[How to respond to patient families that pursue medical treatment excessively].

It is important to know the mental state of the primary caregiver for patients requiring advanced home care. Herein, we report cases of failed medical treatment due to primary caregivers with psychological problems and a strong desire to have the patient live at home. Of the 486 cases analyzed from August 1, 2004 to October 31, 2012, in 10 cases, the primary caregiver had a strong desire to have the patient live at home. Preventing patients from entering home health care has become more difficult recently. Therefore, establishment of guidelines for interacting with primary caregivers is required. The introduction and application of medical ethical consultation is required for this purpose. The medical ethical consultation is designed to avoid the explanation of medical terminology as much as possible. In order to obtain a detailed understanding of the current state of the patient, it is desirable to pursue a clinical ethical interaction.

[A Study on problems associated with a patient's death during home care, based on the duration of home care and patient's age-why terminal home care is difficult for a patient's family].

When a patient receives home care, an important factor is how the family accepts the patient's death. In this study, we observed that the number of long-term in-home terminal care cases increased, as well as the number of short-term in-home care cases. Moreover, the number of cancer cases among the young population is also increasing. Consequently, how to acceptance of a patient's death varies among their family. When tending to patients, suitable support from the medical staff is required. Additionally, various options need to be provided for terminal care.

A Case of Takotsubo Cardiomyopathy Diagnosed After Postponement of Surgery Due to Hypotension and Electrocardiogram Abnormality Upon Entering the Operating Room.

Takotsubo cardiomyopathy (TCM) is a rare disease that is difficult to diagnose. We experienced a case that developed just before surgery. A woman in her 80s with no complications except hypertension was scheduled for colon cancer surgery. Although she was asymptomatic, after entering the operating room, her surgery was canceled due to unexplained hypotension and ST-segment elevation on the electrocardiogram monitor. Emergency coronary angiography was performed immediately, and the presence of TCM was revealed. Her surgery was therefore performed after the improvement in her cardiac function. Once a patient is in the operating room, the normalcy bias kicks in and it becomes difficult to decide to stop the surgery. However, even at this time, it is important to stop the induction of anesthesia if there is any abnormality and to make a differential diagnosis based on the possible development of a serious disease, as seen in this case.

Rice Mutants Lacking Starch Synthase I or Branching Enzyme IIb Activity Altered Starch Biosynthetic Protein Complexes.

Amylopectin, the major component of starch, is synthesized by synergistic activity of multiple isozymes of starch synthases (SSs) and branching enzymes (BEs). The frequency and length of amylopectin branches determine the functionality of starch. In the rice endosperm, BEIIb generates short side chains of amylopectin and SSI elongates those branches, which can be further elongated by SSIIa. Absence of these enzymes greatly affects amylopectin structure. SSI, SSIIa, and BEIIb associate with each other and with other starch biosynthetic enzymes although SSIIa is low activity in japonica rice. The aim of the current study was to understand how the activity of starch biosynthetic enzyme complexes is compensated in the absence of SSI or BEIIb, and whether the compensatory effects are different in the absence of BEIIb or in the presence of inactive BEIIb. Interactions between starch biosynthetic enzymes were analyzed using one ss1 null mutant and two be2b japonica rice mutants (a mutant producing inactive BEIIb and a mutant that did not produce BEIIb). Soluble proteins extracted from the developing rice seeds were separated by gel filtration chromatography. In the absence of BEIIb activity, BEIIa was eluted in a broad molecular weight range (60-700 kDa). BEIIa in the wild-type was eluted with a mass below 300 kDa. Further, majority of inactive BEIIb co-eluted with SSI, SSIIa, and BEI, in a mass fraction over 700 kDa, whereas only small amounts of these isozymes were found in the wild-type. Compared with the be2b lines, the ss1 mutant showed subtle differences in protein profiles, but the amounts of SSIIa, SSIVb, and BEI in the over-700-kDa fraction were elevated. Immunoprecipitation revealed reduced association of SSIIa and BEIIb in the ss1 mutant, while the association of BEIIb with SSI, SSIIa, SSIVb, BEI, and BEIIa were more pronounced in the be2b mutant that produced inactive BEIIb enzyme. Mass spectrometry and western blotting revealed that SSI, SSIIa, SSIIIa, BEI, BEIIa, starch phosphorylase 1, and pullulanase were bound to the starch granules in the be2b mutants, but not in the wild-type and ss1 mutant. These results will aid the understanding of the mechanism of amylopectin biosynthesis.