We have frequently obtained good results with difficult pain using an improved acupuncture anesthesia method, cutaneous meridian stimulation, in which the patients himself can administer stimulation. However we have had a great variety of experience using these methods. There have even been cases in which therapy had no effect whatsoever. It has long been known that the effects of stimulation produced analgesia, (SPA) one form of acupuncture anesthesia, vary remarkably from person to person.
In one hand it has been indicated that the pain-killing effects are related with the endogenous morphine-like substances however recently Takeshige and colleagues, believing that the individual differences in effect are based on the activity of the individual's amino peptidase, administered the peptidase interferrent, D-phenylalanine (DPA) and proved experimentally that so doing causing a change from ineffective to effective in SPA results.
We studied the effects produced by DPA on the cutaneous pain threshold using transcutaneous nerve stimulation, by administering DPA in cases in which the pain threshold did not rise due to transcutaneous electric nerve stimulation alone. The subjects of the study were 9 healthy volunteers between the ages of 24-30 with no neurological diseases and 8 stubborn pain patients. The stimulation points were 2, right LI-4 and right LI-10. Stimulation was administered using a spike-type conductor rubber external electrode.
Results
1. Looking at changes in the pain threshold due to transcutaneous electric nerve stimulation only, it was observed that in 11 of 17 cases there was almost no change or slight fluctuation around the pain threshold.
2. Upon administering 4g. DPA to the 6 cases in which the pain threshold did not change and administering transcutaneous electric nerve stimulation in the same manner as before, the threshold rose in 1 case.
3. The serum concentration of phenylalanine increased 5 times that of pre-medication levels.

The purpose of the present study was to investigate a useful exercise protocol and method of evaluation for determining the gas exchange threshold (VO₂GET) and correlation coefficient between VO₂GET and maximal oxygen uptake (VO₂max), which is an index of aerobic capacity. Five healthy male volunteers (age: 25.6 ± 2.0 yrs; height: 172.9±4.0 cm; weight: 69.5±6.6 kg) performed exercise tests 82 times. Each volunteer randomly conducted a RAMP exercise (1 W⋅3 sec^-1), STEP-1 exercise (20W⋅min^-1) and STEP-2 exercise (40W⋅2 min^-1), respectively, at least 4 to 8 rotations. The gas exchange parameters (VE, VO₂and VCO₂) for incremental exhaustive cycle ergometer exercise were measured using a“breath-by-breath”method. Three different methods of evaluation- (VE/VO₂and VE/VCO₂) exchange (M-1), V-slope method (M-2), and M-1 & M-2 (M-3) -were attempted to determine VO₂GET. The VO₂GET values, determined by three different methods (M-1, -2 and -3) of evaluation, were classified as‘easy’ (J-A) and‘difficult’ (J-B) in all tests. Reproducibility of VO₂max and VO₂GET were assessed using the coefficient of variation (CV) and correlation coefficients (r) between VO₂max and VO₂GET.
The results are summarized as follows:
1) The means of the reproducibility of VO₂max were determined among the 5 subjects by us ing RAMP, 4.8% (n=25), STEP-1, 3.1% (n=28) and STEP-2, 2.9% (n=29) exercise tests; STEP-2 exercise test values (CV) were lower than the others. There was no significant difference in the means of VO₂max among the 5 subjects according to the RAMP and two STEP exercise tests (Two-way ANOVA) .
2) The best reproducibility value of VO₂GET among the 5 subjects was determined using RAMP exercise tests with the V-slope method (M-2) and evaluations were classified as easy (J-A) . The value (CV) was 2.8%. There was no significant difference in the VO₂GET values (M-1 (J-A, -B), M-2 (J-A, -B) and M-3) (Two-way ANOVA) and their means among the 5 subjects concerning RAMP and two STEP exercise tests (Two-way ANOVA) .
3) The best correlation coefficient (r) value between VO₂max and VO₂GET was obtained using RAMP exercise tests with M-2 (J-A) (r=0.976, n=20) .
The present results indicate that the most useful exercise protocol and method of evaluation for determining VO₂GET is the RAMP exercise test with the V-slope method.

We report a case of surgical treatment for idiopathic nonspecific inflammatory aneurysms of the abdominal aorta (AAA) with high-dose steroid therapy. The patient was a 35-year-old man who underwent steroid therapy (30 mg/day prednisolone) for idiopathic nonspecific inflammatory AAA and right common iliac artery aneurysm (CIAA) for 5 months. However, the sizes of the aneurysms were slowly increasing, and they were sacculated types, so surgical replacement was performed. Before the operation we continued to give 30 mg/day prednisolone, because decreasing the medicine made the c-reactive protein (CRP) value rise. Perioperatively the therapy continued, and the postoperative course was uneventful. With appropriate steroid therapy, replacement of idiopathic nonspecific inflammatory aneurysms of the abdominal aorta can be performed. It is also important to follow up the patient from long-term, to monitor for pseudoaneurysms from anastomosis or new aneurysms.

We report a case of surgical treatment for pseudoaneurysm 4 years after Patch-and-Glue Repair of left ventricle free wall rupture (LVFWR) due to acute myocardial infarction (AMI) in 2004 in a 74-year-old woman, she had been followed in our hospital. And 2 years later, echocardiography and MRI showed a pseudoaneurysm at the repair spot which was growing very slowly. Since we found a thrombus in the pseudoaneurysm, a redo operation was performed in 2008. The pseudoaneurysm was successfully extirpated, under cardiopulmonary bypass. The infracted area had degenerated to scar tissue and we could suture tightly without worrying about a fissure in the wall. We can use Patch-and-Glue Repair to rescue the LVFWR patients due to AMI in the acute stage because it is possible to remove the pseudoaneurysm in the future, on pseudoaneurysm excision in a firmly infarcted area is possible in the chronic stage.

Spontaneous coronary artery dissection is a rare but often fatal cause of acute myocardial ischemia that occurs in young or middle-aged and otherwise healthy patients. We report a case of spontaneous left main coronary artery dissection in a young woman who was treated with emergency coronary artery bypass grafting. She improved after surgery but required a long recuperative period because of her cardiac failure and multiple organ failure, developed expiring on the 78th postoperative day. Spontaneous coronary artery dissection is unpredictable, and sudden death is the usual mode of clinical presentation. Prompt diagnosis and coronary artery revascularization are essential in order to achieve a favorable outcome in such cases.

A 57-year-old woman was admitted with intermittent bleeding and pus discharge from her right anterior chest. She had undergone radical mastectomy (Halsted operation) and irradiation for breast cancer 11 years previously. Skin ulcer with a bleeding fistula had appeared at the right clavicular region 6 months previously. An emergency operation was performed, since angiography revealed brachiocephalic pseudoaneurysm with fistulation to the skin. The brachiocephalic artery was exposed through a right cervical and middle sternal incision. The brachiocephalic artery was interposed with two segments of the great saphenous vein joined to make a proper graft in size. The infected area was filled by the greater omentum. A pedicle flap was used to close the large skin defect after removing the fistula. The postoperative course was uneventful and infection improved soon after the operation. The patient was discharged about one month after the operation. We reported a rare case of infected brachiocephalic pseudoaneurysm with fistulation to the skin after radical mastectomy and irradiation for breast cancer.

There is a theory that excessive treament for terminally ill patients is one of the factors in soaring medical costs. To evaluate this theory, we examined the changes in medical expenditures for our inpatients: 41 patients with lung cancer and 69 patients with liver cancer hospitalized for treatment of the department of internal medicine, and 90 patients with stomach cancer and 100 patients with colon cancer hospitalized for surgery from July to December 1997. They were divided to two groups: the patients of group A received active treatment, and the patients of group B received conservative treatment. We selected 10 people randomly from each group, and compared the changes in medical costs.
The cost was significantly low in group B compared with group A. We examined the change in the cost every 5 days. Until 6 days before leaving our hospital, the cost is high sugnificantly in group A compared with group B. The difference between group A and group B in the cost of treatment for lung cancer, and stomach cancer patients disappeared in 5 days before leaving hospital. The cost of treatment for lung and liver cancer patients of group A was a little higher than the average hospitalization fee of internal medicine. Also, the cost of group A stomach cancer patients was a little higher than the averge hospitalization fee of surgery, though there was no difference between the cost of treatment for group A colon cancer patients and the average hospitalization feeof surgery. The fee of group B of either disease was half or less of an average fee for medical treatment.
From this study, no evidence was found that the excessive life prolongation treatment for terminally ill patients was done. So, using authentic data, we should discuss the justifiability of the theory that the excessive treatment for terminally ill patients is one of the factors contributing to a boost in medical costs.

Methadone oral tablets initially became available on the Japanese market in MAR－2013. Methadone, which has different pharmacological properties from other opioids including morphine, can cause serious adverse drug reactions such as respiratory depression and QT prolongation. One of the causes of these reactions is its extremely complex pharmacokinetics. Methadone is mostly metabolized in the liver, with a variety of metabolic enzymes, including cytochrome P450 (CYP) 3A4, CYP2B6, and CYP2D6, being involved. The characteristics of methadone include self-induction of metabolism, delayed excretion due to alkaline urine, and an extremely long half-life requiring a long time to achieve a steady state. Without a full understanding of its complex pharmacokinetics, the blood concentration of methadone is not maintained at a constant level, and serious adverse events could happen due to an unexpected increase in its blood concentration. Herein, for safe clinical use by physicians and pharmacists, we summarize the pharmacokinetics of methadone.