In this study, we invited 716 patients who underwent surgery at our institution over a 2-month period to complete a questionnaire survey on preoperative smoking habits. Surgeons were also asked to complete a questionnaire regarding counselling patients about smoking cessation in the perioperative period. Thirty（8.2%）of 367 respondents were smokers, and 17（56.7%）had a Tobacco Dependence Screener score of ≥5, indicating nicotine dependence. Twelve（40%）of the 30 smokers reported quitting during the preoperative period. There was no significant difference between smokers who continued smoking and those who stopped smoking before surgery in type of surgery performed or the proportion of patients who were nicotine-dependent. In contrast to 44.4 % smokers who kept smoking, 25% of smokers who quit smoking reported receiving advice from their surgeon regarding perioperative smoking. However, 87% of surgeons reported that they advised all patients about the health risks of smoking before surgery. In addition, we were unable to identify any patients who filled in tobacco use interventions as the reason for smoking cession. These findings suggest that the importance of perioperative smoking cessation is not always fully understood by smokers. An effective tobacco intervention strategy, including referral to a smoking cessation counselor, should be implemented in the surgical setting.

A woman in her 50s suddenly complained of severe headache, nausea and vomiting while standing with no obvious cause. Based on several clinical examinations, she was diagnosed with cerebrospinal fluid hypovolemia（CSFH）. However, she also developed impaired consciousness and epilepsy during treatment of the CSFH. Magnetic resonance imaging showed an impending severe brain herniation with marked cisternal narrowing and cerebellar amygdaloid ptosis. Because there was no indication for surgical treatment, an emergency epidural blood patch（EBP）was requested. An epidural puncture through the C7/T1 interspinous space was performed under fluoroscopy using the loss of resistance technique. Following the epidural puncture, contrast medium and autologous blood were administered as an EBP. Her impaired consciousness improved 2 weeks after EBP and she was discharged at 7 weeks.

Wolf-Hirschhorn syndrome（WHS）is a rare disorder with characteristic facial features including cleft lip, cleft palate, and small jaw due to deletion of the short arm of chromosome 4, psychomotor retardation, convulsions, and hypotonia. A 15-month-old girl with WHS was scheduled for lip augmentation for cleft lip. The patient was managed safely during the perioperative period with attention given to the possibility of airway obstruction due to facial deformity and growth disturbance, convulsive seizures, and respiratory infection due to decreased muscle tone.

Advances in cancer treatment have increased the number of patients undergoing long-term cancer treatment. Taste disorder occurs in 40% to 60% of the patients receiving chemotherapy. In many cases, taste disorder peaks approximately a week after starting chemotherapy and then recovers. However, some patients continue to receive cancer treatment without any improvement in their taste sensation. Taste disorder, a side-effect that causes loss of appetite and decreased calorie intake, seriously affects quality of life, so it is a symptom that requires special attention. Here, we summarize findings from the literature on taste disorder in patients undergoing chemotherapy for cancer treatment and introduce our clinical research.

When oral mucositis occurs as an adverse event of cancer therapy, the patient’s quality of life is reduced due to decreased oral intake and limited conversation due to pain. In addition, severe cases of oral mucositis may necessitate a reduction in the chemotherapy dose or a treatment break. Therefore, preventing and treating oral mucositis are important to maintain patients’ QOL and to accomplish cancer therapy. Opioid analgesics are recommended for pain caused by oral mucositis when mouthwashes and acetaminophen are ineffective. In such cases, it is necessary to understand the characteristics of opioid analgesics with respect to abuse and dependence and to take strict precautions to prevent their inappropriate use.

The JCS 2022 Guideline on perioperative cardiovascular assessment and management for non-cardiac surgery was published in 2022. In recent years, the number of high-risk cases such as the frail elderly with multimorbidities undergoing surgeries has been increasing. In such cases, we often face difficulties in decision-making perioperatively, mainly when making decisions on the surgery and on the treatment when patients develop serious conditions after surgery such as chronic critical illness and post ICU syndrome with unacceptable quality of life. In the latter situations, most patients lose the ability to make their own decisions and their surrogates play an important role in serious decision making with regard to the initiation, continuation, withholding, or withdrawing of life-sustaining treatment. The clinical practice guideline recommends a holistic approach by the multidisciplinary team and shared decision making. The treatment choice as well as its risks and benefits are evaluated by the multidisciplinary team. This medical information should be conveyed to patients and their family in a manner they can use them in decision making. One valid method is “best case and worst case scenario”. Next, medical team members should understand patients’value. Preoperative advance care planning is useful. Finally, based on patients’value and medical evaluation, physicians need to make treatment recommendations. This shared decision making process is important.

Anesthesiologists have been encountering non-cardiac surgery patients with cardiovascular disease more frequently in recent years. It can be very stressful and challenging for us to assess and plan for these patients’ perioperative management. The Guideline on Perioperative Cardiovascular Assessment and Management for Non-cardiac Surgery gives us reasonable advice in this situation. The current guideline（revised in 2022）differs from the last one by calling for shared decision making and by including six representative clinical questions（CQ）and recommendations. In shared decision making, anesthesiologists may play an important role in communicating with doctors and patients. The six clinical questions and recommendations are very helpful for anesthetic management, but in other clinical situations anesthesiologists may need to treat other types of problems in relation to the algorithm shown in the CQ of the new guideline.

The year 2022 marks the 150th anniversary of the opening of the Kyoto Ryobyoin, which evolved into the Kyoto Prefectural University of Medicine. In November 2022, lectures honoring Ferdinand Adalbert Junker von Langegg（Junker）were held at the annual meeting of the Japan Society for Clinical Anesthesia. This paper is an amalgamation of these lectures.

Junker qualified in Vienna, worked as a general physician, surgeon and obstetrician and gynaecologist in London, Berlin, Kyoto, Leipzig and Vienna, and also spent time as an army doctor during some of these travels, before returning to the country of his birth, Austria, at the end of his career.

Junker stayed in Japan from 1872 to 1876. Junker contributed to the modernization of medical care as the first foreign doctor and teacher at Kyoto Ryobyoin Hospital. Junker was the only anesthesiologist among the “hired foreigners” employed to change Japan into a modern country during the Meiji Restoration. Junker’s inhaler, which he developed in 1867, has been improved and used for generations. Junker’s career was very unusual for the time and still presents many unanswered questions.

As the first of a three-part series, this article describes the westernization of Japanese medicine from the late Edo period to the early Meiji period and how Junker was invited to the Kyoto Ryobyoin Hospital as the first foreign doctor and teacher.

Here we review the past activities of the Difficult Airway Management（DAM）Committee and identify various challenges. From 2004 to March 2021, 127 DAM practical seminars were held in various locations. The first challenge is to improve the quality and standardization of instruction. In accordance with the accreditation rules, instructors have been trained, but unevenness in instruction has occurred. To remedy the problem, a course on adult education methods was introduced, but its effect has not been confirmed yet. The second challenge is how to deal with diversifying students. It is necessary to modify the course contents and teaching materials according to the specialization and occupation of the trainees. The third challenge is the evaluation of seminar results. The process of evaluating seminar results and providing feedback to improve future seminars has not yet been adequately performed. These issues must be urgently addressed.

The Japanese Association for Medical Simulation（JAMS）has been running the Difficult Airway Management（DAM）training seminar since 2004 to promote safe airway management. Although the safety of airway management has improved over the last 20 years due to the development of airway management devices, anesthetic agents, and guidelines, critical airway conditions continue to occur. The need for DAM is expanding beyond the operating room, and it is expected that DAM training will continue to be required. An update to flexible DAM simulation education that achieves both educational effectiveness and operational efficiency is needed.

How much can fidelity be improved in simulation-based education in Niraikanai’s future?

The HFS Committee is considering the development of a novel simulation seminar for cardiac anesthesia, especially with regard to weaning from cardiopulmonary bypass. We discuss the contents, methods to increase fidelity, and a novel simulation method. New simulation technologies like virtual reality should be incorporated into existing simulation technologies, including high-performance patient simulators, ventilator simulators, and transesophageal echocardiography simulators to improve fidelity. We look forward to the development of Niraikanai’s simulation-based education.

The central venous catheterization（CVC）committee has been working to promote safe central venipuncture and reduce the incidence of complications from CVC. The committee has contributed greatly to the safety of CVC by holding seminars and sharing educational materials, but complications continue to occur and its activities needs to be reviewed. In addition to the past activities, a seminar on peripherally inserted central catheters will be held in the future. We are considering incorporating outcomes-based education into each seminar. Providing opportunities to ensure the acquisition of safe techniques will lead to better outcomes for the committee.

In recent years, our profession has undergone significant changes with particular focus on “physician work style reform” and “quality and safety of medical care”. Overtime work for residents has been greatly restricted, albeit gradually, and it is assumed that the training of residents and young physicians will shift to a focus on simulation education in the future. By putting acquired knowledge and skills into practice in clinical settings, human resource development can be efficiently carried out even within the highly restricted time frame. Relevant scientific societies will need to be able to guarantee the quality and safety of seminars held at various locations. The quality and quantity of education and the continuity of safe education and practice need to be ensured.

To improve the safety of sedation, the SED Committee of the Japanese Association for Medical Simulation（JAMS）has developed “Sedation Practice Seminars” based on the Sedation guidelines of the American Society of Anesthesiologists. In response to the COVID-19 pandemic, we developed a practical online sedation seminar（SED-Online）using a web conferencing system. We believe that education should change its form to meet the needs of society and the times. In the “new normal” simulation education, there is a need to improve teaching methods at various levels in order to maintain the sustainability of simulation medicine education.

The concept of safety has transitioned from the era of skills, through the era of human factors, to the era of management. Safety-II, an application of resilience engineering, began to be emphasized as a safety management approach for health care systems described by complex adaptive systems. Healthcare has achieved its intended outcomes in an overwhelming number of practices by responding flexibly and adaptively to dynamically changing conditions with limited resources. In order to proactively create safety by learning from everyday practices, research is underway on how to implement safety-II. It must be emphasized that safety-II is not a replacement for safety-I. Future safety management should consider Safety-I and Safety-II as complementary and utilize both depending on the situation.

Based on the SBS/AHT hypothesis, which has been accepted by the medical community as the prevailing theory, abuse by caregivers has been suspected in Japan, and parent-child separation and criminal prosecutions have taken place. Recently, however, there has been a string of acquittals in these prosecutions. This is thought to be due to the shaky medical basis for the SBS/AHT hypothesis and the erroneous diagnosis by the prosecuting physician. The medical community needs a zero-based verification of the SBS/AHT hypothesis in light of the seriousness of wrongful separation of parents and children and false convictions.

The Medical Accident Investigation and Support Center（ISC）was established in Japan in 2015 to prevent medical accidents and promote patient safety. When a medical accident occurs, the hospital conducts an in-hospital investigation and submits a report to the ISC. If requested by a medical institution or a bereaved family, the ISC will perform an investigation. As of 2021, the ISC has submitted 94 out of 174 reports（54％）to concerned hospitals and patients’ families.

During an ISC investigation, the hospital concerned is asked to explain and submit documents about the accident. The result of the investigation is then reported to both the hospital and the bereaved family. However, it is important to note that some information analyzed during the ISC investigation may be used for civil procedures, as outlined in the Medical Practitioners’ Act（Article 21）.

It is worth noting that the cause of death cannot be known for a long time in cases where a legal autopsy is required, as an appraisal of a legal autopsy cannot be opened to the public before the opening day of a trial. This can delay the ISC investigation.

In summary, the Medical Accident Investigation and Support Center plays a critical role in preventing medical accidents and promoting patient safety in Japan. However, it is important to know the legal implications of an ISC investigation and the potential delays caused by legal autopsies.