IPMN of the pancreas with a fistula to the stomach

We report on a case of a 74 year old man who was diagnosed with a recurrence of non-invasive carcinoma of intraductal papillary mucinous neoplasm (non-invasive IPMN) by postoperative gastroscopy (GS). A pylorus preserving pancreatico duodenectomy for IPMN in the pancreatic head was performed. A histopathological study revealed non-invasive adenocarcinoma. At first,the local recurrence of the tumor around the superior mesenteric artery circumference was diagnosed and disappeared with gemcitabine. Later,the GS showed the elevated lesion with mucin hypersecretion in the remnant stomach. The lesion had a central dip and a fistula common to the pancreas was confirmed on fisterography. We diagnosed a recurrence of IPMN and administered chemotherapy again. However,he died of his original illness. There are no reports of postoperative recurrence of IPMN checked by GS. It should be remembered that the elevated lesion of the remnant stomach is considered as one of the recurrent patterns of IPMN.

Outcomes of administrative involuntary hospitalization: A national retrospective cohort study in Japan

BACKGROUND Treatment for offenders with mental disorders is a key concern in public mental health.Provision of adequate psychiatric treatment is important for the offender and their community.An approach used in Japan to address this issue is administrative involuntary hospitalization.Under this scheme,a person at risk for harming themselves or others because of a mental disorder can be involuntarily hospitalized in a designated psychiatric hospital.However,this scheme does not include tracking of these patients after discharge.Although some data for administrative involuntary hospitalizations are available,it remains unclear what happens to these patients after discharge.AIM To evaluate follow-up of patients under administrative involuntary hospitalization after discharge and obtain data for later comparisons with outcomes.METHODS We used a retrospective design and conducted a national survey of administrative involuntary hospitalizations.Questionnaires were distributed to 939 facilities across Japan.The questionnaire collected data for selected involuntary hospitalization cases in the hospital on June 30,2010(census date),and the prognoses of each patient on a specified date in 2011 and 2012.We also asked about the treatment provided to each patient.We stratified patients by prognosis(good or poor),and used logistic regression analysis to examine the relationship between treatment and prognosis.RESULTS We received completed questionnaires from 292 facilities(response rate 31.1%);105 facilities had no relevant patients.Our analysis included data for 394 patients with valid data.Official statistics indicated 1503 patients were under administrative involuntary hospitalization as at June 30,2012,meaning the capture rate was 27.2%.Approximately a fourth(104/394)at 1 year,and a third(137/294)at 2 years after the census had unknown prognosis.Treatment content included multi-disciplinary team meetings(78.2%of patients),counseling by public workers(59.9%),and discussion with external specialists(32.5%).Overall,116 patients were categorized as having a good prognosis at 1 year,and 168 had a poor prognosis.At the 2-year point,102 patients had a good prognosis and 150 had a poor prognosis.“Discussion with external specialists”was positively associated with a good prognosis at both 1 year(P=0.016)and 2 years(P=0.036).CONCLUSION We found that facilities in Japan currently have limited ability to track the prognoses of patients who were hospitalized involuntarily.Discussion with external specialists is associated with a good prognosis.

Possible effect of blonanserin on gambling disorder:A clinical study protocol and a case report

BACKGROUND Gambling disorder is characterized by excessive and recurrent gambling and can have serious negative social consequences.Although several psychotherapeutic and pharmacological approaches have been used to treat gambling disorder,new treatment strategies are needed.Growing evidence suggests that dopamine D3 receptor plays a specific role in the brain reward system.AIM To investigate if blonanserin,a dopamine D3 receptor antagonist,would be effective in reducing gambling impulses in patients with gambling disorder.METHODS We developed a study protocol to measure the efficacy and safety of blonanserin as a potential drug for gambling disorder,in which up to 12 mg/d of blonanserin was prescribed for 8 wk.RESULTS A 37-year-old female patient with gambling disorder,intellectual disability,and other physical diseases participated in the pilot study.The case showed improvement of gambling symptoms without any psychotherapy.However,blonanserin was discontinued owing to excessive saliva production.CONCLUSION This case suggests that blonanserin is potentially an effective treatment for patients with gambling disorder who resist standard therapies,but it also carries a risk of adverse effects. Further studies are needed to confirm the findings.

Role of IL28B genotype in older hepatitis C virus-infected patients

The average age of hepatitis C virus(HCV)-infected individuals is becoming increasingly higher in Japan and steps should be taken to treat older individuals infected with HCV. Until an interferon-free regimen becomes available, peginterferon plus ribavirin will play a critical role in the treatment. The perception that older HCVinfected patients may be at higher risk than younger patients for adverse events from peginterferon plus ribavirin treatment but may obtain less clinical benefit from it may be based on the underrepresentation of older patients in clinical trials. A recent genomewide association study revealed that interleukin-28B(IL28B) genotype closely correlates with the treatment response against HCV. The relationship of IL28 B genotype with the treatment response in older HCV-infected patients is also unknown. In this review, we focused on the treatment response in older patients infected with HCV and the effects of IL28 B genotype. IL28 B major genotype is a useful predictor of sustained virological response in the interferon-including treatment of older patients infected with HCV. It also seems useful for avoiding adverse events, although the mechanisms ofthe effects of IL28 B genotype on the treatment outcome are still poorly understood and are currently under investigation. Further studies will be needed.

布南色林治疗精神分裂症的临床应用中日专家建议

第二代(非典型)抗精神病药布南色林对多巴胺D_(2)、D_(3)受体和5-HT_(2A)受体均有较高亲和力,而对肾上腺素α_(1)、5-HT_(2c)、组胺H_(1)、毒蕈碱M_(1)和M_(3)等受体亲和力较低。多项短期和长期临床研究显示:该药对精神分裂症的阳性症状、阴性症状均有较好疗效,并改善患者的部分认知症状和社会功能。本文在循证证据和多位中日专家临床用药经验基础上撰写,希望为临床精神科医生提供用药参考,帮助精神分裂症患者早日康复,回归社会。

Nonalcoholic fatty liver disease and hepatic cirrhosis: comparison with viral hepatitis-associated steatosis

Nonalcoholic fatty liver disease(NAFLD) including nonalcoholic steatohepatitis(NASH) is globally increasing and has become a world-wide health problem. Chronic infection with hepatitis B virus or hepatitis C virus(HCV) is associated with hepatic steatosis. Viral hepatitis-associated hepatic steatosis is often caused by metabolic syndrome including obesity,type 2 diabetes mellitus and/or dyslipidemia. It has been reported that HCV genotype 3 exerts direct metabolic effects that lead to hepatic steatosis. In this review,the differences between NAFLD/NASH and viral hepatitis-associated steatosis are discussed.