Objective: Living wills, written types of advanced directives, are now widespread in western countries, but in Japan, their recognition still remains restricted to a small part of the population. As an initial step to introduction of such patient-oriented medicine, we surveyed present recognition and acceptance patterns concerning living wills in a main regional hospital located in a suburban area of Tokyo.
Methods: Without any preceding guidance on living wills, the questionnaire on living wills was distributed to all the staff working at JA Toride Medical Center in September 2013, and their responses were collected for analysis within one month.
Results: Questionnaires were distributed to all hospital staff, 843 in total, and 674 responses (80.0% of distributed) were obtained. The term of living will was known by 304 (45.1%) of the respondents, and introduction of living wills to patients was accepted in 373 (55.3%) of the respondents, meanwhile, 286 (42.4%) respondents did not indicate their attitude toward living wills. As to styles of document form, 332 respondents (49.3%) supported selection of wanted or unwanted medical treatments and care from a prepared list, and 102 respondents (15.1%) supported description of living wills in free form. As preferred treatment options that should be provided as a checklist, cardiac massage (chest compression) and a ventilator were selected by more than half of the respondents. Based on their responses, we developed an original type of living wills available to patients visiting the hospital.
Conclusions: Although not all the respondents were aware of living wills even in this main regional hospital, introduction of living wills to patients was accepted by many of the hospital staff. Awareness programs or information campaigns are needed to introduce living wills to support patient-centered medicine.

  The water supply system in our hospital was disabled as its elevated water tank was badly damaged by the earthquake that hit northeast Japan on March11, 2011. Subsequently, the dysfunction of suction equipment of a water seal type threw the whole hospital into utter confusion, though temporarily. We realized that injection of some degree of water could recover the suction system on manual. To minimize the damage from a natural disaster and strengthen the hospital ability for all contingencies, we have decided to employ the oil rotary type rather than the water seal type in the system of suction equipment.

We report on a right-handed 43-year-old policeman with atypical Marchiafava-Bignami disease (MBD). The typical clinical manifestations of MBD are reduced consciousness, confusion, seizures, psychotic and emotional symptoms, hemiparesis, dysarthria, ataxia, and coma and death. However, our patient had not developed any of the above symptoms except for slowly progressive cognitive impairment mimicking that of Alzheimer disease. The incidence of MBD may be higher and its prognosis less severe than generally believed. MBD has been underdiagnosed and underreported, and nonspecific general symptoms and encephalopathy in an alcoholic might indicate undiagnosed MBD.
Impaired health ; symptoms <1> ; Marchiafava-Bignami disease ; Problem drinker ; prognostic

We report on three elderly patients with stroke-like onset of atypical Miller Fisher syndrome (MFS). The serum titer of anti-GQ1b IgG was markedly elevated in these patients. Their prognoses were sufficiently good with immunoadsorption therapy with or without intravenous immune globulin (IVIg) therapy. However, some neurological findings were not characteristic of typical MFS. Patient 1 suffered from prolonged dysesthesia in her left extremities, and Patients 2 and 3 showed no ataxia. Moreover, complete bilateral gaze limitation is rare in MFS. The sudden stroke-like onset along with the gaze limitation of these patients suggests that the unexpected elevation in the serum titer of anti-GQ1b IgG due to unknown immune dysregulation might have severely affected the third, fourth, and sixth nerves and this potent antibody rapidly attacked these nerves and induced stroke-like clinical features and complete ophthalmoplegia.
Cerebrovascular accident ; Miller Fisher Syndrome ; Right and left ; Serum ; Atypical

We report our experience with percutaneous endoscopic gastrostomy (PEG) to assess the safety and usefulness of the PEG. We reviewed 21 cases (mean age, 72 years), including 20 patients with neurological impairment and one patient with cancer of the stomach.
Though two minor complications (wound infection and bleeding from the stomach) occurred, wound infection healed with antibiotics and bleeding stopped spontaneously. Six of these patients died (3 died from pneumonia, 2 from respiratory failure, and 1 from stomach cancer), but there were no PEG-related deaths. After PEG procedure, serum protein, albumin and cholesterol improved significantly. PEG was not only safe but also effective for the nutritional support and the 4-year survival rate was 56%. By this method, moreover, half of the patients could leave hospital and return home.
In conclusion, PEG, is thought to be the procedure of choice for the long-term enteral nutrition.

We present here five cases of moyamoya disease-like phenomenon in the elderly patients who had moyamoya vessels in the basal ganglia as a sequela of occlusion of middle cerebral artery (MCA) and/ or anterior cerebral artery (ACA). Ages ranged from 59 to 77 years (mean age: 67.6). Clinical manifestations included transient ischemic attacks (TIAs), reversible ischemic neurological deficits (RINDs) and mild hemiparesis. All the patients were living normal daily lives despite recurrent cerebral ischemic attacks. They had some risks of cerebrovascular disease, such as hypertension, and hyperlipemia. Angiography showed either MCA or ACA occlusion or both. Retrograde leptomeningeal filling of the ischemic region was maintained by the posterior cerebral artery (PCA) and ACA. Obstruction of the intracranial internal carotid artery was not visible. These neuroradiologic findings were not consistent with the criteria for moyamoya disease. The present cases may be related to congenital or acquired abnormalities in the main trunks of cerebral arteries.

Background: Diffusion-weighted magnetic resonance (MR) imaging (DWI) is an excellent examination for detecting acute ischemic stroke, but false-negative cases have been reported recently.Patients and Methods: Since the present MR scanner (1.5-T, Siemens Symphony) was introduced to our hospital, a prospective study was designed in the Departments of Neurology and Radiology to evaluate the DWI findings in patients tentatively diagnosed to have an acute infarction and in those with stroke-like episodes. During the 31 months between June 2000 and December 2002, 572 consecutive patients with acute cerebral infarction or presenting conditions mimicking ischemic stroke, including transient ischemic attack (TIA), sudden-onset isolated vertigo, and loss of consciousness (LOC) with or without seizure, underwent DWI.Results: Four of 366 patients with a cerebral infarction (1.1%) had false-negative DWI in the acute stage, and 10 of 206 patients with conditions mimicking ischemic stroke (4.9%) had false-positive DWI in the acute stage. Of these 10 patients, there were five cases with TIA, four with sudden-onset isolated vertigo, and 1 with LOC with seizure. Sensitivity and specificity values were 98.9% and 97.6%, respectively, when DWIs were performed to diagnose acute cerebral infarction.Conclusion: DWI rarely fails to detect an acute-stage cerebral infarction, but further confirmatory measures may be necessary when there is a negative examination using a clinical or computed tomographic diagnosis to the contrary.
Acute ; Cerebrovascular accident ; DWI ; False ; Cerebral Infarction

  When subacute elderly patients are transferred from an acute hospital to a rehabilitation facility, the likelihood is that the environmental change will decrease the patients' ability to perform the basic activities of daily living (ADLs). In this study, we assessed the effects of the ambient changes on ADLs by the use of the Barthel Index, the reliability as well as validity of which is rated high for assessing the patient's fundamental ability. Our subjects consisted of the patients with hemiplegia who had undergone medical treatment of stroke and those who had been operated on for femoral neck fracture (FNF) in Toride Kyodo General Hospital. They were transferred to the convalescent rehabilitation ward (CRW) of Aida Memorial Rehabilitation Hospital, affiliated with our hospital. We compared the BI scores given to the patients by physical, occupational and speech therapists, when discharged from our hospital, and those scores given by nurses within one week after the patients moved to the CRW. Differences between BI scores given at Toride Hospital and those at the rehabilitation hospital averaged -5.9±16.0 points for stroke patients and -7.3±14.1 pointsfor FNF patients. Spearman's rank correlation coefficient of BI scores in the acute hospital and in the CRW for stroke patients was 0.91 (p<0.001) and 0.69 (p<0.001) for FNF. There was no significant difference in changes in BI scores between stroke and FNF. However, there was a tendency for the patients' functional ability in daily living to be assessed lower in the FNF patients than in the stroke patients. This was probably because the former were older than the latter on the average. The average age of the FNF patients was 81.4 years and that of the stroke patients was 68.5 years.