Background
 In recent years, inbound tourists to Japan are increasing. Although they rarely suffer diseases or injuries during travels, they may feel anxiety for medical services in foreign countries. This study was aimed to consider how inbound tourists visiting Japan feel about Japanese medical cares.
Methods
 Inbound tourists who came to the Tokyo Sightseeing Information Center were investigated. The questionnaire composed of 12 items relating to Japanese medical cares and levels was made in three languages; English, Chinese and Korean.
Results
 A total of 163 tourists including 98 English speakers, 39 Korean speakers and 26 Chinese speakers were enrolled in the study. (1) Native English speakers had a high anxiety about the communication with Japanese medical staffs (p<0.001). (2) Chinese and Korean speakers subjective estimated the Japanese medical level low (p <0.001). (3) Chinese and Korean speakers had a high anxiety for medical costs while traveling (p<0.001). (4) In a case of emergency, English speakers mostly “look for a drugstore and a hospital”, while Chinese and Korean speakers mostly “contact a travel agency and a tour conductor”.
Conclusion
 Considering foreign tourists' needs vary with their nationality and culture, Medical staffs should support them to have desired medical care in Japan.

We report a case of syphilitic aortitis (SA) associated with severe right coronary ostial stenosis, aortic regurgitation (AR), and annuloaortic ectasia (AAE). A 48-year-old man presented to a regional hospital with easy fatigability and nocturnal dyspnea. Echocardiography revealed Seller's grade 3 AR. A computed tomography scan showed AAE, dilatation of the ascending aorta, and calcification of both coronary ostia. Coronary angiography demonstrated that the left coronary artery was intact ; however, the right coronary artery was obscure. Active syphilis was detected on routine blood tests on admission. Therefore, the patient was started on a course of ampicillin/sulbactam (ABPC/SBT). Subsequently, he underwent the Bentall procedure and coronary artery bypass grafting with the right internal thoracic artery. The intraoperative findings showed degeneration of the aorta and severe right coronary ostial stenosis. The pathological findings of the aortic wall and aortic valve were consistent with SA. The postoperative course was uneventful. The patient continued receiving ABPC/SBT for 3 weeks postoperatively, and was then switched to oral amoxicillin.

Introduction: The regional palliative care support center (PCSC) has set the following palliative care goals for correction of misunderstanding and prejudice of the general community against palliative care, home care and home death of cancer patients: practice palliative care early after diagnosis, educate the community to understand palliative care and build a regional palliative care cooperation system. Method: This study reviewed four years (2009-2012) of data from the PCSC. Outcome data of the patients were collected during outpatient care, inpatient care, and in-home care that were supported by the PCSC. The PCSC managed palliative care based on patient conditions and symptoms in the early stage after diagnosis. The PCSC worked to spread the idea and importance of palliative care to the general community and health care professionals of the region, and also worked to promote the regional palliative care cooperation. Result: These efforts led to an increase in the number of first center visit of patients, especially introduction patients, and an extension of the period of treatments of both tumor department and palliative care department. These outcomes resulted in an increase in the rate of in-home care transitions, the length of in-home care and the number of deaths at home. These results suggest that the place of appropriate medical and caregiving treatments and the place of death are converting into home gradually from hospital.

Objective: To identify effective strategies to provide high-quality palliative care in settings where palliative care specialists are scarce, particularly in Japan. Methods: A scoping review of literature (in English) was conducted using Arksey and O’Malley’s methodological framework. Electronic databases (MEDLINE, CINAHL, and the Cochrane Library) were searched and supplemented with a manual search of relevant journal articles. Results: Nine studies met our inclusion criteria. Four key strategies have emerged: (1) developing a video consultation system to improve the timeliness of care; (2) providing online consultations by specialists to support general practitioners; (3) training nurses to manage the palliative care process; and (4) transferring knowledge and information from experts to non-specialists. Conclusion: Based on these strategies, creating a system tailored to the specific needs and readiness of palliative care in Japan is necessary. The effectiveness of these strategies should be evaluated in future research.

Objectives: This study aimed to describe the difficulties faced by physicians in providing palliative care to patients with cancer in facilities without palliative care specialists. Methods: Semi-structured interviews were conducted with 11 physicians involved in cancer treatment who were affiliated with facilities having no palliative care specialists such as Diplomate or Board Certification of the Specialty Board of Palliative Medicine of the Japanese Society for Palliative Medicine. The interview data were analyzed using qualitative content analysis. Results: The participants had “difficulties in palliative care consultation” because they could not consult with specialists or medical staff at their own facility, when immediate response to cancer symptoms was required. This was partly due to “difficulties in regional cooperation”. In addition, the participants had “difficulties in alleviation of symptoms” for highly complex symptoms of patients with cancer. Behind these difficulties, there was “difficulties in foundation of providing palliative care for individual physicians” including limited time available to the participants. Conclusion: These findings show that there is a necessity to establish a continuous external consultation system for specialists to respond to the immediacy of changes in symptoms and highly complex symptoms.