Introduction: This study examined the effectiveness of the modified Hospital Elder Life Program (HELP) for preventing delirium, which was adjusted to be used in acute internal medicine wards at general community hospitals in Japan.Methods: The pre-intervention group consisted of 751 patients aged 70 years or older hospitalized at Nishiyodo Hospital and Amagasaki Medical Co-op Hospital between January and July 2013. The post-intervention group consisted of 775 patients aged 70 years or older hospitalized between March and July 2017 and between October and December 2017. To address risk factors for delirium, a multicomponent intervention (modified HELP) consisting of the following was implemented: handing out pamphlets, orientation to maintain activity levels, sleep improvement, early initiation of rehabilitation, provision of glasses, hearing aids, and dentures, and the termination of continuous intravenous infusion. The Delirium Screening Tool was used to calculate the percentage of inpatients who developed delirium.Results: Of the 751 patients in the pre-intervention group, 108 (14.4%) developed delirium and 88 (11.4%) of the 775 patients in the post-intervention group exhibited delirium (odds ratio: 0.70; 95% confidence interval: 0.48-1.01; p=0.06).Conclusion: The modified HELP, adjusted for use in Japan, did not significantly reduce the rate of delirium during hospitalization. Therefore, a more universal intervention method is needed in the future.

The use of the radial artery (RA) for coronary artery bypass grafting (CABG) is increasing. This study describes mid-term results of the use of RA for CABG. Between March 1996 and March 1999, we performed 134 CABGs using RA or saphenous vein graft (SVG) for the left circumflex branch area or diagonal branch area. The mean age was 62.6±9.6 years in the RA group and 65.0±7.8 years in the SVG group. The average number of anastomoses was 2.7per patient. RA was anastomosed with the postero-lateral branch (PL) in 69 cases, with the obtuse marginal branch (OM) in 29 cases and with the diagonal branch (DB) in 10 cases. SVG was anastomosed with PL in 26 cases, with OM in 14 cases and with DB in 2 cases. The proximal anastomosis was made with the ascending aorta in all cases. No sequential bypass anastomosis was used in any case. The early patency rate of the grafts was 97.9% (93/95) in RA and 91.7% (33/36) in SVG. The clinically negative rate in the treadmill test (TMT) performed later was 99.0% (102/103) in RA and 90.9% (30/33) in SVG. The late patency rate of the grafts was 92.9% (13/14) in RA and 50.0% (3/6) in SVG. Perioperative death occurred in 5 cases. Late cardiac death occurred in 2 cases (0.02%) of the RA group and 1 case (0.03%) of the SVG group. The 3 year-survival rate free of cardiac events was 92.8% in the RA group and 80.9% in the SVG group. The use of RA for CABGs is not only effective for myocardial revascularization, but also can be expected to bring about good patency as a late result.

We performed mitral valvuloplasty for 25 months old infant with endocardial fibroelastosis (EFE) and 21 months old infant with endomyocardial fibrosis (EMF). These two patients showing good post operative cause, have been followed up during 10 and 1 years respectively. The EFE and EMF are severe and progressive restrictive cardiomyopathy of unknown etiology. Most of cases with EFE and EMF have an enlarged left ventricle with incompetent atrioventricular valve. The prognosis of these patient is usually poor. We believe that the surgical treatment in early phase may be able to improve heart failure and also to protect the progression of these disease. This case with EMF is the first report of successfull surgical treatment for the patients with severe congestive heart failure whithin one year after birth in Japan.

Background: At present clinical reasoning skills are not systematically taught in Japanese medical universities. We developed a prototypic preliminary module for clinical tutors to introduce clinical reasoning to Japanese medical students. We hypothesized that tutored medical students would outperform self-study students.
Method: Using the web-based Sequential Question and Answer test that rewarded history and differential diagnosis as proxies for clinical reasoning, we compared the pre and posttest scores of 12 randomized fifth grade tutored students at two universities during four tutor-led 1.5-hour web-based seminars using a structured syllabus to 12 randomized self-study students.
Results: The tutored and self-study groups’ pretest scores were statistically similar at about 40 out of 100 weighted correct points. The tutored students’ posttest scores were 62 points, significantly greater (p = 0.007) than the pretest mean 42 points, compared to the self-study students’ posttest scores of 52 points, significantly greater (p = 0.012) than pretest mean 40 points. The difference between the two posttest groups was of borderline statistical significance (p = 0.08).
Conclusions: We successfully assessed a prototypic module for tutors to introduce clinical reasoning to Japanese medical students. The tutored students achieved higher scores than the self-study students. Further research is needed to exploit the potential of our modular clinical reasoning system.

We describe a case of Takotsubo cardiomyopathy in an 88-year-old woman who underwent endovascular aneurysm repair (EVAR) for an abdominal aortic aneurysm. The patient developed cardiac arrest shortly after the surgery. Following immediate resuscitation, her electrocardiogram showed extensive ST segment elevation in leads V2-V6, and echocardiography revealed apical akinesis with basal hyperkinesis. Emergency coronary angiography confirmed the absence of coronary lesions, and she was diagnosed with Takotsubo cardiomyopathy. Her cardiac function improved within a few days following the administration of catecholamines. Although EVAR is a less invasive surgical procedure, it may trigger Takotsubo cardiomyopathy. Prompt diagnosis and appropriate management of Takotsubo cardiomyopathy are essential to treat critical conditions in the acute phase.

Surgery for a shaggy aortic aneurysm requires a meticulous strategy to prevent embolic complications since the complications are associated with longer length of hospital stay and higher mortality. However, until now, there are no established treatment options to prevent embolic complications. We report a case of a 75-year-old man with a descending aortic aneurysm and a shaggy aorta who underwent thoracic endovascular aortic repair (TEVAR) with major branch artery protection. During the procedure, we placed balloon catheters in the left subclavian and left common iliac arteries, a filter device in the superior mesenteric artery, and a sheath at the ostium of the right common iliac artery. The patient did not develop embolic or other complications and was discharged on the eighth postoperative day. Our strategy of using the balloon occlusion technique and filter placement at the major vessels effectively prevented embolic complications during TEVAR for a shaggy aorta.