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.

After a general clinical observation period of 3 months, men and women from 66-82 yr. of age with hypertension (n=10) were studied to assess the effects of long-term mild aerobic training and detraining on their blood pressure. Ten patients agreed to take part in aerobic training using a treadmill with the intensity at the lactate threshold (LT) for 30minutes 3-6 times a week for mean 17.1±9.8 months while the time course of changes in the resting blood pressure was monitored.
Following the training period the LT increased significantly by the end of the training period (P<0.001) . After 3months of training both the systolic and diastolic blood pressure decreased significantly (P<0.05, respectively) and both blood pressures stabilized at a significantly lower level throughout the remainder of the study. The mean blood pressure decreased significantly for 9 months (P<0.05) . Finally, the systolic, mean and diastolic blood pressure were found to have decreased significantly, by 9, 5, 11 mmHg, respectively by the end of the training period. (SBP and MBP: P<0.05, DBP: P<0.01, respectively) . One month after the training ended the systolic, mean and diastolic blood pressure all increased significantly (SBP and MBP: P<0.001, DBP: P<0.01, respectively) and approached the initial pre-training levels.
In conclusion, the antihypertensive effect of mild aerobic training at the LT was confirmed for older patients taking antihypertensive medications. However, the cessation of such training resulted in a quick return to pre-training levels.

The effects of long-term low intensity aerobic training and detraining on serum lipid and lipoprotein concentrations were examined in 10 older patients suffering from hypertension and coronary heart disease. Training was carried out for 30 minutes 3-6 times a week for a mean of 17.1 months using a treadmill with the intensity level set at the blood lactate threshold (LT) .
Following this training both LT and the serum HDL-c increased significantly (P<0.001, P<0.01, respectively) after 6 months while the TC/HDL-c ratio decreased singificantly (P<0.001) only after 1 month and stabilized at a steady favorable value throughout the remainder of the study. The serum TC, TG and LDL-c did not change significantly by the end of the training period. There was a significant negative correlation between the initial TC/ HDL-c level and the change in the TC/HDL-c level at 1 month after training (r=-0.71, P< 0.02) . Only 1 month after the detraining the HDL-c decreased significantly while the TC/HDL-c increased in comparison with the final training value (P<0.001, P<0.05, respectively) and then returned to the pre-training levels.
In conclusion, these results suggest that long-term low intensity aerobic training could improve the profile of the serum lipid and lipoprotein concentrations in older patients. However, these results might depend on such factors as a low HDL-c level, a high TG level, the length of the exercise period, or the frequency per week and the age of the patient, while the cessation of such training quickly returned the profile to that of pre-training levels.

A 66-year-old man with an abdominal aortic aneurysm and coexisting horseshoe kidney is reported. The aneurysm was successfully replaced by a prosthetic graft without resection of the renal isthmus. Because of renal blood supply and location of renal isthmus, aortic reconstruction presents a significant technical problem. Preservation of multiple renal arteries may be facilitated by preoperative aortography, and retraction of the renal isthmus offers good operative exposure.

A 61-year-old man, who had previously undergone quadruple coronary artery bypass graft surgery, was successfully treated for proximal descending aortic aneurysm using hypothermic circulatory arrest via a left thoracotomy. Preoperative angiograms revealed that the left internal thoracic artery bypass graft to the LAD was patent, and that the aneurysm was located at the descending aorta just distal to the left subclavian artery. Operative procedures were as follows. A left thoracotomy incision was made through the 4th intercostal space. The common femoral artery and vein were cannulated, and the venous cannula was positioned in the right atrium. The patient was cooled by partial cardiopulmonary bypass until the EEG was isoelectric (24°C rectal temperature), and then circulation was arrested. Left ventricular decompression was not performed. After opening of the aneurysm, proximal anastomosis was performed first at the aorta just distal to the left subclavian artery. Another arterial cannula, connected to the Y-shaped arterial line, was inserted into the graft, and perfusion to the brain was restored through this cannula. Distal anastomosis was then completed, and routine cardiopulmonary bypass was reestablished. After the heart was defibrillated, the patient was rewarmed to 34°C before discontinuing the bypass. Circulatory arrest time and total cardiopulmonary bypass time were 17 minutes and 139 minutes, respectively. Postoperative recovery was uneventful.

  One patient was intervened by our palliative care team (PCT) to relieve neuropathic pain due to postoperative recurrence of rectal cancer. The dosage controlled-release oxycodone was increased, analgesic adjuvant drugs were changed and the administration of betamethasone were started. Furthermore, the number of times the patient took controlled-release oxycodone increased two to three times a day. These changes in medication resulted in relief of symptoms. Cetuximab therapy was given twice during the course. The other patient was intervened by the PCT for right upper limb pain and dyspnea due to postoperative recurrence of breast cancer. Morphine sulfate hydrate and analgesic adjuvant were additionally given. As pain increased three days after the administeration of transdermal fentanyl patches, the patches were changed every other day, instead of every three days. FEC100 therapy was given twice during the course. In the present two cases, the PCT was intervened with great zeal and rapid relief of symptoms resulted. In the meantime chemotherapy proceeded uneventfully. We thought that trust of the chief doctor in the PCT was most important for effective intervention.

  The patient was a woman in her 80s, who was referred to the palliative care team in our hospital for pain due to bone metastases from lung cancer. Although gabapentin and ifenprodil tartrate were administrated in addition to opioids and loxoprofen sodium, and the dose of opioids was increased, pain was not relieved remarkably. A switch from gabapentin to pregabalin brought remarkable pain relief. Before the internal use of pregabalin, the patient was often seen lyiing in bed because of pain. However, by pregabalin, she began to walk, pushing her wheelchair and smile often. Her ability to perform the basic activities of daily living was improved. The switch from gabapentin to pregabalin was one effective option when an analgesic adjuvant for cancer pain was chosen.

  Our palliative care team intervened in a patient with sciatica resulting from metastasis to sacral bone after surgery for rectal cancer. Rapid pain control and a change in the route of rescue drug administration from the stoma were needed. Partial opioid rotation was performed. The dose of 25.2 mg in 72 hours in a transdermal fentanyl patch decreased to 16.8 mg in 72 hours, and the dose of 3.6mg in an hour by continuous intravenous injection of morphine was added. The change in the rescue root to intravenous administration by a patient-controlled analgesia pump gave the patient relief from his pain. He was able to attend his daughter's wedding. His family were all pleased with the relief provided. The advantages of this partial opioid rotation are summed up in the following three points: (1) The required time is relatively short; (2) It can be expedient for analgesia due to the addition of different opioids; and (3) The partial opioid rotation produces fewer adverse effects than a full opioid rotation. Adjustment of the amount of drugs for pain relief in cancer patients is important with the situations of the patient and the family taken into consideration fully.

Liverpool Care Pathway (LCP) Japanese version was implemented to electronic medical chart (FUJITSU HOPE/EGMAIN-FX®). The processes were needed as follows; preparation of each templates (criteria for use of the LCP/initial assessment, ongoing assessment, and care after death), preparation of pathway/regimen, incorporation of the templates to the pathway and approval in our hospital clinical pathway committee. One problem we encountered was whether to choose an Excel or a template format for each assessment sheet, and the template format was selected as it presented us with a higher degree of convenience, since each field can be expanded into a table on the screen without scrolling and there is little limitation in the letters of the valiance records that can be used in the template format. The complexity of the three records, “the pathway”, “SOAP & focus” for recording opioid use, and “the progress sheet” for recording vital signs, in addition to the inability to expand enough to capture the same field and show changes in the daily pathway over time through night and day work shifts remain a challenge and need to be improved in the future.