A 51-year-old woman, who had been undergoing regular treatment and follow-up for hypertension since the age of 17, was diagnosed to have a patent ductus arteriosus (PDA) 6 months previously. On experiencing dyspnea, she visited the emergency room, where she was found to have a complete Atrioventricular (AV) Block and therefore was immediately admitted. The next day, she experienced acute heart failure requiring intubation. A DDD pacemaker was then implanted and the patient recovered thereafter. After recovery, a screening contrast-enhanced CT scan revealed coarctation of the thoracic aorta. The arterial pressure gradient between the arms and legs was about 70mmHg. The division of the PDA and the replacement of the coarcted aortic segment were performed under femoro-femoral cardiopulmonary bypass through a left posterolateral thoracotomy. The patient's postoperative course was good, however, she complained of abdominal pain on the 6th postoperative day. An abdominal CT scan showed hemorrhage in the left rectus abdominus and right iliopsoas muscles. This improved after rest. No arterial pressure gradient was observed between the arms and the legs postoperatively. She was discharged on postoperative day 20.Because the average life expectancy of patients with untreated coarctation of the aorta has been reported to be about 34 years, it is recommended that surgical repair be performed as soon as possible. Patients with childhood-onset hypertension should therefore be evaluated to determine the primary disease whenever possible, such as coarctation of the aorta as in this case.

A 95-year-old man suffered repeated episodes of loss of consciousness. Ruptured abdominal aortic aneurysm with giant retroperitoneal hematoma was diagnosed by computed tomography scans, and was referred to our hospital for surgical management. As he was about to be transported cardiopulmonary arrest developed, and emergency operation was started under resuscitation for pulseless electrical activity condition. We found a left common iliac artery aneurysm intraoperatively. We improved his hemodynamics by clamping the infrarenal abdominal aorta, and performed replacement of the left common iliac artery with a tube graft as quickly as possible. We inserted an intestinal drainage tube because of the expected high intraperitoneal pressure which caused by marked edema of the intestinal tract. He was weaned from respiratory support on the 5th postoperative day. He could walk on his own and was successfully discharged on the 28th postoperative day.

Type B intramural hematoma (IMH) is not considered to be a life-threatening condition, and medical treatment is the first treatment choice. We report 2 cases of ruptured type B intramural hematoma. Total arch replacement was performed via median sternotomy, which is not a common surgical strategy for type B dissection. Case 1 : a 77-year-old woman was transferred to our hospital with chest and back pain. CT revealed type B IMH with a large hematoma in the anterior mediastinum. She underwent total arch replacement, but she died of respiratory failure on the 167th postoperative day. Case 2 : a 60-year-old man was transferred to our hospital with chest and back pain. CT revealed a type B IMH with a large hematoma on the anterior side of the arch. He underwent total arch replacement, but died of sepsis on the 13th postoperative day. We had 2 rare cases of ruptured type B IMH. In both cases, postoperative courses were problematic. However, median sternotomy could be an approach for ruptured type B dissection in some cases.

Owing to the fear of worsening their relationship with physicians, several pharmacists hesitate to contact physicians regarding prescription-related questions. We investigated the personal factors of pharmacists contributing to their hesitation to contact physicians regarding prescription-related questions. We analyzed the responses of 213 pharmacy pharmacists. A comparison of the degree of hesitation to contact physicians regarding prescription-related questions revealed that the most hesitant questions were pertaining to “the same prescription content from before”; insurance questions (3.37) were higher than medical questions (3.20) (P＝0.006). The multiple regression analysis results revealed that “pharmacy work is busy and there is no time” was influenced by regular employees (medical (β＝−0.181, P＝0.030) and insurance (β＝−0.257, P＝0.002)). “A co-pharmacist said no questions needed” was influenced by the sex of pharmacists (medical (β＝0.194, P＝0.011) and insurance (β＝0.177, P＝0.020)). Overall, type of questions (medical or insurance) and individual backgrounds (prescription issuing medical institution, pharmacy scale, location, age, sex, employment type, years of service, current management pharmacist, and hospital work experience) have a complex effect on the pharmacists’ psychology. To facilitate pharmacists to contact physicians regarding prescription-related questions, physicians and pharmacists should share information and communicate on a daily basis, such as actively participate in joint training programs. It is also important to create an environment where regular employees and female pharmacists can work comfortably. The smooth resolution of prescription-related questions by relieving the psychological pressure of pharmacists will improve patient safety.