This study examined and improved the quality of inter-professional moral case deliberation (MCD) in a home-based medical care clinic by altering the MCD process and evaluating it using the REFLECT rubric. After altering the MCD process, four of the five main evaluation items in the questionnaire were shifted to a higher evaluation level employing a scaled evaluation. The free-entry field revealed future tasks. This report suggested that improving the quality and assessment of MCD using REFLECT promotes the reflection skills of clinical teams.

We participated in TIPS-FM (Toronto International Program to Strengthen Family Medicine and Primary Care) for two weeks in Toronto in June 2019. This program enabled us to learn many important factors for developing family medicine. Based on Canadian family medicine, which has a long history, we were able to review the missions of family medicine in Japan, and gained further insight into multilayered essentials on the patient-, community-, and global-levels.

Our hospital has a nutrition support team (NST) serving inpatients of all department. Two years ago, the team started activities with the motto “Apt nutritional management for inpatients”. It is an interdepartmental unit consisting of physicians, nurses, dietitians, pharmacists and speech therapists. Initially we found it difficult to make time to join forces, but now it has become possible to screen patients for undernourishment on a weekly basis while making nutritional assessment and planning, and holding consultations. The main purpose of the consultations is to improve the nutritional status of patients according to plans formulated after nutritional assessment made at the request of physicians and nurses in charge of the patients. To achieve the objective, we are expected to concentrate all our efforts and brains. This paper presents some consultation cases we have handled. In addition, the nutritional assessment and nutritional intervention activities of our hospital are described.
Nutrition Assessment ; Nutritional status ; Nutritional Support ; Hospitals ; Consultation

　For female physicians, it is important to nurture an environment that enables them to take advantages of support for child rearing as well as for their return to their original jobs. It is also critical for physicians, whether female or male, to receive education to recognize the professional/occupational missions of being a physician. Once they have received environmental support and mission clarification, they will be able to realize an uninterrupted career in order to attain their social contributions.

　The Committee on Studies of Career Education for Female Physicians has set five learning objectives by examining the required abilities and capabilities of a physician.

The proposed five learning objectives are to acquire:

(1) Professional awareness of the missions of being a physician,

(2) Ability to make career plans,

(3) Flexibility to embrace diverse values of the profession,

(4) Appropriate attitudes for both those receiving and those offering the support, because it should be the responsibility of the medical community,

(5) Recognition of social gender differences and acquires the capability to deal with such differences.

All organizations related to medical education should promote these five learning objectives.

　The Committee on Studies of Career Education for Female Physicians set five learning objectives for all physicians to nurture abilities for continuous public participation by women physicians. Next, we discussed the learning objectives corresponding to the learning period and made a road map. Further more, we proposed our new target-based education program and methods for its assessment.

Objective: In the intensive care unit (ICU), drugs are administered in sequence as the conditions of the patient change rapidly, and there are often cases where many injections are administered simultaneously.  For this reason, it is important to quickly select the appropriate administration route.  In this study, we prepared a quick reference table for incompatibilities of frequently used and highly important injections in the ICU (referred to as the “quick reference table”) that will enable selection of the appropriate administration route, and we investigated the status of use and usefulness of this quick reference table.
Methods: The drugs included in the quick reference table were extracted from prescription records from May to October 2009, and these were finalized by discussions with the nurses in the ICU.  Three reference materials were used: Manual on the Supervision of Injection Preparation (3rd Edition), Data Search on Injection Incompatibilities 2009, and MICROMEDEX®.  The survey was conducted with all 12 nurses in the ICU after 4 months of distributing the quick reference table.
Results: The quick reference table included 57 pharmaceutical items, and compatibility was classified into 10 categories.  The quick reference table was prepared as one A3 page for convenience.  The retrieval rate of the survey was 100%.  The average number of years of practical experience as a nurse was 12.2 years, and 11 out of 12 nurses used the quick reference table.  Of the 11 nurses who used the table, 6 answered that it was “very useful,” while 4 answered that it was “useful.”  All 11 nurses who used the quick reference table answered that they “consulted the pharmacists less frequently.”
Conclusion: Satisfactory evaluations were obtained with regard to the details included in the quick reference table, and the table was estimated to be highly useful and important even for ICU nurses with many years of experience.  Furthermore, it was suggested that the quick reference table was also useful in reducing the workloads of the pharmacists.

Long term physical training is known to cause a change of cardiac functions and this effect is observed at various levels of the heart (from whole heart to subcellular level), although its mechanism is not fully understood. It is reported that cardiac hypertrophy and decreased heart rate can be observed as effects of long term physical training, but change of the catecholamine content in heart tissue induced by training is controversial.
In the present experiment, long schedule of short daily swimming episodes was employed to observe the effect of mild physical training on cardiac functions of rats in the growing stage. We measured body weight, heart weight, heart rate under light anesthesia, variation of R-R-interval of electrocardiogram, and catecholamine contents in cardiac muscle.
1) Wister rats were divided into 2 groups 3 weeks after birth. One group rats was kept sedentary in cages, and the other group was required to free swim in a tank containing water at 30°C. At the beginning of the programme, swimming time was 10 min. Swimming was applied 5 days a week for up to 14 weeks, and swimming time was gradually increased to 30 min.
2) Body weight of rats in the trained group was significantly less than that of the controls, and the heart weight to body weight ratio in the trained rats was significantly higher than in the controls.
3) In the exercised rats, the R-R interval of the ECG was longer than that of the controls, and there was a tendency for the variation of R-R interval in the trained group to be larger than that of the controls.
4) At 10 and 17 weeks, rats from each group were sacrificed after or without a 30 min test swim for measurement of catecholamine content of the ventricular muscle. One time swimming for 30 min increased dopamine content, but did not change norepinephrine content except for the trained group at 10 weeks. There was no significant difference in cardiac catecholamine contents in the rested state of the control and trained groups at 10 and 17 weeks.
5) Results were interpreted as follows: One time swimming for 30 min influences the activity of the autonomic nervous system innervating the heart, and catecholamine metabolism at nerve terminals of the sympathetic nervous system. Long term mild swimming does not cause permanent change of catecholamine contents, and the low heart rate in the trained group cannot be soley explained by the decreased activity of the sympathetic nervous system.

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.

Drug dispensing is a statutory and designated duty of a pharmacist. We aimed to examine the changes in the nature of drug dispensing using a text mining method. Our corpus consisted of text documents from “Chozai Shishin”, the most standard manual for dispensing drugs in Japan, Editions 1 to 13 (Japan Pharmaceutical Association), and we used the KH Coder software for text mining. We constructed networks showing the association between frequent word co-occurrence and edition number, and co-occurrence relations for frequent words in each edition. We found that “patient” superseded “dispensing” as a frequent term over time. “Dispensing” was another frequent term with a highly centralized node in each edition. Accordingly, we targeted the term “dispensing” for network analysis to depict its co-occurrence relations. We found that the range of related words for “dispensing” broadened from “preparation” and “compounding” to include “patient adherence instructions”, “assessment”, “medical treatment”, and “information provision”. Accordingly, we concluded that the content of “dispensing”, which is a pharmacist’s duty, has expanded from the duties of “dispensing drugs” to include “responding to patients” within the definition of “dispensing”, and we were able to present this finding as objective data by using the mechanical method known as text mining.

Drug dispensing is a statutory and designated duty of a pharmacist. We aimed to examine the changes in the nature of drug dispensing using a text mining method. Our corpus consisted of text documents from “Chozai Shishin”, the most standard manual for dispensing drugs in Japan, Editions 1 to 13 (Japan Pharmaceutical Association), and we used the KH Coder software for text mining. We constructed networks showing the association between frequent word co-occurrence and edition number, and co-occurrence relations for frequent words in each edition. We found that “patient” superseded “dispensing” as a frequent term over time. “Dispensing” was another frequent term with a highly centralized node in each edition. Accordingly, we targeted the term “dispensing” for network analysis to depict its co-occurrence relations. We found that the range of related words for “dispensing” broadened from “preparation” and “compounding” to include “patient adherence instructions”, “assessment”, “medical treatment”, and “information provision”. Accordingly, we concluded that the content of “dispensing”, which is a pharmacist’s duty, has expanded from the duties of “dispensing drugs” to include “responding to patients” within the definition of “dispensing”, and we were able to present this finding as objective data by using the mechanical method known as text mining.