Objectives: To create a system to enhance learning by encouraging students to think for themselves and express their ideas in classrooms. This study evaluates the effects of the new utterance reward system （URS） on student attitudes and achievement.
Methods: Fourth–year medical students in the 2009 Hygiene and Public Health course were informed that they would get marks for each classroom utterance that expressed their ideas. We evaluated degree of classroom engagement in the course by comparing number of utterances before and after introduction of the URS in 2008 and 2009. To assess correlations between classroom engagement and student outcomes, we examined the relationship between number of utterances and exam scores. At the end of the course, we distributed questionnaires on student perceptions of the URS.
Results: The number of utterances in 2009 increased compared with that in 2008. Students who made more utterances achieved significantly higher exam marks （epidemiology, r＝0.36, public health, r＝0.40）. Current grade point average rankings （CGAR）, used as an index of general competency, was a confounding factor in the relationship between the URS and achievement. We stratified students into two groups by median CGARs. Stratified analysis of the relationship between number of utterances and exam scores showed no association within the higher–CGAR group. However, this association was significant in the lower–CGAR group in the public health class （r＝0.31, p＝0.03）.
Conclusions: The URS appeared to increase student participation in the classroom and positive perceptions on participation.

Purpose: Traditionally, opioids have been the cornerstone of therapy for patients suffering from cancer pain, regardless of the potential to develop opioid tolerance. In chronic pain patients who experience improving pain by opioid rotation, the clinical role of opioid tolerance is gaining more recognition. Case Report: Presented here is the case of a 60-year-old man with recurrent rectal carcinoma with huge pelvic mass and iliac and neck of femur bone metastases, suffering with intractable 9/10 pain on the numerical rating scale in his right hip and leg. In spite of escalating doses of fentanyl to 50.4 μg/72 hours and started gabapentin for adjunctive pain treatments, the patient continued to experience severe pain. The clinical picture suggested the possibility of opioid torelance. We decreased the fentanyl dose and started oxycodone. Opioid rotation to 30 mg/day sustained release oxycodone and withdrawed fentanyl provided effective pain control. The patient's pain level dropped to a more acceptable 2/10. He was more alert, and his pain was tolerable until his death. Conclusion: Opioid tolerance might be considered in a patient who has no evidence of disease progression, who is on clinically reasonable doses of opioids. Opioid rotation may provide a favorable clinical outcome in those patients who have failed to benefit from adjunctive pain treatments. Palliat Care Res 2011; 6(1): 330-335

Background and Purpose: Nursing healthcare-associated pneumonia (NHCAP) causes distress and unpredictable symptoms. We investigated the frequency of comorbid symptoms and the effects of symptom relief with pharmacotherapy for NHCAP patients with advanced cancer. Methods: We retrospectively investigated the medical records of 15 patients with NHCAP who had died from January 2014 to November 2015. We investigated the frequencies of symptoms (pain, dyspnea, drowsiness, respiratory secretions, nausea, insomnia, fever, dry mouth, wheezing, and depression) and the therapeutic effects of drugs for symptom management (opiates, glucocorticoids, anti-cholinergic agents, and antibiotics). A Validated instruments (Support Team Assessment Schedule-Japan [STAS-J]) was used to assess symptom distress. Results: The symptoms of NHCAP were pain, insomnia, fever, fatigue, oral feeding difficulty, dry mouth, nausea, drowsiness, and depression. Administration of opioids was a useful treatment for dyspnea and pain. The mean number of concurrent symptoms was 4.6 ±1.8. Opioids and glucocorticoids were administrated to patients with pain and dyspnea, and these symptoms were resolved. Antibiotics were used in all patients, who were resolved their wheezing and fever, but no other symptoms. Conclusions: Patients with advanced cancer complicated by NHCAP have multiple distressing symptoms. A focus on ameliorating the most prevalent physical symptoms and psychological distress may improve overall quality of life in this patient population.