A 75-year-old man with end-stage colon cancer began to experience increased pain and distress and significantly deteriorated quality of life (QOL) due to internal hemorrhoids. In order to maintain the patient's QOL, the hemorrhoids were successfully treated with aluminum potassium sulfate and tannic acid (ALTA) injection, which involves minimal patient burden and pain. The outcome of this case suggests that ALTA might be useful and effective for the treatment of internal hemorrhoids in terminally ill cancer patients.

A 65-year-old woman was referred to our department for further examination and treatment of an abdominal aortic aneurysm. Preoperative abdominal 3-D CT revealed a horseshoe kidney with 2 aberrant renal arteries, arising from bilateral common iliac arteries and supplying blood to the renal lower poles. At operation, the abdomen was explored via a long midline incision. The abdominal aortic aneurysm was replaced with a knitted Dacron bifurcation graft without symphysiotomy, and the 2 aberrant renal arteries were preserved. Postoperative 3-D CT showed no sign of renal infarction or dysfunction. Abdominal 3-D CT was useful to reveal aberrant renal arteries of the horseshoe kidney.

Thromboembolic events after cardiac surgery, including ischemic strokes, can be devastating complications, however only a few studies manifest the platelet activation and coagulation state after off-pump coronary artery bypass (OPCAB). Platelet-derived microparticles (PMP) are observed as released vesicles from platelets following platelet activation, and are believed to play a role in some clinical diseases because of their procoagulant activity. The aim of the present study was to evaluate the hypercoagulant state after OPCAB using PMP and other indices. Data were obtained from 15 patients (aged 69±7 years; only men) undergoing elective OPCAB surgery. One hundred milligrams of aspirin were used as postoperative antiplatelet drugs. Preoperative risk factors, operation time, postoperative hospital stay, transfusion and blood samples of CBC, PMP, βTG, PF 4, platelet aggregation, FDP, D-dimer and TAT of pre- and postoperative days (POD) 3 and 7 were studied. There was no difference between the PMP level with or without risk factor. The PMP levels of POD 3 and 7 were significantly higher compared to the preoperative levels (pre-op, POD 3, 7:9.1±5.1, 15.2±10.3, 28.4±24.5/10⁴plt respectively, p<0.05). The levels of FDP, D-dimer and TAT rose significantly on POD 3 and 7 and significantly correlated with the PMP levels. Beta TG, PF 4 and platelet aggregation did not change after OPCAB surgery, and no correlation was found with the PMP levels. Elevated levels of PMP, TAT, FDP and D-dimer persisted until POD 7 and suggested not only platelet activation, but also activation of the coagulation and fibrinolytic system. The findings suggest that 100mg of aspirin may not be adequate for the inhibition of platelet activation after OPCAB surgery.

To elucidate the histological findings of the anlage of the mandibular condyle during very early developmental stages, we analyzed sagittal and frontal plane serial sections of mouse fetuses for which the gestational period was precisely determined. An aggregate of mesenchymal cells around the buccal nerve (peripheral cell aggregate) could be seen at 12.0 days post-conception (dpc). Another cell aggregate (core cell aggregate), which almost coincided with the outline of the condylar head, was detected on the inside of the dome-shaped peripheral cell aggregate at 12.75 dpc. The cells of the peripheral cell aggregate were gradually flattened in accordance with cell differentiation, and formed a fibrous sheath covering the condylar head by 15.0 dpc. The cells of the central region of the core cell aggregate differentiated into hypertrophic chondrocytes by 14.5 dpc, whereas the cells of the fringe of the core cell aggregate differentiated into osteogenic cells to form the bone collar by 15.0 dpc. The continuity of the anlage of the condyle with that of the mandibular ramus was first recognized at 13.0 dpc. As the anlage of the mandibular condyle was observed histologically during very early developmental stages, further research is necessary to characterize the development of this anlage in greater detail.

It is known that drug disposition is altered by concurrent administration of different drugs. Drug-drug interaction may also enhance a side effect that is linked to either drug. The purpose of this report is to demonstrate the usefulness of therapeutic drug monitoring (TDM) in the early detection of side effects induced by drug-drug interaction and its treatment.
The combined use of rifampicin and mexiletine may require an increase in the dose of mexdletin by about 50% due to increased clearance resulting from enzyme induction. In addition, three days after discontinuation of the rifampicin therapy, the serum mexiletine level increased from 0.83 mcg/ml to 2.44 mcg/ml. The patient has developed a tremor. After discontinuation of mexiletine medica-tion, the symptom disappeared in two days.
On the other hand, the patient who took theophylline and mexiletine together developed nausea, vomiting and tachycardia. Four days after initiation of the combination therapy, the serum theophyl-line level was in the toxic range of 27.3 mcg/ml. The patient's theophylline dose was decreased 25%, and side effects completely resolved. The serum theophylline concentration became normal (18.8 mcg/ml) seven days later.
Whatever the mechanism, these drug interactions may be sufficient to necessitate the adjustment of drug dosage, preferabily in accordance with serum drug concentration levels. These results suggest that TDM is useful for the suppression of incidence of side effects by drug interactions.

A 50-year-old man with an extensive thoracic aortic aneurysm underwent staged surgery which consisted of preceding total aortic arch replacement with the frozen elephant trunk technique using J Graft Open Stent Graft^®, followed by open thoracoabdominal aortic aneurysm repair. During the second operation, the descending aorta was cross clamped along with the preexisting stent graft, and Dacron graft was anastomosed directly to the stent graft using a running 4-0 monofilament suture. The anastomosis site was then covered with a short piece of Dacron graft identical with the stent graft in size to secure hemostasis. We herein discuss our approach in this complex case, focusing on prevention of inadvertent events such as deformation of the preexisting stent graft and unexpected bleeding.

Purpose： The aim of this study was to create a list of psycho-social problems and solutions for patients with pancreatic cancer by applying the social problem-solving process. Methods： A semi-structured interview of approximately 1 hour was conducted on two occasions. The participants were 17 patients with pancreatic cancer. Results： Psycho-social problems were divided into two themes: “facing the future uncertainty” and “facing the effects of treatment received”. A list of problems and solutions was created for each problem theme. Realistic goals for “facing the future uncertainty” were ‘maintaining this living condition （n=7）’, ‘preparing for changes to the environment （n=5）’, ‘keeping a sense of control over my own life （n=5）’ and ‘dealing with anxiety （n=3）’. Realistic goals for “facing the effects of treatment received” were ‘restoring the self of pre-illness（n=2）’. Conclusion： For seemingly unsolvable problems, patients can formulate realistic goals that they want to have clarified, and then the problems can be recaptured as solvable problems.

As part of community health care services provided by our hospital, there are regular visits by a nurse and/or a physician to patients in their homes. Durin one year from April 2001 to May 2002, we inadvertently skipped 15 visits. It was feared that if nothing were done, such a failure in duty would occur at least once a month. To find the way out of this situation and to reduce the number of skipped cases to zero, we made concerted efforts, turning to the methodology of Total Quality Management (TQM) activities.We tried to grasp the state of things to begin with, and investigated the root causes of the failure. The causes were analyzed using the fishbone diagram. Based on the results of analysis, preventive measures were adopted. Thanks to this, as of February 2004, there are no cases in which we have been remiss in visiting our patints for care in their homes.
Personal failure ; Patient visit for ; Use of ; Home ; etiology

1) In 2004, Shinshu University School of Medicine started a program for third-year medical students to experience nursing services during both the day and night shifts. The program included lectures on nursing sciences before practice and debriefing sessions after practice.2) Most students viewed this program favorably and felt that the night-shift training was particular meaningful. They also had favorable opinions about the nurses who taught them.3) Some practical issues remain to be solved, such as security during the night shift and the possible excessive burden upon nurses.

Purpose: To compare the effects of aging in patients with acute myocardial infarction (AMI) on their clinical background and hospitalization progress, and to examine the relationships between age and these factors.
Subject: One hundred and fifty-three patients who experienced cardiac rehabilitation after percutaneous coronary intervention (PCI) (63.8±11.1 y.o, 126 men, 27 women).
Method: The patients were divided into the middle aged group (<65 y.o, n=84), young old group (65 to 74 y.o, n=44), and old group (75 y.o≥ n=25). The differences between groups were examined in respect of 13 items about clinical backgrounds (responsibility coronary arteries, CKmax, LVEF, residual stenosis, hypertension, diabetes, hyperlipemia, smoking, and BMI) and hospitalization progress (cardiac complications, locomotorium disabilities, abnormality as 200mECG, and duration of hospitalization).
Results: Left veticular ejection fraction (LVEF) was significantly lower in the old group than in the young old group. The old group had a high rate of residual stenosis. In the coronary risk factors, all of the groups had hypertension at a high rate of 54.5% or over. The middle aged group and young old group had diabetes at about 38%. The middle aged group was prone to hyperlipemia, and had significantly a high smoking rate. Body mass index (BMI) was significantly higher in the middle aged group than in the old group. In hospitalization progress, the old group had a high rate of cardiac complications and locomotorium disability. The duration of hospitalization was significantly longer in the old group than in the other groups.
Conclusion: It would be necessary to give middle-aged persons educational guidance for the improvement of the coronary risk factors, and to provide the old persons with the suitable rehabilitation programs considering various complications.