Background/Aims: Covered self-expandable metallic stents (CMSs) are widely used for malignant distal biliary obstructions (MDBOs) caused by pancreatic carcinoma. This study compared the efficacy and safety of the laser-cut-type and braided-type CMSs. Methods: To palliate MDBOs caused by pancreatic carcinoma, the laser-cut-type CMSs was used from April 2014 to March 2017, and the braided-type CMSs was used from April 2017 to March 2019. The tested self-expandable metallic stents were equipped with different anti-migration systems. Results: In total, 47 patients received CMSs for MDBOs (24 laser-cut type, 23 braided-type). The time to recurrent biliary obstruction (TRBO) was significantly longer in the braided-type CMSs (p=0.0008), and the median time to stent dysfunction or patient death was 141 and 265 days in the laser-cut-type CMSs and braided-type CMSs, respectively (p=0.0023). Stent migration was the major cause of stent dysfunction in both groups, which occurred in 37.5% of the laser-cut-type CMSs and 13.0% of the braidedtype CMSs. There were no differences in the survival duration between the groups. Conclusions The TRBO was significantly longer for the braided-type CMSs with an anti-migration system than for the laser-cuttype. Stent migration tended to be less frequent with the braided-type CMSs than with the laser-cut-type CMSs.

Objective: To validate and recalibrate Charlson and Elixhauser comorbidity indices (CCI and ECI, respectively) in a Japanese hospital-based administrative database.Methods: In this retrospective, cohort study, derivation and validation cohorts were developed to include all hospitalizations for patients aged ≥ 18 years at admission and discharged in 2015 or 2016, respectively, from an administrative database based on 287 hospitals. Seventeen CCI and 30 ECI conditions were identified using the International Classification of Diseases (ICD) -10 codes at admission or during the stay. Predictability for hospital death was evaluated using C statistics from multivariable logistic regression models including age, sex, and individual CCI/ECI conditions or the CCI/ECI score in the derivation cohort. After stepwise selection, weighted risk scores were re-assigned to each condition based on the odds ratios (CCI) or beta-coefficient (ECI), and these modified models were evaluated in the validation cohort.Results: The original CCI/ECI had good predictive abilities for hospital death: C statistics (95% confidence interval) for individual comorbidities and score models were 0.764 (0.762-0.765) and 0.731 (0.729-0.733) for CCI, and 0.783 (0.781-0.784) and 0.750 (0.748-0.752) for ECI, respectively. Modified CCI and ECI had 13 and 27 conditions, respectively, but maintained comparable predictive abilities: C statistics for modified individual comorbidities and score models were 0.761 (0.759-0.763) and 0.759 (0.757-0.760) for CCI, and 0.784 (0.782-0.785) and 0.783 (0.781-0.785) for ECI, respectively.Conclusions: The original and modified CCI/ECI models, with reduced numbers of conditions, had sufficient and comparable predictive abilities for hospital death and can be used in future studies using this administrative database.

Objective: The Charlson and Elixhauser comorbidity indices (CCI and ECI, respectively) are widely used to study comorbid conditions but these indices have not been validated in Japanese datasets. In this study, our objective was to validate and recalibrate CCI and ECI in a Japanese insurance claims database.Methods: All hospitalizations for patients aged≥18 years discharged between January 2011 and December 2016 were randomly allocated to derivation and validation cohorts. Predictability for hospital death and re-admission was evaluated using C statistics from multivariable logistic regression models including age, sex, and individual CCI/ECI conditions at admission month or the derived score in the derivation cohort. After stepwise variable selection, weighted risk scores for each condition were re-assigned using odds ratios (CCI) or beta coefficients (ECI). The modified models were evaluated in the validation cohort.Results: The original CCI/ECI had good discriminatory power for hospital death: C statistics (95％ confidence interval) for individual comorbidities and score models were 0.845 (0.835-0.855) and 0.823 (0.813-0.834) for CCI, and 0.839 (0.828-0.850) and 0.801 (0.790-0.812) for ECI, respectively. Modified CCI and ECI had reduced numbers of comorbidities (17 to 10 and 30 to 21, respectively) but maintained comparable discriminatory abilities: C statistics for modified individual comorbidities and score models were 0.843 (0.833-0.854) and 0.838 (0.827-0.848) for CCI, and 0.840 (0.828-0.852) and 0.839 (0.827-0.851) for ECI, respectively.Conclusions: The original and modified models showed comparable discriminatory abilities and both can be used in future studies using insurance claims databases.

A 77-year-old-woman was hospitalized at our institution following the diagnosis of severe aortic and mitral stenoses. Although she had thrombocytopenia before surgery, bone marrow examination revealed no abnormality. Thrombocytopenia was thought to be caused by shear stress accompanying valvular diseases. She underwent surgery for the replacement of aortic and mitral valves and the resection of left ventricular outflow tract myocardium. Because the mitral valve involved the calcification of the annulus the valve replacement was performed after decalcification using CUSA. After surgery, she experienced a transient sick sinus syndrome ; however, the overall course was good, and the platelet counts spontaneously recovered. More than 12 months have passed since surgery, but the platelet counts remains around 110,000.

Recently, the palliative care team (PCT) at our hospital has included dentists. Among a total of 127 cancer patientsand required PCT intervention from 2009 to 2014, 17 patients (13.3%) had oral symptoms. Therefore, the PCT held discussions in order to determine the optimal way to treat each patient. Various symptoms, including oral pain, dry mouth, taste disturbance, furred tongue, excessive amounts of saliva, appetite loss, and trismus were treated by the dentists. As a result, the oral findings improved in all patients, while the oral symptoms improved in 16 of the 17 patients (94%). Thanks to the fact that dentists have joined the PCT, oral symptoms are effectively relieved, and PCT members now have an increased interest in oral cavity complications. Furthermore, conducting thorough examinations of the oral cavity by the PCT not only results in an improved QOL, but it has also increased the interest in the oral cavity on the part of the PCT. Therefore, more effective palliative care is expected to be achieved by promoting increased cooperation with more clinical departments.

We describe a case of ruptured coronary artery aneurysm with a coronary artery to a pulmonary artery fistula. An 89-year-old woman with general fatigue and dyspnea was admitted. At the visit she went into shock and was restored by rehydration therapy. Enhanced computed tomography shows a coronary aneurysm (maximum diameter of 50 mm) at the left side of pulmonary artery and mild pericardial effusions. She was scheduled for an emergency operation due to the ruptured coronary artery aneurysm with a coronary artery to pulmonary artery fistula. We performed aneurysmectomy and ligation of the coronary artery to the pulmonary artery fistula under cardiopulmonary bypass. We also reviewed 23 cases of ruptured coronary artery aneurysm with coronary artery extending to a pulmonary artery fistula in Japan. The disease is a rare clinical state and regarded as an indication for emergency surgery.

A 64-year-old man originally underwent Bentall procedure for annulo-aortic ectasia for the first time at the age of 38 years. The surgery was to repair a pseudoaneurysm at the anastomotic site of the left coronary artery by direct closure 11 years after the first Bentall procedure. The anastomosis of the right coronary artery was normal at the time of the first reoperation. However, he had surgery to repair a pseudoaneurysm at the anastomotic site of the right coronary artery 26 years after the first operation ; this was accomplished using the button technique. However, seven months after the second reoperation, he again manifested a pseudoaneurysm at the anastomotic site of the left coronary artery and died of rupture of the pseudoaneurysm. We report the case of pseudoaneurysms at the right and left coronary artery anastomoses that occurred three times after the first Bentall procedure.

Palliative care team（PCT）, nutrition support team（NST）and office of nutrition in our hospital developed a special soup service, which was served for ten patients faced with terminal cancer. The members of PCT, NST and the Cook served a special soup to ten patients. Nine of them could taste the soup without vomiting although they had anorexia. It was a good result. The number of days from the last day tasting the soup to death or hospital transfer was between 3 and 20 days（12.5 days on average）, and the number of times they could taste the soup was between 1 and 3（2.0 times on average）. Tasting the soup supports the strength of living, and might bring an improvement in spiritual quality of life.

Infectious endocarditis associated with Streptococcus bovis, which is rare in Japan, is a frequently reported complication of gastrointestinal tumors, especially in colon cancer. We report a patient who was successfully treated for the S. bovis-induced infectious endocarditis complication in colon cancer. A 60-year-old man was admitted to our hospital for detailed examination of high fever of unknown origin, that had lasted for 2 months. S. bovis was identified in the venous blood culture. An echocardiogram showed severe aortic valve regurgitation of the third degree and vegetation on the aortic valve. We therefore diagnosed infectious endocarditis. Colonoscopy revealed sigmoid colon cancer. After endoscopic mucosal resection of the lesion, the aortic valve was replaced. The postoperative course was uneventful and he was discharged from the hospital 36 days post operatively.

We report a case of tricuspid infective endocarditis with peripheral pulmonary artery aneurysm. A 31-year-old man with a history of intravenous drug abuse was admitted to our institution. Echocardiography showed severe tricuspid valve insufficiency and large vegetation (10 mm) attached to the tricuspid valve. Computed tomography (CT) revealed a right peripheral pulmonary artery aneurysm. We operated because of the large amount of vegetation. Before the operation, we performed coil embolization for peripheral pulmonary aneurysm. During the operation, we removed the posterior leaflet with vegetation, and performed tricuspid valve repair. The postoperative course was uneventful. Postoperative echocardiography did not show any tricuspid valve insufficiency or vegetation.