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Hospital ethics committees (HECs) are expected to play extremely broad and pivotal roles such as case consultation, education of staffs on healthcare ethics, and institutional policy formation. Despite the growing importance of HECs, there are no standards for setup and operation of HECs, and composition and activities of HECs at each institution are rarely disclosed in Japan. In addition, there is also a lack of information sharing and collaboration among HECs. Therefore, the authors established the Consortium of Hospital Ethics Committees (CHEC) in October 2020, which has been regularly hosting a couple of core activities. One is the Healthcare Ethics Forum, held monthly online for CHEC members to freely discuss HECs and healthcare ethics consultation. The other is the Collaboration Conference of Hospital Ethics Committees, intended to provide a place for HEC members and administrative officers from across Japan to exchange information of their HECs, learn from each other, and cooperate to operate HECs appropriately. In this paper, the authors introduced CHEC as well as reported the results of a questionnaire survey conducted at the first conference among participating facilities, suggesting the diverse structures and activities of HECs in Japan.

ObjectiveTo evaluate changes in the learning attitudes of primary care physicians.DesignQualitative study through one focus group interview with the programme’s participants. Analysis of the focus group content using the Steps for Coding and Theorization method.SettingJapan.ParticipantsEight primary care physicians who completed a 2-year continuing professional development (CPD) programme using a problem-based learning (PBL) approach, focused on acquiring the skills needed to practise as primary care physicians in the community.ResultsParticipants described positive changes in their attitudes and behaviours as a result of the training programme. These changes were grouped into three main themes: ‘changes in learning methods regarding medical practice’, ‘encounters with diverse perspectives and values, and confidence gained from those encounters’, and ‘showing one’s attitude towards learning and its influence on others’. The experienced practitioners participating in this study reported that the programme helped them apply their skills more broadly; for example, searching the literature for psychosocial aspects of practice and engaging more comfortably with diverse perspectives. They reported the positive impact of their learning on their coworkers.ConclusionA 2-year CPD programme using PBL can influence primary care physicians’ attitudes and learning-related behaviours. Further research is needed to determine which specific aspects of the programme are the most effective and whether the changes in attitudes and behaviours described affect patient care.

A conceptual framework for advance care planning is lacking in societies like Japan's valuing family-centered decision-making.A consensus definition of advance care planning with action guideline adapted to Japanese society.We conducted a multidisciplinary modified Delphi study 2020-2022. Thirty physicians, 10 healthcare and bioethics researchers, six nurses, three patient care managers, three medical social workers, three law experts, and a chaplain evaluated, in 7 rounds (including two web-based surveys where the consensus level was defined as ratings by ≥70% of panelists of 7-9 on a nine-point Likert scale), brief sentences delineating the definition, scope, subjects, and action guideline for advance care planning in Japan.The resulting 29-item set attained the target consensus level, with 72%-96% of item ratings 7-9. Advance care planning was defined as "an individual's thinking about and discussing with their family and other people close to them, with the support as necessary of healthcare providers who have established a trusting relationship with them, preparations for the future, including the way of life and medical treatment and care that they wish to have in the future." This definition/action guideline specifically included support for individuals hesitant to express opinions to develop and express preparations for the future.Adaptation of advance care planning to Japanese culture by consciously enhancing and supporting individuals' autonomous decision-making may facilitate its spread and establishment in Japan and other societies with family-centered decision-making cultures.

Objectives This study aimed to identify training needs among primary care physicians in Japan who had no formal primary care training. Methods We conducted a focus group interview with seven Japanese primary care physicians who had not previously undergone specialist training in primary care and had been recruited to a family medicine training program that used a problem-based learning approach. At the start of the program, the physicians attended the interview. The discussion was recorded, and the transcribed interview was analyzed using the Steps for Coding and Theorization method. Results Three main themes emerged. First, there is a lack of standard re-education programs for physicians who move away from their specializations into primary care. Second, there is insufficient training on primary care in undergraduate and postgraduate medical education in Japan. Third, continuing professional development programs should cover the communication skills, attitudes, and behaviors necessary for primary care practice. Conclusions This study clarified the needs to be addressed in our training program for primary care physicians involved in retraining in primary care. It is important to consider how to best include the communication skills, attitudes, and behaviors necessary for primary care among the topics covered in the program. As the program undergoes further iteration, it will be important to check whether it meets the needs of primary care practitioners. It will be necessary to investigate the needs of re-education programs for more physicians in many areas, and to emphasize the importance of primary care re-education in these abilities in undergraduate and postgraduate medical education.

Aim We compared differences between laypeople and healthcare professionals in the recognition of and intent to use gastrostomy and ventilator treatments in older patients with dementia. Methods Between November 2011 and January 2012, a questionnaire survey was carried out. People who underwent a general health check-up at Nomura Hospital Preventive Medical Center were recruited as the laypeople group. Physicians and nurses working in Mitaka, Tokyo, Japan, were recruited as the healthcare professional group. We assessed the recognition rate of ventilator and gastrostomy treatments. Then we provided two scenarios for participants to determine whether these methods represented life-sustaining treatments that will simply delay an inevitable death. Intentions were compared between cases with and without advance directives. Results Approximately 60% of laypeople did not know what gastrostomy is. Healthcare professionals were more likely to recognize a ventilator as a life-sustaining treatment; in contrast, there were no significant differences in judgments regarding gastrostomy. Both groups were more likely to have intent to use a gastrostomy and a ventilator for family members than themselves. Furthermore, healthcare professionals were more likely to want to use these items for patients than their family members. Advance directive for withholding life-sustaining treatment reduced the intention to use these treatments. Conclusion It is necessary to increase our understanding regarding knowledge of end-of-life care options of both laypeople and healthcare professionals. Geriatr Gerontol Int 2015; 15: 318–325.

Objective This study was designed to address significant gaps in the predominantly western-centric research literature by examining the influence of gender concordance in medical communication and patient satisfaction within the Japanese context. Methods New primary care patients (54 male and 49 female) were randomly assigned to study internists (6 males and 5 females). Recorded visits were coded with the Roter Interaction Analysis System (RIAS). Post-visit, patients completed a Japanese version of the Medical Interview Satisfaction Scale (MISS). Results Female concordant visits showed higher levels of patient-centeredness than all other gender combinations. Female physicians substantially modified their communication based on patient gender while male physicians did not. Gender concordance was associated with higher female, but lower male patient satisfaction relative to gender discordant visits. Conclusion Contrary to normative experience of medicine as a male dominated profession in Japan, and gender-based power differentials, male-gendered clinical communication is less likely to satisfy male than female patients, while female-gendered communication is positively associated with female patient satisfaction. Practice implications Patient satisfaction ratings reflect greater gender flexibility in terms of acceptable physician behavior than Japanese norms would suggest.

症例は60歳代，女性．平成19年夏頃より，約半年毎に右下腹部痛を繰り返し，近医にて虫垂炎と診断され保存的加療で軽快していた．平成21年7月，右下腹部痛出現．近医を受診し血液検査ではWBC 7,700/μl，CRP 1.5mg/dlと炎症所見は軽度であったが，腹部CT検査で虫垂の腫大を認め，当科紹介受診となった．臨床症状は軽快していたが，繰り返す右下腹部痛の既往があり，虫垂炎の術前診断で待機的に虫垂切除術を施行した．虫垂は赤黒色に腫大していたが，粘膜面に肉眼上隆起性病変は認めなかった．病理組織検査では虫垂原発印環細胞癌，切除断端陽性と診断されたため，初回手術後，22日後に開腹下に回盲部切除術（D2）を施行した．術後病理組織診断はsignet-ring cell carcinoma，mp，n0，stageIで現在外来で経過観察中である．虫垂原発印環細胞癌の1例を経験したので文献的考察を加えて報告する．

症例は80歳，男性．スクリーニングの上部消化管内視鏡検査で十二指腸癌と診断された．乳頭部にかかる進展の為，膵頭十二指腸切除術を施行した．病理検査では高分化腺癌で，病変は大部分が十二指腸粘膜上に広がり，その一部が乳頭部を越え下部胆管に進展し，乳頭上の隆起性病変となっていた．深達度はm，脈管浸潤も見られない早期十二指腸癌であった．胆管内進展を示した早期十二指腸癌の症例は稀であり報告する．

Background It has been reported that liver metastasis rarely occurs in a cirrhotic/hepatitic liver. Thus, coexistence of liver metastasis and hepatocellular carcinoma has been scarcely reported. To the best of our knowledge, there are no cases with hepatocellular carcinoma, which developed during an observational period after hepatectomy for colorectal liver metastasis, in the worldwide English literature. Here we present a case of hepatocellular carcinoma which occurred during a period between the first and second hepatectomy for repeated colorectal liver metastasis. Case presentation A 65-year-old Japanese woman underwent rectal resection for advanced rectal cancer. Hepatitis C cirrhosis was diagnosed at that time and antiviral therapy was offered but rejected because of socioeconomic reasons. At the age of 68, she developed two colorectal liver metastases originating from the rectal cancer, which were treated by local ablation and partial hepatectomy. At the age of 71, solitary recurrent colorectal liver metastasis was observed adjacent to the previously ablated lesion in segment 4, and thus segmentectomy 4 was performed. During surgery, a small tumor in segment 8 was incidentally identified. Taking into account her history, the tumor was considered to be recurrent colorectal liver metastasis and it was extirpated by partial hepatectomy. However, the segment 4 tumor was diagnosed as recurrent colorectal liver metastasis on the basis of histological findings and the segment 8 tumor was diagnosed as hepatocellular carcinoma. Although she had a cut surface abscess postoperatively, she was discharged from hospital 21 days after the surgery and is currently doing well 18 months after the second hepatectomy. She is currently receiving interferon and ribavirin therapy to eliminate hepatitis C virus. Conclusions If antiviral therapy was performed earlier for the present case and viral elimination was achieved, hepatocellular carcinoma might not have developed. This case reemphasizes the importance of antiviral therapy for preventing carcinogenesis of hepatocellular carcinoma in patients with viral hepatitis even if they have other cancers.

Prostaglandin E1 (PGE1) has several potential therapeutic effects, including cytoprotection, vasodilation, and inhibition of platelet aggregation. This study investigates the protective action of PGE1 against hepatic ischemia/reperfusion injury in vivo using a complementary DNA microarray. PGE1 or saline was continuously administered intravenously to mice in which the left lobe of the liver was made ischemic for 30 minutes and then reperfused. Livers were harvested 0, 10, and 30 minutes postreperfusion. Messenger RNA was extracted, and the samples were labeled with two different fluorescent dyes and hybridized to the RIKEN set of 18,816 full-length enriched mouse complementary DNA microarrays. Serum alanine aminotransferase and aspartate aminotransferase levels at 180 minutes postreperfusion were significantly lower in the PGE1-treated group than in the saline-treated group. The cDNA microarray analysis revealed that the genes encoding heat-shock protein (HSP) 70, glucose-regulated protein 78, HSP86, and glutathione S-transferase were upregulated at the end of the ischemic period (0 minutes postreperfusion) in the PGE1 group. Our results suggested that PGE1 induces HSPs immediately after ischemia reperfusion. HSPs might therefore play an important role in the protective effects of PGE1 against ischemia/reperfusion injury of the liver.

Objective Although the intraocular pressure (IOP) is the most important factor related to the onset and progression of glaucoma, there is little evidence on long-term aging effects on IOP. This article examines the changes of IOP over 10 years in normal eyes to assess physiologic changes related to aging. Design Population-based long-term longitudinal study. Study Population and Observation Procedure Two thousand nine hundred eighty-seven Japanese male aircraft crew members underwent IOP measurement by Goldmann apparatus and received physical and complete ophthalmologic examinations every year for 10 years. A total of 2330 healthy persons (21–49 years; mean age, 35.9±6.8 [standard deviation]) who had no history of treatment for ophthalmic diseases, current illnesses, and no missing data for 10 consecutive years were analyzed. Main Outcome Measures For analysis of the longitudinal index (trend), the linear regression coefficients for 11 points of measurement were determined. Ophthalmologic and physiologic factors affecting the 10-year mean values and a trend of IOP were examined by multivariable linear regression analysis. Results Intraocular pressure tended to decrease with age in all age groups. The mean linear regression coefficient (right eye/left eye) = −0.076/−0.060 (95% confidence interval [CI]: (−0.094 to −0.057)/(−0.078 to −0.041), −0.073/−0.060 [95% CI: (−0.084 to −0.062)/(−0.071 to −0.049)], and −0.060/−0.050 [95%CI: (−0.075 to −0.046)/(−0.064 to −0.036)] (mmHg/year) in the 20s, 30s, and 40s, respectively). In investigating correlations between the10-year mean values of IOP and factors examined in this study, multivariate analysis showed a significantly inverse correlation with spherical power (partial regression coefficient [ B ] = −0.155/−0.144) and positive correlation with esophoria ( B = 0.536/0.521), systolic blood pressure ( B = 0.021/0.022), heart rate ( B = 0.024/0.024), and hematocrit ( B = 0.041/0.043) with IOP. The trend of IOP was significantly positively associated with the trends of systemic factors: body mass index (BMI) ( B = 0.117/0.119), blood pressure (systolic) ( B = 0.020/0.020), and hematocrit ( B = 0.057/0.045), but not with any ophthalmologic factor. Conclusions The long-term observation clearly demonstrated that, in normal eyes, the IOP decreased with aging. The IOP value was negatively associated with spherical power and positively with esophoria, blood pressure, heart rate, and hematocrit. The change of IOP could be affected mainly by the change of body mas index, blood pressure, and hematocrit.

Objective Nutritional disturbances such as ascites and hypoalbuminemia frequently arise after hepatectomy for liver cancer with liver cirrhosis. We examined the possibility of maintaining a favorable state of nutrition by outpatient administration of branched-chain amino acid (BCAA) granules. Methods Forty-three patients who had gross liver cirrhosis complicated by liver cancer and underwent surgery up to May 2002 were given BCAA granules (n = 21, BCAA group) or no granules (n = 22, control group). Results 1) Background details such as age, sex, surgical technique, blood loss, and duration of surgery showed no significant differences. 2) Among objective findings, improvement of ascites and edema tended to occur sooner in the BCAA group, but without a significant difference. 3) Although serum albumin recovered its preoperative value 9 mo after surgery in the control group, only 6 mo was required for recovery in the BCAA group. Total protein showed similar changes, but neither group showed any difference in changes of aspartate aminotransferase, alanine transferase, or platelets. 4) One year postoperatively, the change from the preoperative indocyanine green retention rate at 15 min after intravenous administration tended to be worse in the control group, but not significantly so. 5) In the BCAA group, hyaluronic acid and type IV collagen 7S improved significantly sooner than in the control group. Conclusions BCAA supplementation after hepatectomy promotes rapid improvement in protein metabolism and inhibits progression to liver cirrhosis. Administration of BCAA after hepatectomy is considered beneficial to a patient’s nutritional state.

症例は55歳, 男性. 体重減少の精査から膵頭部癌を診断された. 術前診断はPV (+) のT4N2M0でStage IVbの膵頭部癌で, 膵頭十二指腸切除術, D3リンパ節郭清, 門脈合併切除再建を行った. 術後の病理診断はpPV (-) であったが, pRP (+), pPLph (+) でfSsage IVbであった. また, 肝転移好発因子である静脈侵襲vがv3であったため, 術後6週目からゲムシタビン併用全肝照射療法を開始した. 10Gy照射, ゲムシタビンは200mg/m2で3回投与後より発熱が生じ, さらに14Gy照射後に全身の発疹が見られた. 治療開始後26日に呼吸困難が出現し, 胸部X線撮影で間質性肺炎と診断された. ただちにステロイド療法を開始し, 症状は劇的に改善し, 照射開始後41日目に軽快退院した. 本療法は少量のゲムシタビンと放射線療法の併用だが, 肺が照射野に入る全肝照射時には間質性肺炎が起こる可能性があることを念頭に置くべきである.

The objective of this study were to evaluate the efficacy of hepatic resection for large hepatocellular carcinomas (HCCs) and examine clinicopathologic factors influencing overall survival after resection of a large HCC. The pre-, intra-, and postoperative factors and long-term outcome of 26 patients with HCCs10 cm who underwent hepatic resection (group A) were compared with the those of 143 patients with HCCsor =10 cm (group B). Hepatic resection for large HCCs can be performed with a mortality rate of 3.8%, which was similar to the rate for group B (2.1%). The overall cumulative survival results for group A (1 year 41.0%, 3 years 29.3%, 5 years 29.3%; median survival 10.1 months) were markedly worse than those for group B (1 year 93.1%, 3 years 74.5%, 5 years 44.7%; median survival 53.4 months) (p0.0001). Multivariate analysis identified venous invasion as an independent risk factor of survival of patients with a large HCC. The overall cumulative survival results in patients with venous invasion (1 year 28.0%, 3 years 0%; median survival 6.4 months) were markedly worse than in patients without venous invasion (1 year 64.8%, 3.5 years 64.8%; median survival, 51.8 months) (p0.0066). We concluded that hepatic resection can be performed safely for HCCs10 cm with a low mortality rate. It appears reasonable to believe that hepatic resection is the treatment of choice for large HCCs without venous invasion.

【目的】転移性肝癌に対する局所凝固療法の有用性について検討した.【対象】当科で局所凝固療法を施行した転移性肝癌は15例21病変であった.施行理由はH3多発肝転移例の切除対側葉13病変,肝切除拒否4病変,呼吸機能不良4病変であった.【結果】マイクロターゼ凝固療法16病変,ラジオ波焼灼療法は5病変であった.腫瘍径は, 1cm未満7例, 1-2 cm 10例, 2-3 cm 2例, 3 cm以上2例で,平均腫瘍径は1.7cmであった.平均観察期間8.3ヵ月で2cm未満の9病変に再発を認めなかったが, 4病変(19%)に局所再発を認めた. H3肝転移7例に対しMCTを併用した肝切除を施行し, 4例は無再発生存中であるが, 3例は多発肺転移と残肝多発再発のため死亡した.【結語】 2 cm未満の病変に対しては局所凝固療法が有効である.切除不能H3多発肝転移に対して,局所凝固療法を併用することで,根治切除の可能性を広げることができると考えられた.

SummaryThe use of sedating agents by aircrew and those with safety-critical occupations has raised serious concern and has been extensively debated for several years. This meeting report summarizes the findings of an international panel of experts in aerospace medicine and L allergic rhinitis who were brought together to discuss issues related to the use of antihistamines, in particular the selective, H1-receptor antagonist fexofenadine, in pilots. The presentations covered a wide range of topics including methods for accurately assessing sedation and impairment, and the validity of laboratory testing versus simulator assessments. The panel also examined data on sedation and impairment levels with currently available antihistamines and assessed the impact of these data on their use by pilots and aircrew. It was the consensus of the meeting that fexofenadine can be safely recommended for use in individuals involved in skilled activities, such as pilots, without the concern of sedation above recommended the...

Hepatoduodenal ligament invasion (HLI) is an inhibiting factor for the curative resection of advanced gallbladder cancer. The aim of this study was to clarify the indications for surgical resection in patients with advanced gallbladder cancer with and without HLI by analyzing outcomes. The subjects were 58 patients with advanced gallbladder cancer who underwent aggressive resection, and 20 nonresected patients diagnosed as haring HLI. The presence of stromal cancerous infiltration at six sites in the hepatoduodenal ligament was investigated. The extent of cancer spread was classified into two grades by the number of sites where cancer cells detected: low grade, one or two invasion sites; high grade, three or more sites. Pancreatoduodenectomy, vascular reconstruction, and extensive hepatectomy were frequently performed in the patients with HLI. The cumulative 5-year-survival rate of the HLI patients was 10.9%, significantly worse than that of the resected patients without HLI (46.6%; P < 0.01). Patients with paraaortic lymph node metastasis died within 1 year. The cumulative 5-year-survival rate after curative resection was 38.1%, significantly better than that after noncurative resection (0%; P < 0.05). The survival was significantly worse in patients with high-grade invasion than in these with low-grade invasion (P < 0.05), being equivalent to that in the nonresection patients. Of four factors, operative curability, hepatic lobectomy, HLI grade, and paraaortic lymph node metastasis, the HLI grade and hepatic lobectomy were considered to be significant prognostic factors by Cox's multivariate analysis (backward stepwise method). Aggressive surgical resection for curative purposes should be limited to patients with low-grade HLI and metastasis-negative paraaortic lymph nodes.

The aim of this study was to analyze the patency of expandable metallic stents in malignant biliary obstruction and to evaluate the efficacy of adjuvant therapy accompanied by biliary stenting. We analyzed 29 patients in whom bile duct stenting was performed for malignant biliary obstruction. Their types of disease were: hilar ductal carcinoma (n = 8), gallbladder carcinoma (n = 11), and pancreatic carcinoma (n = 10). Initially, 46 expandable metallic stents were placed in 29 patients. In 23 of the 29 patients, adjuvant therapy was administered. Seventeen patients underwent radiotherapy, and 16 patients received various systemic chemotherapies. In principle, hyperthermia was performed twice a week, simultaneously with radiotherapy. Patient survival and the probability of stent patency were calculated using actuarial life table analysis. There was no significant difference in stent patency among the patients according to type of disease. Hyperthermia did not influence the stent patency rate. The median stent patency time was significantly greater in the chemo-radiation group than in the no-adjuvant therapy group: 182 days versus 68 days, respectively (P = 0.017). Moreover, a significant increase was seen in the median survival time in the chemo-radiation group: 261 days versus 109 days (P = 0.0337). Complications occurred in 9 patients (31.0%). Stent occlusion occurred in 6 patients (20.7%), with all of these patients managed successfully using a transhepatically placed new expandable metallic stent, employing the stent-in-stent method. Stent migration occurred in 2 patients after radiotherapy. Adjuvant therapies such as radiotherapy and systemic chemotherapy, in combination with stent insertion, resulted in an increase in the patency period of expandable metallic stents and in increased patient survival time.

The pancreas and duodenum are uncommon sites for metastasis from renal cell carcinoma. Pancreatic or small intestinal metastases mainly occur when there is widespread nodal and visceral involvement and evidence of metastatic disease elsewhere in the body. We describe herein the case of a 68-year-old man in whom metastases arising from renal cell carcinoma developed concomitantly in the duodenum and pancreas. The patient presented with duodenal bleeding; but as no other metastatic lesions were observed at the time of surgery, total pancreatectomy with duodenetomy was performed. We believe that metastases may easily develop in the duodenum and pancreas owing to the similar tissue characteristics.

症例は48歳女性.意識障害を主訴に近医を受診.低血糖を指摘されて,当院内科を受診.精査の結果,膵インスリノーマの診断で,手術目的に外科転科となった.術前画像検査では,膵頭部下縁に径1cm大の血流に富んだ腫瘍を認めた.また,内科で施行した選択的動脈内カルシウム負荷試験では膵体部背側膵動脈領域に腫瘍の局在が疑われた.開腹下において肝円索より門脈内にカニュレーションし,術中に間欺的門脈血インスリン値測定を行った.腫瘍圧迫によりインスリン値の急増を認め,腫瘍摘出直後より速やかに正常に戻り,完全摘除を確信した.これらの変化は末梢血中インスリン値測定よりも明らかであった.以上より,肝円索からの術中門脈血採血は簡便でインスリン値を鋭敏に反映し,インスリノーマの局在診断や完全摘除の指標に有用であると考えられた.

Pulmonary thromboembolism (PTE) after air travel, firstly reported by Symington in 1977, is also called “economy class syndrome.” We recently treated 3 such cases after patients took long-haul flights. All 3 were Japanese women arriving in Japan after 11.7 to 13.5 hours of flight in economy class. Their major symptoms were dyspnea, convulsion, and loss of consciousness. All had risk factors such as obesity, age greater than 40 years, and immobilization in a cramped seat. One took oral contraceptives and another had antiphospholipid syndrome. All 3 were immediately diagnosed with PTE, thanks to findings of ultrasonic echocardiography and computed tomography (CT). They were treated with heparin and immediately transferred to a university medical center. All were eventually discharged with no apparent adverse sequelae. The number of passengers who travel overseas is rapidly increasing. Although the occurrence of deep vein thrombosis and subsequent PTE is very rare, it is serious and may be life-threatening, so the possibility of its occurrence must be kept in mind.

OBJECTIVES: Ethical issues have recently been raised regarding the appropriate care of patients in persistent vegetative state (PVS) in Japan. The purpose of our study is to study the attitudes and beliefs of Japanese physicians who have experience caring for patients in PVS. DESIGN AND SETTING: A postal questionnaire was sent to all 317 representative members of the Japan Society of Apoplexy working at university hospitals or designated teaching hospitals by the Ministry of Health and Welfare. The questionnaire asked subjects what they would recommend for three hypothetical vignettes that varied with respect to a PVS patient's previous wishes and the wishes of the family. RESULTS: The response rate was 65%. In the case of a PVS patient who had no previous expressed wishes and no family, 3% of the respondents would withdraw artificial nutrition and hydration (ANH) when the patient did not require any other life-sustaining treatments, 4% would discontinue ANH, and 30% would withhold antibiotics when the patient developed pneumonia. Significantly more respondents (17%) would withdraw ANH in the case of a PVS patient whose previous wishes and family agreed that all life support be discontinued. Most respondents thought that a patient's written advance directives would influence their decisions. Forty per cent of the respondents would want to have ANH stopped and 31% would not want antibiotics administered if they were in PVS. CONCLUSIONS: Japanese physicians tend not to withdraw ANH from PVS patients. Patients' written advance directives, however, would affect their decisions.

Background. Medical decisions concerning the end of life (MDEL) have recently been the subject of sustained ethical debate in Japan. However, no study has been undertaken to provide a picture of the kinds of ethical dilemmas Japanese physicians encounter in their care of the terminally ill. We therefore conducted a national survey of Japanese physicians involved in medical care for the terminally ill in their everyday practice. Methods. A postal questionnaire was sent to 500 physician members of the Japan Society of Cancer Therapy for an inquiry into their experience on ethical dilemmas in MDEL. Results. A total of 339 physicians (68%) responded, of whom 11% answered that they were always, 26% often, and 39% sometimes perplexed by ethical dilemmas in MDEL. A total of 386 dilemmas were reported by 267 respondents as the most perplexing, including those related to decisions about life-sustaining treatment, patients' families' demands or requests for medical care, patients' refusal of or demand for medical care, and truth-telling to a terminal cancer patient. Many respondents wondered whether cardiopulmonary resuscitation should be performed for a terminally ill patient, in what situation life-sustaining treatment should be withheld, and whose wishes for medical care should be prioritized in the face of disagreement between patients and their families. Conclusion. Our study suggests that Japanese physicians are faced with various perplexing ethical dilemmas. Serious efforts to resolve these problems in research, education, and physician-patient communication are imperative.

症例は58歳の男性.左肩甲部腫瘤を主訴に当院整形外科に入院し, 生検で転移性腫瘍と診断された.術前CTで下部食道壁の肥厚を, 内視鏡検査で下部食道癌と診断された.左肩甲部腫瘤に対し整形外科で肩甲帯遊離術を施行.腫瘍は肩甲骨下の筋肉内に存在し, 病理は低分化扁平上皮癌であった.2か月後, EiEaの食道癌に対して, 右開胸開腹胸部食道切除術, 2領域郭清, 亜全胃管胸骨後再建術を施行した.術後経過良好であったが, 6か月目に脳転移で再発した.病理組織は類基底細胞癌, a2, v2, ly0, n2であった.類基底細胞癌は本邦で30例の報告があるが, 本症例は筋肉転移を来した.きわめてまれな症例であると思われた.

透析患者の皮膚〓痒症は, 未だ不明な点が多い. ラクチュロースは, 尿素の腸管循環を促進し, 血中アンモニアを低下させるが, 同様の機序による尿毒症性物質の低下を期待し, 透析患者にラクチュロースを投与し, 〓痒感に対する効果を見るとともに, 血中グアニジノ化合物およびAGEsとの関連についても検討を加えた.対象および方法: 白鳥の〓痒症の分類II度以上の透析患者15名 (男9, 女6) に, ラクチュロース16gを夕食後, 4週間投与した. 次の4週間は朝, 夕に16gを投与した. 〓痒感は, 自己採点させ, 投与前, 4週後, 8週後に, 血液一般検査, 生化学検査およびβ2マイクログロブリン, メチルグアニジン, グアニジノ酢酸, インドール硫酸, p-クレゾール, ペントシジンを測定した.結果: 投与前2.87±0.17であった〓痒感は, 4週後には1.87±0.22点に, 8週後には1.60±0.25点へと減少した (p

We compared differences between laypeople and healthcare professionals in the recognition of and intent to use gastrostomy and ventilator treatments in older patients with dementia.Between November 2011 and January 2012, a questionnaire survey was carried out. People who underwent a general health check-up at Nomura Hospital Preventive Medical Center were recruited as the laypeople group. Physicians and nurses working in Mitaka, Tokyo, Japan, were recruited as the healthcare professional group. We assessed the recognition rate of ventilator and gastrostomy treatments. Then we provided two scenarios for participants to determine whether these methods represented life-sustaining treatments that will simply delay an inevitable death. Intentions were compared between cases with and without advance directives.Approximately 60% of laypeople did not know what gastrostomy is. Healthcare professionals were more likely to recognize a ventilator as a life-sustaining treatment; in contrast, there were no significant differences in judgments regarding gastrostomy. Both groups were more likely to have intent to use a gastrostomy and a ventilator for family members than themselves. Furthermore, healthcare professionals were more likely to want to use these items for patients than their family members. Advance directive for withholding life-sustaining treatment reduced the intention to use these treatments.It is necessary to increase our understanding regarding knowledge of end-of-life care options of both laypeople and healthcare professionals.

Introduction We present a case of completely obstructed anastomosis after rectal resection which was nonsurgically and successfully treated with a blunt penetration technique using a commonly used device for transanal ileus drainage. The technique we used in this case has not been previously reported. Case presentation A 79-year-old Japanese man underwent redo rectal resection for completely separated anastomosis which was caused by anastomotic leakage after a sigmoidectomy performed 3 years previously that was remedied by diverging ileostomy. Immediately after the redo surgery, fluoroscopy showed good passage through the colorectal anastomosis but no anastomotic leakage. However, fluoroscopy and colonoscopy prior to the ileostomy takedown showed complete obstruction of the anastomosis. Unlike usual anastomotic strictures, the lumen between colon oral and rectum anal to the anastomosis was completely discontinued by a membranous structure. Therefore, a conventional balloon dilatation technique was unsuitable for this condition. We applied a blunt penetration technique using a commercially available device designed as a transanal drainage system for obstructing colorectal cancer to restore the continuity between the colon oral and rectum anal to the anastomosis. After restoring the continuity, we performed conventional balloon dilatation for the anastomosis and successfully treated the anastomotic obstruction. Subsequently, the patient underwent ileostomy takedown and is currently doing well 12 months after the ileostomy takedown. Conclusions The penetration technique we applied is easy and less stressful to adopt because it does not require usage of materials specialized for other particular purposes. Furthermore, we believe that this technique is superior in safety to other reported methods for this condition even if applied in the wrong direction because this technique does not utilize electrocision or sharp needle puncture.