This paper deals with a case which was firmly diagnosed as ileum perforation caused by an ingested fish bone during an emergency operation for acute appendicitis.
A 49-year-old man was referred to our hospital because of right lower abdominal pain. On close exploration, acute appendicitis was suspected, and an emergency laparotomy was performed. During the operation, we confirmed redness and swelling of the appendix, thickening of the mesoappendix, and typical presentations of appendicitis. Moreover, there was massive retention of blood in the small intestine, and an intestine about 20cm from the terminal ileum was adherent to the inside of the right common iliac artery. When the adhesion was dissected, a fish bone was detected. From these findings, it was thought that iliac perforation due tothe fish bone had involved the appendix. Appendectomy and a partial excision of the ileum were performed.
It was inferred that, since the patient had previously undergone a total gastrectomy with Roux-en Y reconstruction, there was no secretion of gastric juice, resulting in poor digestion of the fish bone. Though the fish bone could be easily evacuated to the small intestine because of a lack of physiological barriers such as the pyrolic ring, it was considered, the perforation occurred because of astricture of the intestine caused by adhesion.

Introduction: We experienced a case of pneumatosis cystoides intestinalis with intra-abdominal free air following steroid therapy for an end-stage brain tumor. Case: The patient was a 67-year-old man. He had received surgery and chemotherapy for the brain tumor, but the disease progressed and his consciousness deteriorated. Eventually, he developed aspiration pneumonia and was hospitalized. His consciousness level remained poor even after the pneumonia improved. His survival prognosis was considered to be approximately 1 month, and he was transferred to a palliative care ward. After the transfer, administration of betamethasone 8 mg/day was started for the purpose of improving his level of consciousness. Temporary improvement was observed, and administration of this drug was continued with dose adjustments, as appropriate. Six weeks after the start of betamethasone administration, when his consciousness level again deteriorated, aspiration began to recur. Chest X-rays, obtained to assess pneumonia, showed intra-abdominal free air. Pneumatosis cystoides intestinalis was confirmed by computed tomography. He had few abdominal symptoms, and was managed conservatively. He died of respiratory failure. Conclusion: Pneumatosis cystoides intestinalis is mostly secondary, and steroid therapy is considered to be one of the causes. But follow-up observation is often conservative, and judgment of discontinuation of steroid needs to be made in consideration of its effect and prognosis is there.

We set out to assess our treatment strategy of acute aortic dissection associated with atherosclerotic aortic aneurysm, and to assess its results. A total of 228 patients with acute aortic dissection were admitted to our hospital between 1994 and 2009. Among these, 30 cases were associated with atherosclerotic aortic aneurysm and we retrospectively analyzed their patient data. Of these, 5 patients received diagnoses of Stanford A dissection and 25 patients demonstrated Stanford B. Coexisting aneurysms consisted of postabdominal aortic replacement in 9 patients, ascending aortic aneurysm in 1, arch aortic aneurysm in 6, descending aortic aneurysm in 2, thoracoabdominal aortic aneurysm in 3, and abdominal aortic aneurysm in 9. Patients were divided into 3 groups based on the relationship between aneurysm and dissection : acute aortic dissection occurred after graft replacement of an aortic aneurysm (Group 1, n=9), dissection coexisted with aneurysm in a different segment of the aorta (Group 2, n=8), and dissection extended to or involved the aneurysm (Group 3, n=13). Our treatment strategy for all patients excluding those with aortic rupture or malperfusion is described below. In the cases of Stanford A dissection, emergency ascending aortic replacement or total arch replacement was performed. In cases of Stanford B, patients were treated conservatively in the acute phase. Surgery for the coexisting aortic aneurysm was then performed in the chronic phase, if the aneurysm was large. We think that the interval between dissection onset and aneurysm surgery should be extended to at least 1 month, because the aortic wall was too fragile to perform anastomosis in the acute phase in the present cases. As a result, there were 2 hospital deaths in Group 3, but there was no aortic rupture during treatment in the acute phase in any of these 3 groups. There were no vascular-related deaths during follow up. Our treatment strategy obtained favorable outcomes.

A case of 38-year-old woman with corrected transposition of great arteries is reported. She was admitted for acute cardiac failure caused by not only the left-side atrioventricular regurgitation for the ruptured chordae tendineae, but also the right-side one. We have to perform double valve replacement emergently due to the progression of biventricular failure. Very few reports have described a surgical repair of the right-sided valve replacement. The postoperative course was favorable.

Objective：There are few reports on decision-making support at palliative care clinics in designated regional cancer care hospitals. This study clarified the types of decisionmaking support patients with cancer and their families were provided by specialized outpatient palliative care services. Method：We retrospectively examined the medical records of 110 patients who had been referred to the palliative care clinic for home care between April 2012 and March 2014. Results：The median duration of receiving services from the palliative care clinic was 23 days（range：1～492 days）. The mean number of visits to the clinic was 4.7 visits（range：1～29 visits）. A total of 89 patients（80％）needed decision-making support. Of those 89 patients, 33（30％）required support in making a decision about anticancer treatment. Twenty-six（78％）of those 33 patients had just received the diagnosis or were receiving anticancer treatment. Conclusion：The study suggested that decision-making support in early stages is an important role for a palliative care clinic in a designated regional cancer care hospital.

　　We worked out TTR values in patients receiving warfarin treatment in Abashiri-Kosei General Hospital. The patients were divided into two groups - those with satisfactory TTR values and those with poor TTR values - and associations between patient factors and average dosing interval were examined in the two groups. A total of 178 patients joined this study. The average TTR value worked out at 65.1±24.8%. It was found that the average TTR value for those patients aged at 70 and above came to 72.7±21.4%, which was significantly high as compared with 51.06plusmn;24.6% for those under 70 years of age. When the average TTR value was calculated after the optimal PT-range for the group of those below the age of 70 was changed from 2.0～3.0 to 1.6～2.6, it rose from 51.0% to 74.9%. These findings made it clear that PT-INR, regardless of age, was under control within the range from 1.6 to 2.6 in this hospital in accordance with the results of the J-RHYTHM Registry analysis.

　　The World Health Organization (WHO) recommends antimicrobial use density (AUD) as an indicator for evaluating the amount of antimicrobials used, an index that is now widely employed in many facilities. Defined daily doses (DDD) set by WHO are used for calculating AUD. However, discrepancies have been noted between other countries and Japan in the standard dosage of antimicrobials, which may cause a problem evaluating antimicrobial use with the DDD. Therefore, in this study, we calculated AUD (modified antimicrobial use density: mAUD) with the DDD (modified defined daily dose: mDDD) of our hospital for the carbapenem antimicrobial meropenem (MEPM), mAUD, and resistance rate of Pseudomonas aeruginosa. From 2010 through fiscal year 2016 (ending in March), AUD was 5.9±1.4, 7.0±2.9, 8.2±2.3, 6.8±2.1, 7.3±2.2, 7.0±2.1, and 8.0±3.0 and mAUD was 11.7±2.7, 12.0±4.9, 11.3±3.1, 11.0± 3.4, 11.4±3.5, 11.5±3.5, and 11.2±4.2, respectively. The corresponding resistance rate of P. aeruginosa was 35.1%, 37.9%, 10.0%, 6.0%, 22.6%, 10.6%, and 10.0%. A significant positive correlation was found between mAUD and the resistance rate of Pseudomonas aeruginosa (P < 0.01, r = 0.88). Our results confirm that the mAUD is an effective index for controlling resistance of P. aeruginosa.

At Tokyo Women's Medical University, our curriculum for first-year students is designed to teach the dynamics and etiquette of human relations. During the third year, medical students are expected to anticipate and plan effective therapeutic communication and interaction with patients. A discussion group of 6 students and a member of the human-relations committee first clarify the purpose and develop the training; students then independently participate in human-relations training during the summer vacation. After training, experiences are discussed during class. Although this curriculum has been used for some 10 years, its benefits have been assumed but not validated. We used student reports and questionnaires to examine the effects of this curriculum. The results clearly show that planning and training give the students an opportunity to learn how to establish an effective physician-patient relationship.

Purpose: In terminally ill patients with advanced cancer,it is recognized that delirium is reversible in 20-50% of the patients with it. Identification of its cause is vital to ensure the quality of life of the patients with delirium at the end of life. We would like to report a case of the advanced cervical cancer patient with delirium, successfully treated by intravenous administration of vitamin B1. Case: An 83-year-old woman, who was diagnosed the advanced cervical cancer with carcinomatous peritonitis, was admitted to Shizuoka Cancer Center Palliative Care Unit. Four days after the admission, she presented sleep-wake cycle disturbance, poor attention, poor concentration,and short-term memory loss, and these conditions were diagnosed with delirium. Vitamin B1 deficiency was suspected by normal examinations including laboratory results and head computed tomography except for the low level (19ng/ml) of vitamin B1. One week after starting intravenous administration of vitamin B1, the symptoms of delirium were improved. Conclusion: In this case, delirium by vitamin B1 deficiency developed even though having adequate oral intake (about 1,000kcal/day), indicating malabsorption of vitamin B1 due to hypoperistalsis and edema of the bowel. Advanced cancer patients can easily develop vitamin B1 deficiency due to inadequate oral intake, increased consumption of vitamin B1 and malabsorption of vitamin B1. Therefore,the examination of vitamin B1 deficiency is necessary for patients with delirium that cannot be specified. Palliat Care Res 2009; 4(2): 330-333

PURPOSE : To determine risk factors for excessive sensitivity to cold (ESC) in relation to physical features.DESIGN : A prospective cohort study carried out between July 7 and November 14,2008.PARTICIPANTS AND METHODS : Seventy female junior college students with no ESC at baseline, and a median age of 20 years, participated. We used a numerical rating scale (NRS) to classify each ESC sensation over the five days in this July-November period.To confirm physical symptoms, we used Terasawa's diagnostic scores for ki, ketsu, and sui. We defined ESC as mean NRSgeq ≥ 5.RESULTS : We documented 17 participants with ESC in November. The multivariate adjusted odds ratio for ESC was11.6 (95% CI 1.9 to 97.5) for the physical characteristic “edema”. Participants with ESC were shorter in stature than participants without ESC (-5.9cm ; 95% CI -8.6 to -3.1).CONCLUSION : Participants with edema and short stature have a high risk for ESC.