Objective To summarize and analyze the clinical experience in the use of ultrasonic scalpel in skeletonized internal using bilateral sketetonized internal mammary artery harvested by ultrasonic scalpel in Juntendo University Hospital.Results The number of distal anastomoses was(4.1±1.5).Major complieations included severe arrhythmia in 2 patients.cerebral infarction complicated with sepsis in 1,diffuse intraveseular coagulopathy complicated with multiple organ failure in 1 patient.and pneumonia in 2 patients.There were 2 patients dead in-hospital.The mean follow-up period Was(15.6±3.2)months.There Was no late death or cardiac-related events during the follow-up periods.Condusion It is simple and safe to skeletonize the internal mammary artery using the ultrasonic scalpel.The early effect of bilateral skeletonized internal mammary artery grafting was satisfactory.

Topic of the conference was evaluation of attitude and competence of candidates on the entrance examination, and concrete procedures of interview, essay test and so on and notes for assessing process were discussed.Further improvement in the method of interview and essay test and the standardization of their assessment and clarification of the validity of these tools by accumulation of their follow-up data were important.

A 71-year-old woman was admitted with severe back pain. She was diagnosed of type A dissecting aortic aneurysm and two-vessel coronary disease by CT scan and angiography. An acute-phase operation was started 32 hours after onset, performing replacement of ascending aorta and a two-vessel bypass. The affected aortic wall was so thin and fragile that the cut ends of these wall were treated with 25% solution of glutaraldehyde, a fastacting crosslinking agent, for 7min. As a result, a sufficient degree of reinforcement was obtained to complete the anastomotic procedure safely. She made a good recovery of cardiac function after the surgery, but was left with such complications as permanent complete atrioventricular block and a little aortic regurgitation. Following pacemaker insertion she was discharged and has returned to her normal activity. It appears that when treating the affected aortic wall with glutaraldehyde, a piece of gauze placed in the left ventricular cavity stopped up the aortic valve by half. As a result, glutaraldehyde was perhaps transferred from the gauze to the aortic valve and a part of the conduction system, causing injury to them. If meticulous care is exercised during the procedure to avoid unnecessary invasion of surrounding tissues, this technique will provide a useful means to accomplish safe anastomoses of cardiac vessels.

Objective: The hospital is changing its formulary reference from paper-based to intranet.  There was concern that both paper-based and intranet versions of the formulary would be necessary.  Revising the paper-based hospital formulary each time package inserts are revised is difficult.  For your review we report on the creation of the iPhone® electronic formulary which enables rapid off-line formulary retrieval and easy updates while at the same time providing low cost service in a light device.
Methods: The CSV (Comma Separated Value) of the hospital formulary dictionary was made using a standard personal computer.  The CSV data file was converted using JAMES2DIC into a HTML file format.  Next, the converted HTML file is transformed into the EPWING (Electronic Publishing WING) format using EBStudio.  Finally, we forward the EPWING dictionary file from the personal computer to the iPhone®.  The retrieval becomes possible by using EBPocket for iOS of EPWING/electronic book viewer software for the iPhone®.  The number of items was assumed to be 29 items thought for a lot of inquiries to exist.
Results: We compared the paper-based formulary with the iPhone® electronic formulary.  As a result, the iPhone4® electronic formulary shortened the retrieval time, was smaller, lighter, and excellent at a lower price.
Conclusion: The iPhone4® electronic formulary enables the user to perform complex full-text searches and retrieve information at a much higher speed than is possible with paper based formularies.  It has the additional advantage of seamless integration and deployment of formulary additions or reference material revisions.  We believe we have successfully created a practical electronic formulary.

The patient was a 74-year-old man with a history of previous aorto-coronary bypass grafting 14 years previously. Echocardiography showed severe aortic valve stenosis. Computed tomography showed severe circumferential aortic calcification of the whole aorta, including the aortic root. Coronary cineangiography showed patency of the endoric graft. Avoiding graft injury and aortic cross clamping, we performed apicoaortic conduit. His postoperative course was uneventful, he was discharged very much improved on the 11th postoperative day. This procedure is useful in high risk patients with aortic valve stenosis.

A 60-year-old man, who underwent repair of ventricular septal defect (VSD) 40 years previously, presented with dyspnea on effort and leg edema. Further examination showed residual VSD, mitral and tricuspid valve insufficiency, atrial flutter and pulmonary hypertension. We performed repair of the residual VSD, mitral valve replacement, tricuspid valve annuloplasty, and the Maze procedure. After surgery, systolic pulmonary arterial pressure decreased from 70 to 39 mmHg. On the 4th postoperative day, his hemodynamic state was stable and he weaned from ventilator. He showed hypoxia with sticky excretions, and reintubation was done 10 h after extubation. After intubation, pulmonary hypertension continued, nitroglycerine administration was not effective but inhaleted nitric oxide (NO) improved pulmonary hypertension. On the 15th postoperative day, sildenafil administration from nasogastric tube was started the day before extubation. On postoperative echocardiogram on the 35th postoperative day, the systolic pulmonary arterial pressure was 30-40 mmHg and left ventricular function was severely impaired because of the paradoxical movement of the ventricular septum after repair VSD. Sildenafil was safely used for the patient with heart failure and secondary pulmonary hypertension associated with congenital heart disease.

We report a patient with gingival metastasis of lung cancer in whom the use of sedatives was successfully avoided by employing holistic care approaches. A 64-year-old man had been receiving chemotherapy with the diagnosis of advanced lung cancer. Eighteen months later, a rapidly growing gingival metastasis was observed. Arterial embolization was performed, but it failed to control the bleeding. No active treatment was performed, and he was subsequently transferred to our hospital. He desired death, with markedly pessimistic views, and wished to undergo deep and continuous palliative sedation (DCPS) due to severe total pain (particularly psychological and spiritual) from the beginning. However, he died peacefully before receiving DCPS. We present a literature review of gingival metastasis from lung cancer, as well as our assessment and palliative care for the total pain of this patient.

The left atrium and left atrial appendage have unique genetic anatomical and physiological features. Recently, advances in diagnostic imaging technology have provided much new knowledge. Clinically, the risk of developing atrial fibrillation increases with age. In order to reduce the public health burden such as cerebral infarction caused by atrial fibrillation, we need to find some predictive risk factors and preventive strategies for cerebral infarction and more effective treatments. The new concept of atrial myopathy has emerged, and animal models and human studies have revealed close interactions between atrial myopathy, atrial fibrillation, and stroke through various mechanisms. Structural and electrical remodeling such as fibrosis and deterioration of the balance of autonomic nerves and complicated interactions between these mechanisms lead to deterioration of atrial fibrillation and a continuous vicious cycle, and finally thrombosis in the left atrial appendage. Although anticoagulant therapy for patients with atrial fibrillation is strongly recommended, it is difficult for many patients to continue optimal treatment. In the nearly future, it will be important to understand the anatomy and physiology of the left atrial appendage and to understand the shape changes, size and the changes of autonomic function, and thrombus formation conditions associated with LAA remodeling during atrial fibrillation, and then we should provide early therapeutic intervention.

1)Professionalism should be explicitly introduced as a fundamental content into curricula/programs of undergraduate medical education, postgraduate clinical training, and of continuing medical education provided by professional societies and the Japan Medical Association.
2)We need to enhance our research activities on goals and objectives which should be accomplished through professionalism education, effective learning strategies, appropriate assessment methods, as well as the impact of informal and hidden curricula.
3)We propose that the medical profession should collaboratively develop various activities to win the trust of the general society in tandem with the introduction of professionalism education.

It is not uncommon for edema in the end stage of advanced cancer to be caused by nephrotic syndrome (NS) as well as by cachexia, hypo-proteinemia due to malnutrition, or lymphedema. Such edema not only causes patients' quality of life (QOL) to be deteriorate, but may also result in earlier death in the absence of accurate diagnosis and treatment. We report a case of nephrotic syndrome with advanced uterine cancer, in which the patient's QOL was greatly improved by the accurate and timely diagnosis and treatment of NS. A 65-year old woman suffering from recurrent uterine cancer (lung and brain metastases) was admitted as an emergency due to deterioration of her general condition. Edema of both legs was severe, and laboratory findings (TP 5.0 g/dl, ALB 1.3 g/dl, T-Chol 369 mg/dl, proteinuria 3+) at the time of admission met the diagnosis criteria for NS rather than cachexia. We first administered albumin to stabilize circulation, and started treatment with prednisolone and cyclosporine, which greatly improved her general condition and edema of her legs. Subsequently, NS repeatedly improved and worsened and the tumors gradually progressed. The patient died of multiple organ failure induced by disseminated intravascular coagulation (DIC) at 81 days after admission. NS caused by malignancy is not uncommon. In general, however, such cases of NS are associated with solid tumors, such as gastrointestinal and lung cancer. NS caused by uterine cancer is very rare. We suggest that NS should be borne in mind in addition to cachexia, hypo-proteinemia or lymphedema as a possible cause of edema in the end stage of advanced cancer. Palliat Care Res 2011; 6(1): 316-323