1)The Keio University School of Medicine introduced a "white coat ceremony" in 2006 and the taking of an oath written by medical students in 2007 for fourth–year students as part of medical professionalism education just before the start of clinical clerkships.
2)Through activities in 2009, the oath–writing project was highly evaluated by students, and 84% of students felt that Keio University should continue the project.
3)A challenge for the future is finding new ways to encourage more students to participate in the project.

To identify the factors affecting the high mortality rates associated with ruptured abdominal aortic aneurysm (rAAA), a review was made of the records of 35 consecutive patients (33 males, 2 females, mean age 69.9yr.) treated surgically between 1988 and 1997. Preoperatively profound shock (systolic pressure less than 70mmHg) was seen in 19 patients and loss of consciousness in 9. Maximum diameter of the AAA was 79±20mm and the preoperative hemoglobin level was 9.1±2.4g/dl. Proximal aortic clamp was performed at the intrathoracic aorta in 3 cases, the suprarenal aorta in 6, balloon occlusion in 4, and the infrarenal aorta in 22. Since 1994, diltiazem and nitroglycerin have been routinely given for latent myocardial ischemia and early induction of continuous hemodialysis for renal failure was attempted postoperatively. The overall hospital mortality rate was 20%. Multisystem failure was the most frequent cause of hospital death (57.1%), followed by pneumonia with sepsis in 28.6%, and intraoperative cardiac arrest (14.3%). By univariate analysis of various factors associated with the mortality rate, loss of consciousness, abnormality on electrocarciogram (ECG) and duration of shock for more than five hours were statistically significant. Multivariate analysis with stepwise logistic regression demonstrated that an ECG abnormality and duration of shock more than five hours were associated with high mortality, but not at statistically significant levels. These findings suggest that factors that are predictive of death (loss of consciousness and ECG abnormality) may be a reflection of shock in this patient population.

A 78-year-old woman, after mitral valve repair by placement of No. 29 Duran annuloplasty ring 6 years previously at another hospital, was admitted because of chronic heart failure and hemolytic anemia. A Doppler echocardiogram showed that mitral regurgitation was still present but not severe. The diagnosis of hemolysis was made by decreased serum haptoglobin, elevated serum lactate dehydrogenase (LDH) and progressive anemia. We estimated that the mechanism of hemolysis was related to the mitral annuloplasty with a ring and improvement of symptoms would be impossible without removal of the ring. On 25 June, 2001, the reoperation was performed through a median sternotomy, but adhesion was so severe that a standard left atriotomy was impossible. Therefore, the right thoracic cavity was opened through a mediastinal pleurotomy and a transseptal approach was taken through right atriotomy. The annuloplasty ring was partially detached from the mitral valve ring, and that part was non-endothelialized. We concluded that an eccentric regurgitant blood stream directed to the non-endothelialized portion of the annuloplasty ring appeared responsible for the hemolysis. The ring was removed and mitral valve replacement was performed with a 25mm Carpentier Edwards bioprosthesis. The removal of the source of hemolysis and the mitral valve replacement allowed prompt recovery from severe hemolysis. Decreased serum haptoglobin, elevated LDH and progressive anemia recovered postoperatively. The reoperation used was safe and effective in relieving hemolysis. The scanty literature concerned was reviewed.

Purpose: In Kasugai City Hospital, we have introduced palliative care clinical pathway with a focus on decision-making support on the intention of recuperation location in addition to symptom relief. In this study, it is intended to explore the factors that make it difficult to home discharge of cancer inpatients with the intention of discharged home on the basis of the information on the clinical pathway. Methods: The subject patients were cancer inpatients who had expressed the intention of the discharge to the home during period from June 2014 to August 2015. We examined the medical records of the target patient retrospectively. Logistic regression analysis was performed in order to clarify the factors that make it difficult to home discharge. Results: Of 43 patients, 25 patients (58.1%) were discharged from the hospital to the home. As a result of logistic regression analysis (multivariate analysis), delirium and living alone have been extracted as the predictive factors that makes it difficult to home discharge. Conclusion: Delirium and living alone have been suggested as the factors that makes it difficult to home discharge of patients who wish to home discharge. Early detection and early treatment of delirium are important, and early collaboration between the hospital discharge support department and palliative care team for the living alone patient is also necessary.

OBJECTIVE: To assess the use of colony-stimulating factors (CSFs) in patients with ovarian cancer who receive adjuvant paclitaxel and carboplatin chemotherapy in clinical practice and to assess whether the frequency of CSF use differs among hospitals in Japan. METHODS: CSF use in patients with ovarian cancer who received first-line paclitaxel and carboplatin was analyzed retrospectively using data from the Japanese hospitalization payment system. RESULTS: A total of 1,050 patients at 104 hospitals were identified. The median age was 60 years (range, 22 to 88 years). Of these, 163 patients (15.5%) were diagnosed with neutropenia and 134 patients (12.8%) received CSFs. Among the patients who received CSFs, 125 (93%) received them for the treatment of neutropenia without fever and 1 received them for febrile neutropenia. In total, CSFs were administered for 272 cycles of chemotherapy. Among them, CSFs were used as treatment for neutropenia without fever in 259 cycles (95%), as prophylaxis (primary or secondary) in 12 cycles (4%), and as treatment for febrile neutropenia in 1 cycle. Among hospitals, a median of 4.0% of patients received CSFs with an interquartile range of 25% (Q1, 0%; Q3, 25%). A logistic random effects model showed that the variation in the proportion of patients receiving CSFs among the 104 hospitals was 2.0 (p<0.001), suggesting that the use of CSFs varied across hospitals. CONCLUSION: Most patients received CSFs for neutropenia without fever. Standardized and evidence-based use of CSFs is critically required among hospitals in Japan.
Asian Continental Ancestry Group ; Carboplatin* ; Colony-Stimulating Factors* ; Drug Therapy ; Febrile Neutropenia ; Fever ; Hospitalization ; Humans ; Japan* ; Neutropenia ; Ovarian Neoplasms* ; Paclitaxel* ; Retrospective Studies

Enrolled in our study were 16 seriously handicapped persons (9 males and 7 females) institutionalized in our medical center. They were 20 to 58 years of age (mean 35 yrs). In the previous study, we found they had no evidence, serological or clinical, of osteomalacia but were verified as having significantly low bone mineral density (BMD) at the calcaneus and lumbar vertebrae. Serum levels of 25-OH-vitamin D were low and positively correlated with the lumbar vertebral BMD. Thus we postulated that low BMD was at least partly due to the lack of ultraviolet exposure. In the present study, the lumbar vertebral BMD of the above subjects were measured before and after increasing their exposure to sunlight. We found that mean lumbar BMD increased signigicantly from 770 mg/cm² to 786 mg/cm² (P<0.05, Wilcoxon, paired test). The Z-score also increased significantlyfrom 78 ± 13% to 80 ± 12%(P<0.05, Wilcoxon, paired test).
These findings suggest low BMD could be corrected to some extent by increasing sunlight exposure of institutionalized persons. Former members of farming communities who are retired, handicapped, or otherwise limited to indoor activity, can also recover their BMD and prevent osteoporosis by an increased daily exposure to sunlight.

Objective: To examine the association between the mobilization level during intensive care unit (ICU) admission and independence in activity of daily living (ADL), defined as Barthel Index (BI)≥70. Methods: This was a post-hoc analysis of the EMPICS study involving nine hospitals. Consecutive patients who spend >48 hours in the ICU were eligible for inclusion. Mobilization was performed at each hospital according to the shared protocol and the highest ICU mobility score (IMS) during the ICU stay, baseline characteristics, and BI at hospital discharge. Multiple logistic regression analysis, adjusted for baseline characteristics, was used to deter-mine the association between the highest IMS (using the receiver operating characteristic [ROC]) and ADL. Results: Of the 203 patients, 143 were assigned to the ADL independence group and 60 to the ADL dependence group. The highest IMS score was significantly higher in the ADL independence group than in the dependence group and was a predictor of ADL independence at hospital discharge (odds ratio, 1.22; 95% confidence interval, 1.07–1.38; adjusted p=0.002). The ROC cutoff value for the highest IMS was 6 (specificity, 0.67; sensitivity, 0.70; area under the curve, 0.69). Conclusion These results indicate that, in patients who were in the ICU for more than 48 hours, that patients with good function in the ICU also exhibit good function upon discharge. However, prospective, multicenter trials are needed to confirm this conclusion.

Background: Appetite loss in older adults raises the risk of malnutrition and frailty. The recent emphasis on psychological and social support for appetite loss reveals the importance of robust social networks. Depression is linked to a decline in appetite and social networks. Social networks may influence appetite directly and indirectly through depression. This exploratory cross-sectional study categorizes social networks into family and friend networks to elucidate their direct and indirect effects. Methods: The study analyzed 193 community-dwelling older adults (women 78.2%; mean age 77.1±5.3 years) who participated in health-checkup events in two cities in Japan. Appetite was assessed using the Japanese version of the Simplified Nutritional Appetite Questionnaire, and family and friend networks were assessed using the Lubben Social Network Scale-6. Depression was assessed using the Geriatric Depression Scale-15. Based on previous research, we constructed a causal model examining the impacts of family and friend social networks and depression on appetite and calculated the direct and indirect effects through structural equation modeling. Results: The family network had a direct effect on appetite (path coefficient=0.18) and an indirect effect via depression (path coefficient=0.0608). Conversely, the friend network was not directly associated with appetite but had an indirect effect through depression (path coefficient=0.095). The model exhibited a good fit. The mechanism of influence on appetite varied between the networks. Conclusion To prevent appetite loss, social networks with family and friends should be assessed separately, and tailored support should be provided for each.

Methods: Forty-nine adults who underwent single-level L4/5 interbody fusion for degenerative spondylolisthesis were divided into BE-ELIF (n=27) and OLIF (n=22) groups based on the surgical approach used. Clinical outcomes were assessed using the Visual Analog Scale and the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ). Radiographic parameters, including distance of spondylolisthesis, disc height, segmental lordosis, lumbar lordosis, pelvic tilt, and sagittal vertical axis, were evaluated preoperatively and at final follow-up. Results: OLIF provided significantly better relief of pain in lower limbs and buttocks at 1-year follow-up. No significant between-group differences were observed in JOABPEQ domains. BE-ELIF resulted in greater improvements in spondylolisthesis distance and disc height, while other parameters did not differ significantly between the two groups. Conclusions For L4/5 degenerative spondylolisthesis, BE-ELIF demonstrated superior spondylolisthesis reduction and disc height improvement than OLIF. Although BE-ELIF was associated with some inferior clinical outcomes, it provided satisfactory results, effective realignment, and a low complication risk.

Background: Appetite loss in older adults raises the risk of malnutrition and frailty. The recent emphasis on psychological and social support for appetite loss reveals the importance of robust social networks. Depression is linked to a decline in appetite and social networks. Social networks may influence appetite directly and indirectly through depression. This exploratory cross-sectional study categorizes social networks into family and friend networks to elucidate their direct and indirect effects. Methods: The study analyzed 193 community-dwelling older adults (women 78.2%; mean age 77.1±5.3 years) who participated in health-checkup events in two cities in Japan. Appetite was assessed using the Japanese version of the Simplified Nutritional Appetite Questionnaire, and family and friend networks were assessed using the Lubben Social Network Scale-6. Depression was assessed using the Geriatric Depression Scale-15. Based on previous research, we constructed a causal model examining the impacts of family and friend social networks and depression on appetite and calculated the direct and indirect effects through structural equation modeling. Results: The family network had a direct effect on appetite (path coefficient=0.18) and an indirect effect via depression (path coefficient=0.0608). Conversely, the friend network was not directly associated with appetite but had an indirect effect through depression (path coefficient=0.095). The model exhibited a good fit. The mechanism of influence on appetite varied between the networks. Conclusion To prevent appetite loss, social networks with family and friends should be assessed separately, and tailored support should be provided for each.