A 40-year-old man was admitted because of prolonged fever after extraction of teeth. Infective endocarditis, congestive heart failure and hepatorenal failure were diagnosed in a series of examinations. Electrocardiograms showed complete atrio-ventricular block and QT prolongation. After continuous hemodiafiltration (CHDF) and high doses of antimicrobials promptly initiated for the treatment of multiple organ failure, the aortic valve with regurgitation and vegetation was replaced with an artificial valve. Serious arrhythmias occurred after the operation, which disappeared by the administration of antiarrhythmic agents. In cases of infective endocarditis with multiple organ failure, preoperative intensive treatment such as CHDF in combination with high doses of antimicrobials and surgical intervention represent a good strategy for successful outcome.

Total pelvic exenteration (TPE) is sometimes required for radical treatment of locally advanced or recurrent gynecologic cancer [1]. However, TPE with a transabdominal approach requires highly advanced techniques in the case of repeated surgery due to the effects of primary surgery and/or chemoradiotherapy, especially when a transabdominal approach is used. Recent technical advances in transanal/transperineal endoscopic surgery have proved beneficial for complicated surgery in the deep pelvis [2]. Here we introduce our surgical procedure for combined laparoscopic and transperineal endoscopic TPE (TpTPE) for pelvic recurrence of cervical cancer. A 42-year-old woman was diagnosed with vaginal stump recurrence of cervical cancer involving the rectum, bladder, and ureters following hysterectomy and pelvic lymph node dissection as primary surgery and chemotherapy/chemoradiotherapy for previous recurrences. We decided to perform TpTPE with a combined laparoscopic approach. The GelPOINT advanced access platform was fixed through a perineal skin incision around the tightly closed anus, external urethral orifice, and vagina. With sufficient pneumopelvic pressure (12 mmHg), TpTPE was performed under a good surgical view without any effect of the primary surgery. A ureterostomy and sigmoid colostomy were created and a right gracilis muscle flap was used to reconstruct the pelvic defect. The total operative time and estimated blood loss were 887 minutes and 497 mL, respectively. Histopathological examination revealed recurrent cervical cancer invading the rectum, bladder, and bilateral ureters with negative surgical margins. The postoperative course was uneventful except for paralytic ileus. The patient was discharged on postoperative day 18. TpTPE is a technically feasible and effective approach for locally advanced pelvic tumors.

Purpose: Does longer study time motivate students to learn and make them feel a sense of accomplishment? Whilst “Human Biology,” one of the required courses in the first year of the medical school, was in need of a total course design reformation to make a shift from teaching to learning, it was necessary to examine whether longer study time is effective for better learning outcomes.　Methods: To get students to learn outside of class, we flipped the course. Since the scores from weekly quizzes, which are held at the beginning of every class, and mid-term and final exams were returned to the students, fully calculated and strictly applied to their grades, students became motivated to study before class. During class time, lessons were taught in the active learning style. We used covariance structure analysis to examine the relationship between the out of class learning design, the syllabus reformation, students’ learning attitudes in the class, and their sense of accomplishment.　Results: Study time outside of class increased from 4 hours per week in 2013 to 10 hours per week in 2016, and the students became more satisfied with the course. Our analysis shows that this well-structured syllabus and designing of lessons made the students study more both inside and outside of class, and allowed students to achieve the higher goals of the course.　Conclusion: Designing out of class learning and incorporating it well with assessment resulted in longer study time and a stronger sense of accomplishment.