The participation of primary care physicians is essential for the success of ambulatory-care teaching. The “PEP2 Workbook” was developed by the Preceptor Education Project of the Society of Teachers of Family Medicine and provides clinicians with a variety of efficient and effective strategies for ambulatory-care teaching. Strategies include preparation for office visits by students, activities on the first day, one-minute preceptor teaching skills, observation of the student, providing feedback, and dealing with problems. Primary care physicians can apply these strategies readily in clinical practice to improve office-based teaching.

This study aimed to clarify whether continuous hemodiafiltration (CHDF) or hemodialysis (HD) was more effective after open heart surgery in dialysis patients. We evaluated 48 consecutive hemodialysis patients (28 men and 20 women, mean age : 68±10 years) who underwent coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) between January 2003 and December 2008. The patients were divided into 2 groups according to their postoperative dialysis treatment either continuous hemodiafiltration (CHDF) (CHDF group, n=36) or hemodialysis (HD) (HD group, n=12). Surgery in the CHDF group included 13 concomitant operations, 16 CABGs and 7 AVRs. There was only 1 concomitant surgery in the HD group, and there were 6 CABGs and 5 AVRs. There was no difference between the 2 groups regarding operation time, aortic clamp time, cardiopulmonary bypass time or intraoperative volume balance. CHDF was started significantly earlier than HD (8.0±5.8 vs. 21.0±1.0 h, p <0.01), which resulted in the removal of a greater volume of body fluid, during the first postoperative 24 h in the CHDF group (1,200±110 vs. 550±50 ml, p <0.01). However, there was no difference between the 2 groups regarding the amount of postoperative chest drainage. There were 6 hospital deaths in the CHDF group (17% ; 3 heart failures, and 1 each of pneumonia, arrhythmia and massive intestinal necrosis). There was also 1 hospital death in the HD group (8.3% ; heart failure). Most of the hospital deaths occurred after concomitant operations (6/7, 86%). It is beneficial to start CHDF soon after open heart surgery in hemodialysis patients.

Bicuspid aortic valve (BAV) is one of the more common congenital anomalies. It is well known that the ascending aorta and aortic root sometimes dilate in patients with BAV, even when the valve function is normal. We examined the morphological type and histological features of the dilated ascending aorta in patients with BAV. Of 276 patients who underwent aortic valve replacement (including coronary artery bypass grafting) from 2004 onwards, 60 (21.5%) with BAV were included in this study. The type of BAV was defined according to the Sievers classification. Type 1 BAV was the most common, and enlargement of the ascending aorta (≥45 mm) was the most common in the L/R type of BAV (48%). The morphology of the dilated ascending aortic wall was evaluated using three-dimensional CT angiography. The majority of dilations were asymmetric, but dilation was symmetric in the patient with dilation of the aortic root. Histological examination graded cystic medial necrosis of the ascending aortic walls using the aortic wall score. All patients with BAV had degeneration of the aortic wall, even when there was no dilation. The aortic walls of patients with dilated aortic roots showed advanced degeneration compared with the aortic walls of other patients. Therefore, aggressive root replacement may be appropriate, when the root is mildly dilated in patient with BAV.

To improve the quality of palliative care in the Kyoto region, we thought that closely connecting hospice and palliative care units (PCU) is necessary. Subsequently, we established the Kyoto PCU Liaison Committee in September 2017. This committee was created as a place to casually discuss the problems that individual PCU facilities have, deliberate on their worries together, grow and develop, and support newly launched facilities. Furthermore, discussions were held on current topics (emergency hospitalization, blood transfusion, smoking, bereaved family meetings, etc.) at the liaison meetings. While meetings were adjourned in 2020 due to the COVID-19 pandemic, we continued to exchange opinions on infection control, PCU management, etc., using the email network at first. Later, these meetings resumed via web conference systems. Thus, by having face-to-face relationships on a daily basis, we were able to maintain cooperation between PCUs even during the pandemic, and collaborate with cancer treatment hospitals. Overall, by forming a team of PCUs in Kyoto Prefecture, we aim to enable patients and their families to live with peace of mind wherever they are.