The higher level postgraduate education hospitals are required to have a system with well-developed programs, instruction, and supervision of doctors in clinical training. The Social Medical Corporation Kojunkai Daido Hospital has been maintaining efforts to be a clinical training hospital of excellence.

　In order to nurture supervisory doctors, the first workshop for supervisory doctors in clinical training was held at Daido Hospital on February 22nd and 23rd, 2014. With consciousness reform in mind, interprofessional relations between the many types of medical professional were established.

　Daido Hospital was evaluated by the Japan Council for Evaluation of Postgraduate Clinical Training on December 12th, 2014. It was an opportunity to recognize the need for further improvement as a clinical training hospital.

　On March 7th, 2015 the Objective Structured Clinical Examination for the second year of training doctors in Daido Hospital was held. Clinical training guidance doctors, Nurses, and paramedics learned the skills necessary for the methods and the evaluation in clinical teaching and evaluation.

　Daido Hospital continues making efforts by conducting a review of the clinical training based on the evaluation of the clinical ability of residents, the ability for education and the clinical skill of teaching doctors, and the training environment.

　Social Medical Corporation Kojunkai Daido Hospital is aiming to be the best training hospital. By enhancing seminars in the hospital, we commenced a postdoctoral training program for medical instructors in February 2014 and November 2015. Since we received an accreditation for the clinical training program in 2014, we created an OSCE program on our own for trainees in August 2015 and June 2016. We also collaborated with the University of Nagoya for the OSCE program and held seminars in August 2015 and June 2016. We introduced the EPOC system for the evaluation of trainees in 2014, and Cybouze® for the constructive evaluation of and sharing of information on trainees in April 2016. Our residents obtained high scores for in the examination to evaluate knowledge of trainees held in February 2016, which shows the high quality of our educational program, established by the endless efforts of the educational committee and instructors.

[Objective]Mie University Hospital Department of Anesthesiology established an integrated acupuncture care clinic in April 2010. A total of 8 incidents and accidents occurred during a period of eight months from commencement in April through November of 2010.
Re-examination of the issues from the incident and accident reports, led to the creation of a clinical manual for the acupuncture clinic as a means to improve the safety of the acupuncture clinic.
[Methods]Based on the contents of the reported incidents, which were collected from electronic medical records up to November 1st 2010, a safety manual was created for the prevention of recurring incidents and accidents. Following a request for approval to the Safety Division of Mie University Hospital, the safety manual underwent screening and inspection and was eventually approved.
After the introduction of the manual, the occurrence of incidents and accidents, was tracked using electronic medical records for a period of four months from December 2010 to March 2011.
[Results]The incidents and accidents that occurred before the creation of the manual were all related to acupuncture (dropped acupuncture needles: 5, needles taken home: 1, and leaving needles inserted: 2). Incidents and accidents have not been reported since the introduction of the manual, that is, for a period of four months from December 2010 to March 2011.
[Conclusion]Clinical practice based on the manual suggests the possibility of preventing incidents and accidents, as none have been reported since the introduction of the manual. The safety manual is still incomplete, as it emphasizes mainly the management of acupuncture and not its entire context. If any further negative incidents or accidents occur, a review and improvement of the present manual will be required. In order to deal with any new negative incidents or accidents, organizing a team will be indispensable.
Since Mie University Hospital has an established Safety Division, soliciting the cooperation of the infectious disease control and medical safety experts to ensure safe clinical practices in the acupuncture core clinic should also be arranged.
The results suggest that the creation of a safety manual can be a means of preventing the occurrence of incidents and accidents.

A 79-year-old woman presented to our hospital with a complaint of feeling a cold sensation in her right foot. After performing a contrast-enhanced computed tomography angiography, severe stenosis in the right persistent sciatic artery (PSA) was identified. However, stenting was considered inadvisable due to compression issues when sitting. Following anticoagulant therapy, the patient’s symptoms improved. However, after seventeen months, she experienced recurrent severe pain in her right foot. Catheter angiography revealed occlusions in both the anterior and posterior tibial arteries. To address the issue, we conducted endovascular therapy, followed by a femoro-popliteal artery bypass and ligation of the PSA. Unfortunately, despite these efforts, a below-knee amputation was eventually performed. Limited experience with the PSA and delayed intervention may have led to the need for amputation. Therefore, it is crucial to emphasize the importance of prompt therapeutic intervention following the onset of initial symptoms.

The Hawaii-Okinawa Medical Education Fellowship is a longitudinal FD program developed and administered by the John A. Burns School of Medicine at the University of Hawaii and Okinawa Prefecture to train young clinical teachers who will play a central role in residency education. The program also supports the building of networks among clinical teachers. Each year, around six participants learn the skills required of clinical teachers through monthly seminar participation and a year-round curriculum development project. To date, about 60 physicians have completed the fellowship, and many of them are active as clinical teachers at medical institutions in Okinawa. The community of practice consisting of the graduates of this fellowship is gradually expanding. It is expected to contribute more and more to the enhancement of clinical education in Okinawa.

SUMMARY OF EVENT: Bacterial, mycotic peritonitis and Candida fungemia developed in a patient with moderate ascites who had undergone endoscopic ultrasound-guided biliary drainage (EUS-BD). Antibiotics and antifungal agent were administered and ascites drainage was performed. Although the infection improved, the patient's general condition gradually deteriorated due to aggravation of the primary cancer and he died. TEACHING POINT: This is the first report to describe infectious peritonitis after EUS-BD. Ascites carries the potential risk of severe complications. As such, in patients with ascites, endoscopic retrograde cholangiopancreatography (ERCP) is typically preferred over EUS-BD or percutaneous drainage to prevent bile leakage. However, ERCP may not be possible in some patients with tumor invasion of the duodenum or with surgically altered anatomy. Thus, in patients with ascites who require EUS-BD, we recommend inserting the drainage tube percutaneously and draining the ascites before and after the intervention in order to prevent severe infection.
Anti-Bacterial Agents ; Ascites ; Bile ; Candida ; Cholangiopancreatography, Endoscopic Retrograde ; Drainage ; Duodenum ; Endosonography ; Fungemia ; Humans ; Peritonitis

Background: The anti-programmed death 1 (PD-1) antibody has led to durable clinical responses in a wide variety of human tumors. We have previously developed the caninized anti-canine PD-1 antibody (ca-4F12-E6) and evaluated its therapeutic properties in dogs with advance-staged oral malignant melanoma (OMM), however, their therapeutic effects on other types of canine tumors remain unclear. Objective: The present clinical study was carried out to evaluate the safety profile and clinical efficacy of ca-4F12-E6 in dogs with advanced solid tumors except for OMM. Methods: Thirty-eight dogs with non-OMM solid tumors were enrolled prospectively and treated with ca-4F12-E6 at 3 mg/kg every 2 weeks of each 10-week treatment cycle. Adverse events (AEs) and treatment efficacy were graded based on the criteria established by the Veterinary Cooperative Oncology Group. Results: One dog was withdrawn, and thirty-seven dogs were evaluated for the safety and efficacy of ca-4F12-E6. Treatment-related AEs of any grade occurred in 13 out of 37 cases (35.1%).Two dogs with sterile nodular panniculitis and one with myasthenia gravis and hypothyroidism were suspected of immune-related AEs. In 30 out of 37 dogs that had target tumor lesions, the overall response and clinical benefit rates were 6.9% and 27.6%, respectively. The median progression-free survival and overall survival time were 70 days and 215 days, respectively. Conclusions The present study demonstrated that ca-4F12-E6 was well-tolerated in nonOMM dogs, with a small number of cases showing objective responses. This provides evidence supporting large-scale clinical trials of anti-PD-1 antibody therapy in dogs.