A 6-year-old boy who had been found to have hypertrophic obstructive cardiomyopathy presented with severely limited symptoms of heart failure due to progressive left ventricular outflow obstruction. Cardiac catheterization revealed the peak systolic pressure gradient of 87mmHg at left ventricular outflow, and systolic anterior motion of the anterior mitral leaflet with concomitant mitral regurgitation was observed by echocardiography. Transaortic septal myectomy was performed using transesophageal echocardiography guidance before, during and after surgery. Although the patient needed permanent pacemaker implantation for postoperative complete heart block, the procedure reduced the left ventricular outflow obstruction and relieved his symptoms.

　　Yuri Kumiai General Hospital is a community-based core hospital that treated approximately 14,000 patients in the emergency outpatient clinic in 2014, with approximately 7,800 walk-in patients on Saturdays, Sundays, and holidays. In April 2014, we incorporated an inhospital triage system for walk-in patients on weekends and holidays to quickly diagnose the conditions of patients in a crowded waiting room and promptly treat those requiring urgent care. Furthermore, in April 2015, we introduced the Japanese Triage and Acuity Scale (JTAS) to standardize the quality of triage care. Evaluation and analysis of 7,454 triage forms to identify future challenges revealed that the triage rate was 88% immediately after the incorporation of the JTAS, with 93 incomplete triage forms, 13 undertriage cases, and 18 overtriage cases. This showed that the severity of emergency was determined based only on subjective symptoms and complaints, with no application of objective physical assessment. We presented a list of analysis results to triage staff, further assessed undertriage cases, and provided feedback in monthly workshops. At 1 year after introduction, the rate of triage increased to 95%, with 12 incomplete forms, 9 undertriage cases, and 21 overtriage cases, and the number of cases increased where the severity of emergency was determined accurately from the entire clinical picture including vital signs and the cause of injury. These findings suggest that use of the JTAS enabled a standardized triage system to be established and that the assessment of undertriage cases and organization of continuous workshops improved the quality of triage and the skill of triage nurses.

A cyanotic baby boy was given a diagnosis of single right ventricle, double outlet right ventricle, hypoplastic aortic arch, mitral atresia, atrial septal defect and pulmonary-ductus-descending aorta trunk. On day 4, extended aortic arch anastomosis and pulmonary artery banding were undertaken. At age 70 days, severe cyanosis and respiratory distress appeared and advanced rapidly. Angiography revealed critical subaortic stenosis and pulmonary hypertension, and the patient required urgent Damus-Kaye-Stansel anastomosis with concomitant right modified Blalock-Taussig shunt. Patients with single ventricle and hypoplastic aortic arch are a high-risk subgroup of progressive subaortic stenosis after initial pulmonary artery banding, and therefore need careful observation and may require early relief of subaortic stenosis.

Two years have passed since a patient who started to use the respirator for a tuberculosis sequela and chronic respiratory failure at home. During this period, the patient got several short-term admissions into the hospital. After his first discharge, the patient and his family felt anxiety about recupration at home. It was the first time for us to provide home care services to a respirator wearing patient. However, the shift to recuperation at home was realized as an understanding was reached between physicians who decided upon care home and the patient's wife who wished “to live with the husband together”. The patient is now playing a role as a father and as a husband, and he is leading a full life. In this study, the personal and familial circumstances of the patient, decision-making about home care and community support were analized. We coucluded that there were several important factors for successful recuperation at home:specification of contents of concrete medical support to a patient and a family;an immediate suitable action at the time of change of a patient's condition;taking periodic rests of a patient and a family;and a good family relationship.
Patients ; Ventilators, Mechanical ; seconds ; Family ; Home

Saffron (Crocus sativus L.) is classified as a beneficial herb in the treatment of “Oketsu,” eliminating blood stagnation. The clinical symptoms of “Oketsu” include feeling cold and arthralgia. The pathological condition of “Oketsu” is considered to be increased blood viscosity and microvascular disorders.However, no useful biomarker has been reported for evaluation of the degree of “Oketsu.” Here, we investigated the clinical effect of saffron on the symptoms of “Oketsu” in patients with autoimmune diseases. At the same time, we measured the plasma levels of platelet factor 4 (PF-4) and beta-thromboglobulin (β-TG) as platelet activation markers. Seventy-one patients (66 women and 5 men, mean age 52.3 ± 16.1) were studied. They were administered saffron (300mg∼900mg) with traditional Kampo medicine. The clinical symptoms of “Oketsu” improved (80.9%, n=38/47) and we measured PF-4 and β-TG in pre-and post-saffron treatment periods. The plasma levels of PF-4 and β-TG significantly decreased after saffron therapy (PF-4 : before 49.6 ± 29.8, after 24.0 ± 19.6ng/ml, β-TG : before 117.5 ± 64.0, after 64.6 ± 47.1ng/ml;paired t-test, p < 0.0001, respectively). These results suggest that saffron is effective in treatment of the symptoms of “Oketsu” in allergy and collagen disease patients. Moreover, PF-4 and β-TG may be useful biomarkers of the degree of “Oketsu.”

Endoscopic ultrasound (EUS)-guided intervention has been established as a safe, effective and minimally invasive procedure for various diseases in adults, but there have been limited reports in pediatric patients. Herein, we report our experience with successful EUS-guided drainage of an intra-abdominal abscess in a 1-year-old infant concomitant with disseminated intravascular coagulation. The abscess was punctured via the stomach using a standard, convex-type echoendoscope, and the patient's condition improved after naso-cystic catheter placement. Although the clinical course was complicated by delayed hemorrhage from the puncture site, the bleeding was successfully managed by endoscopic hemostasis using a standard forward-viewing endoscope.
Abdominal Abscess* ; Abscess ; Adult ; Catheters ; Disseminated Intravascular Coagulation ; Drainage* ; Endoscopes ; Hemorrhage ; Hemostasis, Endoscopic ; Humans ; Infant* ; Punctures ; Stomach ; Ultrasonography