A young child with VACTERL association who refused oral intake and had relied on gastric tube feeding for almost all of her nutritional intake since birth was initially managed with nutritional guidance based on the assumption that refusal was due to oral hypersensitivity. However, no improvement was observed in the refusal of oral intake, and her inherent developmental delay and bilateral hearing loss prevented the continuation of nutritional guidance. A speech-language-hearing therapist was then consulted to assess the patient’s swallowing function, and the diagnosis was that the lack of experience of oral intake itself and the dependence on tube feeding were more likely causes of the refusal than oral hypersensitivity. We therefore decided to use the approach proposed by Tazumi et al. for stepwise management of eating disorders requiring tube feeding in young children. This allowed us to create a step-bystep management plan toward achieving oral intake, resulting in gradual but significant changes in the patient's eating behavior. Although oral intake has not been achieved as of the time of writing, we are continuing to manage the patient with this trial-and-error approach.

A woman in her 60s was being treated for diabetes and hypertension but had impaired activities of daily living (ADL) due to severe obesity (150 kg). She was transported to the emergency department because of disturbance of consciousness in August 201X. Imaging findings showed decreased permeability of the whole right lung field. She was intubated and started on ceftriaxone plus levofloxacin for severe infection with respiratory failure. Erysipelothrix rhusiopathiae was detected in blood cultures, leading to a diagnosis of sepsis due to a large pressure ulcer on the posterior aspect of the thigh. We switched levofloxacin to clindamycin and continued medical treatment, and she was extubated on the 10th day of illness. However, type 2 respiratory failure was prolonged because of alveolar hypoventilation due to obesity and she required noninvasive positive pressure ventilation. Also, she had difficulty getting out of bed due to obesity, disuse syndrome, and pressure ulcer. Cooperation among staff from many professions, including respiratory nursing, intensive care nursing, wound, ostomy and continence nursing, physical therapy, and nutrition management, led to improvement of ADL and weight loss (to 109 kg), allowing her to be transferred out of the intensive care unit.