SUMMARY A 52-year-old woman developed scleroderma, primary biliary cirrhosis, and Sjogren's syndrome after cosmetic silicone injections. These conditions may possibly represent 'human adjuvant disease'.A 52-year-old Japanese woman underwent breast augmentation with silicone injections in 1958. Thereafter she was in good health until 1974, when she developed a dry mouth (Fig. 1). Three years later she developed swollen stiff fingers and polyarthralgia. After that she had Raynaud's phenomenon in winter. In 1979, when she visited the Second Tokyo National Hospital, she had persistent polyarthralgia and proximal scleroderma.Hard masses were palpable beneath the breast skin. Moist rales were audible over the lower lung fields bilaterally. Her

Infection is a life-threatening complication after liver transplantation (LT). A recent outbreak of multidrug-resistant Pseudomonas aeruginosa triggered changes in our infection control measures. This study investigated the usefulness of our bundled interventions against postoperative infection after LT. This before-and-after analysis enrolled 130 patients who underwent living donor or deceased donor LT between January 2011 and October 2014. We initiated 3 measures after January 2013: (1) we required LT candidates to be able to walk independently; (2) we increased the hand hygiene compliance rate and contact precautions; and (3) we introduced procalcitonin (PCT) measurement for a more precise determination of empirical antimicrobial treatment. We compared factors affecting the emergence of drug-resistant microorganisms, such as the duration of antimicrobial and carbapenem therapy and hospital stay, and outcomes such as bacteremia and death from infection between before (n 5 77) and after (n 5 53) the LT suspension period. The utility of PCT measurement was also evaluated. Patients' backgrounds were not significantly different before and after the protocol revision. Incidence of bacteremia (44% versus 25%; P 5 0.02), detection rate of multiple bacteria (18% versus 4%; P 5 0.01), and deaths from infections (12% versus 2%; P 5 0.04) significantly decreased after the protocol revision. Duration of antibiotic (42.3 versus 25.1 days; P 5 0.002) and carbapenem administration (15.1 versus 5.2 days; P < 0.001) and the length of postoperative hospital stay (85.4 versus 63.5 days; P 5 0.048) also decreased after the protocol revision. PCT mean values were significantly higher in the bacteremia group (10.10 ng/mL), compared with the uneventful group (0.65 ng/mL; P 5 0.002) and rejection group (2.30 ng/mL; P 5 0.02). One-year overall survival after LT significantly increased in the latter period (71% versus 94%; P 5 0.001). In conclusion, the bundled interventions were useful in preventing infections and lengthening overall survival after LT.

Patients with iron deficiency anemia are able to continue donating blood for autologous use so long as they have sufficient iron supplementation. However, the elderly or those with rheumatoid arthritis occasionally fail to donate a sufficient volume of blood before surgery as a result of phlebotomy-induced anemia, which is caused in turn by impaired erythropoietin production.

This report presents a case of primary pleomorphic rhabdomyosarcoma arising in the duodenum. A 63-year-old male with persistent melena was referred for a solid tumor in his right upper abdomen detected using ultrasonography. Gastrofiberscopy revealed a protrusion in the upper part of the duodenum, with a large ulcer on the top of it. Enhanced computed tomography showed that the tumor extended to the pancreas. Pancreaticoduodenectomy was performed, despite the absence of malignant cells in the biopsy specimen, with a preoperative diagnosis of duodenal cancer. The tumor consisted of multiple cell types, and immunohistochemical staining was positive for desmin, HHF-35 and alpha smooth muscle actin. Electron microscopy revealed primitive Z-band structures in the tumor. The final diagnosis was pleomorphic rhabdomyosarcoma of the duodenum. This is the first report of primary rhabdomyosarcoma occurring in the duodenum, confirmed by immunohistochemical staining and electron microscopy.

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