The early postoperative use of continuous hemodiafiltration (CHDF) was effective in the postoperative management of two patients with chronic renal failure (CRF) undergoing cardiovascular operation. The first case was a 74-year-old man with a ruptured abdominal aortic aneurysm who underwent emergency Y-shaped artificial graft replacement. The second case was a 55-year-old man with aortic valve stenosis and regurgitation who underwent aortic valve replacement with a mechanical cardiac valve. Both patients had had chronic renal failure for several years before the operation, and the second patient had been on intermittent hemodialysis. Although a large amount of blood transfusion was needed postoperatively in both cases, CHDF enabled us to maintain the electrolytes in the normal range and control the water balance. The influence on the hemodynamics was minimized by adjusting the filtration rate. In conclusion, CHDF is useful for the management of CRF in the early postoperative period following cardiovascular surgery.

　We report on our experience at the highly interactive special session "General Cardiology Hangout" at the 63rd Annual Scientific Session of the Japanese College of Cardiology, in which the e-portfolio system of Tokyo Medical University and a personal response system (PRS) were used to collect real-time free comments and feedback from the audience.

　In order to effectively manage an interactive session at an academic meeting by collecting feedback from the audience through a PRS and free comments, it is necessary to train facilitators who have the ability to organically extract and integrate the opinions and feedback from the audience in a relevant matter, and to develop tools that are both more user-friendly and secure.

　To improve hospital quality, the development of authorized clinical instructors is urgently needed. Therefore, we held a workshop to develop clinical instructors. At a monthly meeting of the clinical training committee in June 2014, an agenda for holding a workshop was proposed. At the meeting in July 2014, most committee members said they were reluctant to hold a workshop because of heavy clinical duties. However, the hospital president strongly suggested that a workshop might be a foundation for reforming the stagnated hospital and persuaded committee members to hold a workshop to improve the instructors’ skill in teaching residents. At the September meeting, the workshop schedule was discussed. All members of the taskforce, except the chief coordinator and a lecturer, were selected from hospital physicians, and 3 preparatory meetings and 1 rehearsal were held. With the help of administrative staff, our first workshop for clinical instructors was held at Daido Hospital in February 2014. Our workshop helped create new hopes for improving educational tasks at our teaching hospital and improved the educational skills of participants. We also achieved mutual understanding as a team to accomplish a single goal.

Objective: The aim of this study was to identify the content and methods of ethics education for medical representatives as part of the continuing education program and to suggest a preferable supportive method of ethics education accordingly.
Method: A questionnaire was mailed to the medical representative education managers of all 214 companies, all members of the MR Education & Accreditation Center, Japan.  The questionnaire was carried out from 31st July 2009 to 25th August 2009, and data from this questionnaire survey was analyzed by simple and cross tables.
Results: Out of the 182 (response rate: 85.0%) who responded, we analyzed the 173 institutions for analysis as they responded as having the continuing education program.  In terms of education, “the fair competition code” was the most widely educated (82.6%).  Although “the fair competition code” required most time, “the ethics as a medical representative” was considered as the most important.  The simple kappa coefficient between actual educating item and important item was 0.29.  Answers were affected by whether he/she had experience as a medical representative.  As the method of ethics education, “lecture” style was most common (87.4% of respondents), “group work discussion” was considered the most effective (70.6%) for training a medical representative to think and learn by himself/herself.  The respondents of 82.2% referred to the continuing educations’ guidelines made by MR Education & Accreditation Center, and 81.0% respondents felt “training materials for lectures and/or discussions” necessary in the future.
Conclusion: The ethics education for medical representatives placed a disproportionate emphasis on the importance of “the fair competition code.” Dissociation was seen between the actual education and the education considered as important by the respondents.  Accordingly, there is a need for appropriate materials for training and for a more adequate curriculum, taking time and content of education into consideration, especially for contents which training ways aren’t built up.

A case of xenograft valve dysfunction presenting with musical cooing murmur is reported. The patient was a 47-year-old woman and had received mitral valve replacement with porcine xenograft (Carpentier-Edwards 31-M) 10 years before Preoperative echocardiogram showed vibration of a leaflet outside the stent of the bioprosthetic valve. Cardiac catheterization revealed stenosis as well as regurgitation of the bioprosthetic valve. The resected xenograft valve showed a tear which produced regurgitation and musical cooing murmur in one of three pliable leaflets and it also showed pannus formation which caused stenosis.

A case of a 51-year old male with pulmonary valve endocarditis accompanied by aortic regurgitation, and ruptured aneurysm of Valsalva sinus was reported. Repeated blood cultures grew α-streptococcus on a single occasion. After medical treatment, resection of pulmonary valve vegetation, resection and patch closure of aneurysm, and aortic valve replacement were performed successfully. Twenty one cases of pulmonary valve endocarditis reported in Japan, including our case, were collected and reviewed. Causative organism was streptococcus in 93% of cases. No case of intravenous drug abuse was found in this series. A variety of preexisting heart diseses were found in 20 cases out of 21 (95%). All these diseases were congenital ones, such as ven-tricular septal defect, patent ductus arteriosus, pulmonary stenosis and ruptured aneurysm of Valsalva sinus. This fact means that jet lesion of pulmonary valve is a major predisposing factor of pulmonary valve endocarditis. Surgical procedures were reported in 12 cases: resection of vegetation in 4 cases, resection of pulmonary valve in 2, and pulmonary valve replacement in 5. Appropriate surgical procedures should be chosen, depending upon the activity of infective endocarditis, severity of destruction of the valve, and pulmonary vascular resistance.

A 69-year-old man, who had undergone coronary artery bypass grafting using the right gastroepiploic artery 2 years previously, was hospitalized with acute epigastralgia. Gastroscopy showed an early gastric cancer in the greater curvature of the corpus and ultrasonography of the abdomen revealed acute cholecystitis due to a stone impacted in the cystic duct. The subtotal gastrectomy and the cholecystectomy with preservation of the right gastroepiploic artery graft were performed. The surgical margin of the resected specimen was negative for cancer. The postoperative course was uneventful. After coronary artery bypass grafting using the right gastroepiploic artery, annual gastroscopy is recommended.

An 86-year-old woman visited our hospital at 20:00 with the chief complaint of right hip joint pain that had started at around 19:30. The abdomen was soft and slightly bloated, and there was tenderness in the right hip joint. Computed tomography (CT) revealed protrusion of the small intestine through the right obturator foramen, and right-sided impacted obturator hernia was diagnosed. Intestinal necrosis was unlikely because her symptoms had started only a short time earlier, so manual reduction was performed. The right hip joint pain was rapidly alleviated, and CT confirmed release of the incarcerated bowel. Elective laparoscopic repair was then performed. Hemorrhagic ascites in the abdominal cavity, but no obvious intestinal ischemia, was evident. Intestinal dilation was relieved, enabling us to perform surgical maneuvers in a good surgical field. The postoperative course was favorable, and there has been no recurrence as of 2 years 11 months after surgery. Obturator hernia is common in elderly women, who often have several comorbidities. Avoidance of emergency surgery by manual reduction is therefore significant, and laparoscopic surgery that enables assessment and treatment of the contralateral side is beneficial.

From April 1987 to March 1990, we performed open heart surgery using extracorporeal circulation in 90 patients (average age, 51.8 years old) and vascular surgery (graft replacement of abdominal aortic aneurysm and surgery for ASO) in 29 patients (average age, 58.1 years old). Among there, 8 patients with open heart surgery (EEC group) and 9 patients with vascular surgery (vascular group) had suffered from renal insufficiency preoperatively. In the two groups, we compared operative mortality, complications and postoperative severity of renal failure. Preoperative renal insufficiency was defined as a serum creatinine level of more than 1.4mg/dl and postoperative renal failure was defined as 2.0mg/dl. There was no significant difference in operative mortality, in postoperative creatinine, Ccr, BUN and serum potassium and in effectiveness of hemodialysis in the two groups. In conclusion, it seems that we should not hesitate to perform cardiovascular surgery with extracorporeal circulation for patients with renal insufficiency or in hemodialized patients.

Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) is widely performed not only as an alternative to transpapillary biliary drainage, but also as primary drainage for malignant biliary obstruction. For anatomical reasons, this technique carries an unavoidable risk of mispuncturing intrahepatic vessels. We report a technique for troubleshooting EUS-guided portal vein coiling to prevent bleeding from the intrahepatic portal vein after mispuncture during interventional EUS. EUS-HGS was planned for a 59-year-old male patient with unresectable pancreatic cancer. The dilated bile duct (lumen diameter, 2.8 mm) was punctured with a 19-gauge needle, and a guidewire was inserted. After bougie dilation, the guidewire was found to be inside the intrahepatic portal vein. Embolizing coils were placed to prevent bleeding. Embolization coils were successfully inserted under stabilization of the catheter using a double-lumen cannula with a guidewire. Following these procedures, the patient was asymptomatic. Computed tomography performed the next day revealed no complications.