A 78-year-old male was referred to our facility due to persistent fever and arthralgia. Transesophageal echocardiography revealed fragile vegetations measuring 26 mm in length attached to the mitral valve (MV), along with severe mitral regurgitation. Magnetic resonance imaging showed multiple cerebral infarctions. He also had an abscess at his left sternoclavicular joint caused by Streptococcus agalactiae, which was identical to the strain identified in his blood culture. He was diagnosed with active infective endocarditis due to Streptococcus agalactiae and severe mitral regurgitation. To prevent postoperative mediastinitis, which could be a complication of median sternotomy in the presence of a left sternoclavicular joint abscess, he underwent urgent minimally invasive mitral valve surgery. Intraoperative Findings: The MV exhibited massive vegetation and partial valve destruction on the medial side of P2 and throughout P3, along with an annular abscess. The MV and annular abscess were debrided down to the left ventricular muscular layer. Mitral valve replacement was performed with reconstruction of the mitral posterior annulus using a bovine pericardial patch. The postoperative course was uneventful, and the left sternoclavicular joint abscess diminished with intravenous antibiotic therapy. He was discharged on the 36th day after surgery, and no relapse has been observed.

Purpose: Surgical resection of remnant gastric cancer (RGC) is technically challenging and difficult. Minimally invasive surgery (MIS) has been adopted for various procedures, but reports of MIS for RGC remain limited. Herein, we report the surgical techniques and short-term outcomes of MIS for RGC. Methods: We conducted a retrospective cohort study involving 61 consecutive RGC patients who underwent open or minimally invasive (laparoscopic or robotic) total gastrectomy for potentially curable RGC at our institution (January 1999–August 2025). A propensity scorematched cohort was used for an exploratory evaluation of the safety and efficacy of MIS for RGC, focusing on feasibility rather than superiority over open surgery. Results: Of these 61 patients, 53 underwent open surgery and eight underwent MIS gastrectomy for RGC. The median age was 70 years. The cohort comprised 53 men and eight women. The initial procedure was open surgery in 58 patients and MIS in three patients.Propensity score matching showed significantly reduced intraoperative blood loss in the MIS group compared with the open surgery group (39 mL vs. 576 mL, p < 0.05), and significantly longer operation time in the MIS group (352 minutes vs. 297 minutes, p < 0.05). Postoperative hospital stay was significantly shorter in the MIS group (12 days vs. 17 days, p < 0.05). The incidence of postoperative pancreatic fistula was lower in the MIS group, although not significantly different (0% vs. 16.7%). Conclusion MIS, including robotic gastrectomy, is feasible and safe for RGC, with potential perioperative benefits requiring multicenter validation.

Methadone, which has unique mechanism of long-acting mu receptor agonism paired with N-Methyl-D-Aspartate（NMDA）antagonism, is thought to have potential to control pain no longer responsive to other opioids. Fatal adverse effects of methadone are respiratory suppression and QT interval prolongation, which leads to ventricular tachycardia. Here we report a case of a patient who benefited from starting on methadone in hospital and increasing methadone safely in a home-based care setting. A 79-year-old Japanese woman, who developed local recurrence after resection for primary retroperitoneal leiomyosarcoma, presented with frequent burning pain in right groin area. After receiving palliative radiation therapy, she took oxycodone and adjuvant analgesics but without relief, and began experiencing somnolence. She underwent opioid switching from oxycodone to methadone with her breakthrough pain remarkably improved. When her breakthrough pain recurred after discharge, escalating dosages of methadone was performed successfully with no serious adverse effects even in a home-based care setting, by forming multidisciplinary collaboration for the management of prescribing methadone among healthcare providers near her home.

The main purpose of basic clinical training for housestaff is to acquire the ability to be a primary physician who can properly manage acute medical problems, develop intimate bonds with patients, and provide them with continuous care. We emphasize the importance of training in the office, clinic, or patients' homes. Although residents have so far spent most of their clinical rotations in an inpatient setting, a training program that devotes substantial time to ambulatory care is indispensable to improve basic clinical training in primary care medicine.