A 62-year-old woman, who received implantation of a prosthetic graft for treatment of a descending aortic aneurysm 15 months previously, was admitted with hemoptysis. An aortogram demonstrated communication from the distal anastomosis to S⁶ of the left lung. After removal of the aorta across the distal anastomosis concomitantly with left lower lobectomy, we replaced a short segment of the graft. Culture of the pus obtained from the anastomotic site was positive for MRSA. Postoperatively, although the left pleural cavity was irrigated continuously with 1% popidone iodine solution, massive bleeding from the distal anastomosis appeared again 2 weeks later. This time, to remove the infected graft as much as possible, two extraanatomical bypasses were created between the right axillary and right femoral arteries, and the ascending and abdominal aorta. The closed prosthetic and aortic stumps were covered by a viable omental flap. Four months later, bleeding occurred again at the site of the proximal anastomosis. The last radical surgery was performed extrapleurally through a trapdoor thoractomy made in the left infraclavicular region. There was a 1.5cm long laceration of the aorta just proximal to the oldest graft-aortic anastomosis. The aorta was divided and closed between the left common carotid and subclavian arteries. The left subclavian artery was ligated at its origin. The pleural cavity was continuously irrigated with popidone iodine to clean up the microorganisms. She was discharged from the hospital on the 258 POD and has been doing well since then.

Objective: There are only a few studies evaluating the effects of drug information services on pharmacotherapy.  We, therefore, studied the effects of providing drug information such as the effectiveness and safety of aliskiren on its pharmacotherapeutic efficacy by comparing before versus after drug information provision.
Methods: Pharmacists provided drug information such as the effectiveness and safety of aliskiren coadministered with either ACE-I (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker) to physicians and other healthcare professionals.  We compared the number of patients for whom aliskiren was prescribed, the proportion of diabetic patients taking both aliskiren and ACE-I (or ARB), the proportion of patients with low eGFR (estimated glomerular filtration rate), and the proportion of patients with hyperkalemia and related conditions, before versus after providing the drug information to the healthcare professionals.
Results: The number of patients for whom aliskiren was prescribed decreased.  The proportion of patients taking both aliskiren and ACE-I (or ARB) decreased significantly after providing the drug information (p=0.007).  The proportion of diabetic patients taking both aliskiren and ACE-I (or ARB), the proportion of patients with low eGFR, and the proportion of patients with hyperkalemia also decreased, after providing the drug information.
Conclusion: This study showed the drug information service to be clinically beneficial, achieving better pharmacotherapy.  Pharmacists should evaluate and provide information on the effectiveness and safety of drugs announced by authorities in a timely manner to achieve optimal patient care.

Background: Previous surveys have demonstrated that a significant proportion of inpatients did not receive adequate pain management at an acute care hospital in Japan. Aim: The aim of this study was to evaluate the usefulness of a hospital-wide audit for assessing pain management with opioids according to the electronic medical records (EMRs) Methods: The subjects of this audit were inpatients receiving strong opioids who had not been consulted by the pallia. tive care team (PCT). The PCT held a weekly pharmacist-led conference to evaluate the adequacy and appropriateness of analgesics, including opioids, as well as drugs administered for adverse effects according to information collected by the PCT pharmacists. The PCT subsequently recorded the advisory comments in the EMRs. Each week, the PCT monitored whether the suggestions had been accepted by primary physicians and whether the pain and/or adverse effects had improved. Results: Among a total of 4,978 cases evaluated during the 3-year survey period, 888 (17.8％) had inadequate pain and/or adverse effect management. Symptoms improved in 82.3％ of cases for which PCT proposals were accepted. Conclusion: The results suggest that this hospital-wide audit may be useful for improving pain management with opioids at an acute care hospital.

We report two emergency mitral valve replacements performed successfully on 16-week and 29-week pregnant women for infective endocarditis in the active phase. The first patient was in severe acute heart failure on admission, and the fetus was already dead. Induced abortion was performed uneventfully 6 days after mitral valve replacement. The second patient presented with several episodes of systemic embolization. An echocardiography revealed giant movable vegetation on the mitral valve. The patient had emergency mitral valve replacement just after the Caesarian section. Both the patient and her baby weighting 1, 374g had an uneventful good courses with no complication. We concluded that in emergency operations in pregnancy, saving the mother's life should have priority over all else, but we should find the way to rescue the fetus life if at all possible. Therefore, depending on the situation, we should not hesitate about doing a simultaneous operation, Caesarian section and heart surgery, for that purpose.

Purpose：This study investigated the current state of medical care and home palliative care for terminally ill cancer patients in Japan. Methods：We conducted a retrospective questionnaire study of 352 cancer patients who received home palliative care from 6 specialized home care clinics and discontinued home care or died from January to June in 2012. Results：The questionnaire was answered by 290 patients〔165 men（57％）, mean age：72±13 years〕who started home palliative care after completing cancer treatment. Home visits from nurses were used by 238 patients（98％）and 95 patients（39％）used home care workers. Within a month before discontinuation of home care or death, 72 patients（30％）received fluid therapy and 127 patients（52％）received strong opioids. The outcome of home palliative care was death at home in 242 patients（83％）and discontinuation of home care in 48 patients（17％）. The reason for discontinuation was family physical and mental problems or physical problems of the patient. Conclusion：This study demonstrated the current state of home palliative care by specialized home care clinics.

Between January 1981 and December 1996, we performed valve replacement in 281 patients using bileaflet prosthetic valves in mitral and/or tricuspid positions. Thrombosed valve were seen in 10 patients (7 in mitral, 3 in tricuspid positions). In 5 patients, coumadin had been stopped for several reasons (pacemaker implantation, melena, drug allergy), but in the other 5 patients, anticoagulation was within the therapeutic range at the time of presentation. For thrombolytic therapy urokinase or tissue plasminogen activator were used. The treatment was successful in 5 patients (4 mitral, 1 tricuspid), and unsuccessful in 5 patients (3 mitral, 2 tricuspid). Three of the 5 unsuccessful patients were treated surgically (3 with re-mitral valve replacement, 1 with thrombectomy). Prompt surgical treatment can be used as the first line of therapy for thrombosed valves. Thrombolytic therapy may be useful in some cases of bileaflet valve thrombosis without critical hemodynamic collapse. Doppler echocardiographic assessment of increasing peak velocity and pressure half time is useful for detecting thrombosed valves.

BACKGROUND/AIMS: The objective of this study was to compare the clinical characteristics of patients with autoimmune pancreatitis (AIP) with or without Mikulicz's disease (MD) and with MD alone. METHODS: We investigated the clinical findings in 15 AIP patients with MD (group A+M), 49 AIP only patients (group A), and 14 MD only patients (group M). RESULTS: The male-female ratio was significantly higher in group A+M (73%, p<0.05) and group A (78%, p<0.01) than group M (21%). Serum immunoglobulin G (IgG) levels were significantly higher in group A+M than in group A (p<0.01) and group M (p<0.05). Serum IgG4 levels were significantly higher in group A+M than in group A (p<0.01). Other organ involvement was observed in 73% (11/15) of patients in group A+M. The number of patients with diabetes mellitus was significantly higher in group A+M (66%, p<0.01) and group A (51%, p<0.05) than in group M (7%). All of the patients responded well to steroid therapy, but the relapse rate in group A+M (33%) was significantly higher than that in group A (3%, p<0.01). Salivary gland function was impaired in all groups compared with the control group, but the degree of dysfunction was less in group A compared with group A+M and group M. CONCLUSIONS: The relapse rate of AIP in MD patients was significantly higher than that of AIP in patients without MD.
Diabetes Mellitus ; Humans ; Immunoglobulin G ; Mikulicz' Disease ; Pancreatitis ; Recurrence ; Salivary Glands

BACKGROUND: Sedentary behaviors have recently become an important public health issue. We aimed to investigate the relationship between screen time and nutrient intake in children and adolescents. METHODS: The present study was conducted in 2013. Data were collected from children and adolescents aged between 6 and 15 years old in Shika town. Questionnaires were distributed to 1459 subjects, 1414 of whom participated in the study (96.9%). Sedentary behaviors were assessed based on participants' screen behaviors (television (TV) viewing, personal computer (PC) use, and mobile phone (MP) use). The main outcomes were the intake of nutrients from a validated food frequency questionnaire. Analysis of covariance (ANCOVA) was used to examine the significance of differences in nutrient intake estimates. Multivariate linear regression analyses, adjusting for age, BMI, and physical activity, were used to provide parameter estimates (β) and 95% CI for the relationship between screen time and nutrient intake. RESULTS: In boys, longer TV viewing times correlated or tended to correlate with a lower intake of protein, potassium, calcium, iron, vitamin K, vitamin B-2, and total dietary fiber. In girls, longer TV viewing times correlated with a lower intake of protein, sodium, calcium, vitamin D, and vitamin B-2. Longer TV viewing times correlated with a higher intake of n-6 fatty acids in girls. PC use was related or tended to be related to a lower intake of potassium, iron, vitamin K, and folic acid in boys, but not in girls. A relationship was observed between MP use and a lower intake of vitamin K in boys, and MP use and a higher intake of vitamin D in girls. CONCLUSIONS The present results revealed that longer TV viewing times are associated with less protein, minerals, vitamins, and total dietary fiber intake in children and adolescents. It was also revealed that boys with PC use have less minerals and vitamins. These results support the need to design intervention programs that focus on decreasing TV viewing time in both sexes and PC use in boys while encouraging adherence to dietary guidelines among children and adolescents.
Adolescent ; Body Mass Index ; Child ; Cross-Sectional Studies ; Diet ; Energy Intake ; Exercise ; Female ; Humans ; Japan ; Male ; Screen Time ; Sedentary Behavior ; Sex Factors ; Socioeconomic Factors