One of the idiosyncracies of Oriental medicine is pulse diagnosis, the detailed stipulation of the pulse of the radial artery from which fullness or emptiness as described in JUNIKEIRAKU one manifestation of the general physical and pathological condition of the body is determined and the treatment points along the meridians, that is the appropriate acupoints decided. In this diagnostic technique the examiner places his index, middle and ring fingers on the wrist of the patient's hand above the radial pulse and by applying weak or strong pressure compares the largeness or smallness of the pulse under each finger tip and so doing determines the fullness or emptiness of the six meridians on each side or the 12 meridians on both sides.
In order to make this subjective method of fingertip touch diagnosis objective we used a fingertip size transducer and developed a way of measuring and recording pressure fluctuation changes resulting from the various absolute pressures exerted by the fingertips of the examiner.
Method:
The pressure transducer used was a semi-conductor curve gauge, 8mm. in diameter capable of indicating up to 500g/cm² of direct loaded pressure. The input from this one pressure inducer was amplified through different amplifiers, the absolute pressure from DC conversion in one amp, and the pressure variation component from AC conversion in another amp. It was assumed that the pressure load in pulse diagnosis was 100g/cm² for floating pulse, 200g/cm² for sunken pulse and in the pressure variation component deficiency was below 5g/cm² and excess 15g/cm², and evaluated accordingly.
Subjects:
Pre-surgery patients and pain complaint outpatients were used as subjects. Measurements was recorded.
Results:
1. In most of the cases pulse diagnosis at the 6 areas above the radial artery revealed that centered on the styloid process at areas approximately 1cm. apart different pressure variations were observed.
2. Measurement of the pulse of a pre-surgery stomach cancer patient revealed Stomach and Heart Constructor Excess when the patient was in a reclining position however this reading changed with changes in posture. When the patient assumed a sitting position the pulse showed Stomach Excess however the pressure variation of the Heart Cosntructor decreases.
3. The pressure variation components vary with acupuncture stimulation.
4. In our experience we observed cases in which excess or deficiency of the various meridians varied due to acupuncture stimulation. These variations obeyed the laws of “creation and harming” of the 5 Elements Theory.

One of the characteristics of the diagnostic method in Oriental medicine is a pulse diagnosis. In this technique, the examiner places his index, middle and ring fingers on the wrist of the patient's hand above the radial artery and determines the fullness or emptiness of the six Meridians on each hand. In order to make this subjective method more objective, three pressure transducer sensors were placed over the radial artery and its method was previously described.
In this study, we used this objective pulse diagnosis and selected the proper Meridian points according to 5 element theory and improper points without considering it. Then we investigated the changes of the pain threshold by the thermo-dolorimetric method before and after the acupuncture stimulation.
An allergic patient who developed athmatic attack by many drugs was going to have nasal polypectomy. Acupuncture points were selected by this pulse diagnosis. 9 healthy volunteers were examined whether five element or non-five element points would elevate pain threshold.
Results
(1) The elevation of pain threshold by thermo-dolorimetric method before and after the acupuncture stimulation were observed only when the proper Meridian points were stimulated.
(2) Nasal polypectomy was performed under acupuncture analgesia without pain following the selection of 5 element points by this objective pulse diagnosis.

The aim of this study was to explore the changes in the rates of discharge to home from the palliative care unit in the region where the regional palliative care intervention program, their home death rate, and their ratio to whole home death cancer patients in the region. During the study period, the palliative care unit changed an administrative policy actively end-of-life care to support patients at home. The rate of discharge to home from the palliative care unit increased 11% to 22% during the study period, and their home death rate increased 10% to 41%. The overall home death rate of cancer patients however remained 6.8% to 8.1%, and their ratio to whole home death cancer patients in the region was less than 10%. To establish health care system to support cancer patients at home, changing administrative policy of palliative care units is insufficient and increasing quality community palliative care resources seems to be essential.

We report a case of successful treatment for bladder hemorrhage with intravesical alum irrigation. A 60 s woman, who had renal pelvis carcinoma and moderate renal dysfunction（eGFR＝48 mL／min／1.73 m²）, was hospitalized to our palliative care unit, for pain control of her lumber metastasis. During hospitalization, the patient showed dysuria and a lot of intravesical blood coagulum, which was caused from bladder metastasis. After bladder flushing, continuous bladder irrigation with saline was started. However, when we reduced the irrigation speed, dysuria appeared again. Thus, we started intravesical alum irrigation. Six days after this irrigation has started, we stopped the irrigation because no gross hematuria was seen any more. On the blood test done ninth day after irrigation, serum alminium level was 0.4μg／dL（normal value＜0.8μg／dL）. Three months after discharge from the hospital, the patient died, however, no gross hematuria or anuria were seen up to that time. Serious adverse effects with intracesical alum irrigation were reported in patients with renal dysfunction. However, if the renal dysfunction was moderate, intravesical alum irrigation with reduced doses seem to be safe and effective.

Methadone, which has unique mechanism of long-acting mu receptor agonism paired with N-Methyl-D-Aspartate（NMDA）antagonism, is thought to have potential to control pain no longer responsive to other opioids. Fatal adverse effects of methadone are respiratory suppression and QT interval prolongation, which leads to ventricular tachycardia. Here we report a case of a patient who benefited from starting on methadone in hospital and increasing methadone safely in a home-based care setting. A 79-year-old Japanese woman, who developed local recurrence after resection for primary retroperitoneal leiomyosarcoma, presented with frequent burning pain in right groin area. After receiving palliative radiation therapy, she took oxycodone and adjuvant analgesics but without relief, and began experiencing somnolence. She underwent opioid switching from oxycodone to methadone with her breakthrough pain remarkably improved. When her breakthrough pain recurred after discharge, escalating dosages of methadone was performed successfully with no serious adverse effects even in a home-based care setting, by forming multidisciplinary collaboration for the management of prescribing methadone among healthcare providers near her home.

Background: The palliative care unit (PCU) at the National Cancer Center Hospital East changed the administrative policy to strengthen the transition to palliative home care. This study aimed to identify the factors tended to transfer to palliative home care in Japan. Methods: We reviewed the medical records of consecutive cancer patients admitted to our PCU during period from October 2010 until September 2011. Patients with performance status 4 and duplication were excluded in this study. We identified variables associated with the discharged group and the others group, using the univariate and multivariate analyses. Results: There were 223 patients (Pts) during periods, 63 Pts (28.3%) discharged to palliative home care and 160 Pts (71.7%) deceased in our PCU. Univariate and multivariate analysis identified: admission from their own home, a good PS of ≤ 2, good oxygen saturation, a good amount of oral intake, maintain of PS at day 15, no dyspnea and no abdominal distention as predictions of a transition to home from our PCU. Conclusion: Our study indicated the factors tended to transfer to palliative home care from PCU in Japan, however this study had some limitations. A prospective study is required to validate these factors.

Background  The number of foreign tourists visiting Japan has increased to about 30 million people per year. 1.5% of them were injured or became sick during their travelin Japan and had to undergo medical treatment. Among the foreign tourists, 27% were not covered by travel health insurance.Case  A 40-year-old man from Southeast Asia who was visiting his relative in Japan experienced sudden hemiparesis and was diagnosed with cerebral infarction. During the initial treatment, it was found that the patient did not have health insurance and the relatives could not afford to pay the treatment costs. No other source of financial support was available to him During our consultations with the patient and his relatives about the medical treatment including medical expenses, he continued to be treated as an outpatient and it was aimed at an early return to his home country.Discussion  Foreigners, who are not covered under travel health insurance, could fall ill or sustain an injury during their stay in Japan. Appropriate medical care should be provided regardless of their ability to pay. However, a situation that could lead them to incur huge medical expenses from availing medical care should be avoided. For medical consultations of non-insured foreigners, it is better to consult the available systems and pay attention about feasible medical expenses. There is a need for a long-term vision of medical care to make a smooth transition from medical treatment in Japan to treatment in their home country.Conclusion  Although medical institutions can offer only a limited response, it is necessary to accumulate case examples from across the nation and prepare specific countermeasures and counselors.

We report a case of refractory cancer pain that was successfully treated with opioid switching by adding methadone to the preceding opioid. A 38-year-old man had severe epigastric pain and back pain because of paraaortic lymph node metastasis of a gastroesophageal junctional carcinoma. His pain was treated with continuous intravenous morphine administration and the frequent use of a rescue dose. When the morphine dose was increased, respiratory depression developed; thus, his pain was considered refractory to the morphine, and methadone was added on. The pain was relieved after initiating methadone, and the frequency of the rescue dose was markedly decreased. The methadone dose was gradually increased in parallel, and the morphine dose was reduced and finally discontinued. No methadone-induced side effects were noted, and the patient was discharged with good analgesia. In our case, adding methadone without decreasing the preceding opioid dose under strict monitoring made it possible to stably switch the opioid without increasing pain.

Objectives: To explore background factors contributing to learning needs among physicians in palliative care specialty training. Methods: We conducted a questionnaire survey of physicians in specialty training in palliative care who were within 15 years after medical school graduation. The unmet learning needs (referred to as “needs”) were evaluated on a 5-point scale. Factor analysis was performed to identify underlying subscales of needs. Univariate analysis was performed using an average score of each subscale as a dependent variable and background factors as independent variables. Results: Of 284 physicians, 253 (89%) responded, and 229 were eligible after we had excluded resident physicians with less than 2 years of clinical experience and board-certified palliative care physicians. Factor analysis identified six subscales of the unmet learning needs: research, time, specialist, network, quality, and comprehensiveness. Background factors with significant between-group differences with the effect size of 0.4 or more included: 1) not working at a certified training facility, 2) not working or training at a big hospital, and 3) the number of palliative care physicians being 2 or less in the facility. Conclusion: Improvement of the training system is urgently needed for young physicians who are working at small or non-certified facilities for specialty training, or who have few palliative care colleagues.