Tokito is used to treat patients with an asthenic, cold constitution, who have symptoms of chronic pleuritic pain, epigastralgia, and backache. There is no previous report on treatment of pruritus cutaneus with tokito. However, here we report a case of combined cutaneus pruritus and coldness, successfully treated with tokito. Our patient was a 38-year-old female, who reported having had facial pruritus cutaneus for one year. She attended our clinic in May of the year, because she had taken a turn for the worse. She was sensitive to cold, had poor circulation, felt cold in the abdomen, and reported that sleeping was difficult due to a cold back. We prescribed tokito (5.0 g/day). Her symptoms improved within six days. However, her symptoms, especially cold abdomen and cold back, returned when she drank cold water or stopped taking tokito. She was quite informative in that she prepared detailed records of her symptoms on visiting our clinic.
Tokito contains herbal medicines common to daikenchuto and tokikenchuto and hangekobokuto. Therefore, tokito could be a suitable herbal medicine for patients with pruritus cutaneus caused by coldness and qi stagnation and spleen deficiency.

A 76-year-old man with hypertension had an enlarged distal aortic arch aneurysm with a maximum dimension of 55 mm. Coronary computed tomography angiogram showed none of stenosis in a coronary artery, but penetrating atherosclerotic ulcer at ascending aorta. We performed open surgical repair combination of ascending aortic replacement and less invasive quick open stenting (LIQS) to reduce operative risk, because of his advanced age. The operation was carried out without any complications (Operation time : 242 min, Cardiopulmonary bypass time : 154 min, Aortic cross clamp time : 71 min). The patient's postoperative course was unremarkable, and he was discharged 19 days after surgery. LIQS is effective to reduce operative risk for high-risk patients, and it can be easily combined with other procedures.

Objective : Prevention of gastrointestinal bleeding is imperative in perioperative management of open-heart surgery. Although both proton pump inhibitors (PPIs) and Warfarin are often prescribed to patients following cardiac surgery, the US FDA warns that PPIs increase the international normalized ratio (INR) when used concomitantly with Warfarin, by being metabolized by cytochrome P-450 (CYP) 2C19. We assessed whether this drug interaction depends on the genotype of CYP2C19 (Extensive Metabolizer, EM ; Intermediate Metabolizer, IM ; Poor Metabolizer, PM) or the type of PPI. Methods and Results : In this observational prospective study, the CYP2C9, CYP2C19, and VKORC1 genotypes of 78 patients were analyzed. After excluding cases with ^*1/^*3 of the CYP2C9 genotype and those with C/T of the VKORC1 genotype, 60 patients were assigned to Warfarin+Rabeprazole (RB group, 30 cases) or Warfarin+Lansoprazole (LP group, 30 cases). Warfarin was started with an initial dose of 3 mg, and INR values were measured on days 4, 8, 14, 28, and 56. There was no significant difference in median Warfarin dose between the LP group (2.5 mg/day) and RB group (3.0 mg/day), (p=0.88). The time in the therapeutic range (TTR) (Rosendaal) was significantly higher in the RB group (83.7%) than in the LP group (49.4%), and the time in the over range was significantly higher in the LP group (41.9%) than in the RB group (0.0%). In the LP group, TTR values were higher in CYP2C19 Extensive Metabolizers (EMs) than in Intermediate Metabolizers (IMs) and Poor Metabolizers (PMs), but there was no statistically significant difference between them. Conversely, in the RB group, there was no difference in the values of any CYP2C19 genotype. A multivariate analysis showed that high age and low TTR were risk factors for bleeding. Conclusion : We consider it possible that lower TTR values in the LP group were affected by the CYP2C19 genotype. In an aging society, Rabeprazole is safer and more effective as a proton pump inhibitor after open-heart surgery.

Allergic rhinitis is an allergic disease affecting the nasal mucous membrane, and is aggravated by many kinds of factors. Here we describe 4 cases of allergic rhinitis successfully treated with tokishakuyakusan. Case 1 was a 31-year-old woman who suffered from coldness and irregular menstruation. We administered tokishakuyakusan, and her allergic rhinitis improved. When she stopped taking tokishakuyakusan, her allergic rhinitis recurred. Case 2 was a 40-year-old woman who suffered from seasonal pollenosis every year. Her pollenosis did not respond to keishibukuryogankayokuinin, administered for uterine myoma, but when we switched to tokishakuyakusan, her pollenosis improved. Case 3 was a 49-year-old woman who suffered from allergic rhinitis. She had not responded to many herbal medicines, but when we administered tokishakuyakusan, her allergic rhinitis rapidly improved. Case 4 was a 65-year-old woman who suffered from allergic rhinitis. She did not respond to kakkontokasenkyushin'i, but when tokishakuyakusan was added, her allergic rhinitis improved. Efficacy of tokishakuyakusan for rhinitis is not described in the classic literature. Our results suggest that tokishakuyakusan could be a suitable herbal medicine for asthenic, cold constitution of patients with allergic rhinitis caused by blood stagnation and blood deficiency as well as water disturbance.

The purpose of this study was to clarify the changes in the sense of difficulty hospital staff felt toward palliative care before and after a palliative care team of the pediatric hospital started in-hospital consultation. A self-administered questionnaire about the difficulty, consisting of 21 items in five areas, was used to conduct a survey in 2015 for the pre-consultation period, and in 2018 for the post-consultation period. Responses were obtained from 222 people in the pre-consultation period (response rate of 70.9%) and from 384 people in the post-consultation period (response rate of 87.3%). Over 70% of the respondents were nurses and midwives. A lower sense of difficulty was observed in three of the items including “relief of painful symptoms”, “family care during caregiving”, and “support when oneself and surrounding staff feeling inadequate and lost”. Further, a significant decrease was observed in the sense of difficulty in six items reported by nurses and midwives in departments receiving the interventions. Eleven of the 16 cases in which the palliative care team intervened involved multiple requests for intervention for 2 patients with pain control difficulties, suggesting that the consultation activities contributed to the decrease in the sense of difficulty experienced by nurses and midwives.