Aspergillus infective endocarditis (ASIE) is a very rare disease that carries an extremely poor prognosis. We report a case of ASIE successfully treated by a tricuspid valve replacement and administration of an antifungal drugs. The patient was a 69-year-old man who was taking steroids for an autoimmune disease and was admitted to our hospital because of a persistent fever of 39°C. As chest CT showed infiltrative shadows in both lung fields and the aspergillus antigen was detected in the blood, we diagnosed invasive pulmonary aspergillosis (IPA), and initiated administration of micafungin sodium (MCFG). Later, the patient's heart failure worsened, and echocardiography revealed vegetation measuring 8 mm in diameter in the anterior cusp of the tricuspid valve. As this indicated a definitive diagnosis of ASIE, administration of voriconazole (VRCZ) was initiated. However, the vegetation grew into a movable wart measuring 20 mm in diameter within a week, based on which a diagnosis of drug-resistant ASIE was made, and surgery was considered indicated. Very large vegetations were found in the anterior cusp of the tricuspid valve, anterior papillary muscle, the tendinous chord of the medial papillary muscle and the trabeculae carneae of the right ventricle. Based on the findings, it was judged that tricuspid annuloplasty was impossible and tricuspid valve replacement was performed using a biological valve. As to the antifungal medication, long-term administration of VRCZ and MCFG was continued. The patient followed a favorable course and was discharged from the hospital on the 220th day. The patient aking lifelong VRCZ and has shown no evidence of recurrence of the ASIE. To improve the prognosis of ASIE, rapid and radical surgical resection of the vegetations and appropriate administration of antifungal drugs are important.

We evaluated the surgical strategy for thoracic aortic aneurysm associated with abdominal aortic aneurysm. From January 1982 to March 1999, 24 consecutive patients underwent surgical treatment for thoracic aortic aneurysm with abdominal aortic aneurysm. Staged operation was performed if one was only slightly dilated, but extensive operation was needed if the size of both aneurysms was greater than 6cm. In cases of thoracic aortic aneurysm with abdominal aortic aneurysm up to 4cm in size, surgical treatment was performed only for the thoracic aortic aneurysm. Circulatory support during operation was established from the ascending aorta, and circulatory arrest with deep hypothermia and retrograde cerebral perfusion were used for brain protection during surgery for thoracic aortic arch aneurysm. Hospital mortality was 12.5% (3/24 cases). The causes of death were cerebral infarction and respiratory failure. Antegrade systemic perfusion and aortic no-touch technique were an effective method of surgery for thoracic aortic aneurysm with abdominal aortic aneurysm to avoid perioperative embolism and major complications. We successfully performed staged operation, but regular radiographic follow-up was needed.

Periannular abscess and mycotic aneurysm due to infective endocarditis are very difficult conditions to treat surgically. Beginning in 1983, we introduced a translocation technique on 9 such cases. In particular, 7 patients who underwent a new sutureless translocation technique all showed an uneventful course and were discharged. There was no hospital death, but four patients died in the late period (2 heart failure, 1 ventricular tachycardia and 1 thrombotic valve). The sutureless translocation method consists of insertion of a composite valve into the ascending aorta (a ring was detached from an intraluminal ringed graft and a prosthetic valve was sutured to it at that point) and coronary artery bypass grafting to the right and left coronary arteries. Our new technique was simple, required only a short aortic clamping time (mean 173.9min) and there was no significant bleeding. This new translocation technique provides a solution for the treatment of periannular abscess and mycotic aneurysm due to infective endocarditis.

Diagnosis of cardiac rupture caused by blunt trauma is sometimes difficult when multi-organ injuries are associated with profound shock. Only prompt diagnosis and urgent treatment can save the patients. We have encountered 16 cases of blunt cardiac rupture, including 4 that survived in the past 10 years. All cases of cardiopulmonary arrest on arrival were unable to be resuscitated. Also, all cases of profound hemorrhagic shock caused by multi-organ injury succumbed. Among the cases in which the region of cardiac rupture was identified, only cases of injury to the right heart chambers were saved. No case of rupture in the left heart chambers survived. It is definitely important to suspect cardiac injury and make a prompt diagnosis to save patients with blunt chest trauma. Ultrasonic cardiography is highly effective for urgent diagnosis of cardiac rupture because it can be performed readily, noninvasively and, therefore, repeatedly.

Although sequential bypass with in situ arterial conduits (the left and right internal thoracic arteries; LITA and RITA, the right gastroepiploic artery; GEA) in coronary artery bypass grafting (CABG) is technically demanding, it is one of the most important procedures using a limited number of in situ arterial conduits to revascularize a wide area. In this report, we retrospectively investigated the clinical outcome of CABG with 4 or more distal anastomoses using only in situ arterial conduits. From December 1990 to May 1999, 62 patients underwent CABG with in situ arterial conduits, with at least one sequential bypass. There were 59 men and 3 women patients with mean age of 59.6 years (41 to 82 years). Mean postoperative follow-up period was 32 months (1 to 101 months). The total number of distal anastomoses was 4 (1 sequential bypass) in 54 patients, 4 (2 sequential bypasses) in 6 patients, 5 (1 sequential bypass) in 1 patient and 6 (3 sequential bypasses) in 1 patient. There were 5 emergency operations (8%), 37 patients (60%) had a history of myocardial infarction, 30 patients (48%) had diabetes mellitus and 6 patients (10%) had chronic renal failure and were on hemodialysis. Left ventricular ejection fraction was 40% or less in 15 patients (24%). There were no early deaths. Angiographic patency was satisfactory for each graft (sequential: individual, LITA 96.7%: 100%, RITA 100%: 100%, GEA 89.5%: 97.4%). Patency of a distal anastomoses of GEA was rather poorer than that of proximal (p=0.03). Three patients died during the follow-up period (all of them due to malignancy). The 5-year actuarial survival and cardiac event-free rate was 94.6% and 87.2%, respectively. In conclusion, although an indication of GEA sequential grafting needs further study, in situ arterial grafting with at least one sequential arterial conduit was associated with excellent results and achieved more complete revascularization with exclusive use of in situ arterial conduits in patients with diffuse coronary artery disease.

A survey was carried out in a rural area in Thailand as a part of the study on the physical development and nutritional status of children of developing countries in Asia. Four hundred and sixty-three school children of both sexes, from 6 to 14 years of age, had anthropometric measurements and examinations of clinical signs related to nutritional deficiencies. Blood, urine and feces were also exaimined.
1) Thai children were remarkably smaller than Japanese and growth retardation was observed at 21.4% and 37.3% of those in age groups 6-9 and 10-14 years, respectively. And judging from the weight-for-height, about one-fourth of them were considered malnourished in varying degrees
2) Upper arm muscle circumference, calculated with upper arm circumference and subcutaneous skinfold of the same place, revealed that the development of muscle was obviously retarded.
3) Signs of hypovitaminoses such as xerosis of the skin, decreased patellar reflex, cheilosis, angular lesion were frequently observed.
4) Mean values of hemoglobin and serum iron concentrations were low in general and about 20% of the children were judged anemic according to the WHO criteria for nutritional anemias. Cholesterol values were also lower than those of Japanese and American children
5) The overall positive rate of intestinal parasites' eggs was 43.2% and hookworm eggs were most frequently observed, follwed by Giardia lambria
For the improvement of growth and nutritional status of Thai children, the preventive measures against parasitic and infectious diseases through improvement of environmental hygiene are essential as well as food supply.

A 30-year-old woman who had no specific symptom was diagnosed with Turner syndrome at the age of 6 years. Subsequently, she was followed up at a hospital. However, she stopped going to the hospital when she was 18 years old. At 30 years of age, she underwent examinations involving echocardiography and enhanced chest CT at a hospital, which revealed severe aortic valve regurgitation and extreme dilatation of the aortic root. We performed the Bentall procedure through a median sternotomy following which she had an uncomplicated postoperative course. Aortic root enlargement increases the risk of aortic dissection in patients with Turner syndrome. However, no aortic events occurred before the surgery in this case. We considered the reason was related to the mosaic karyotype of this case.

After bleeding is controlled with hemostats during surgery, the residual material should be resorbed without adverse effects such as inflammation, infection or scar formation. To evaluate the biocompatibility of hemostats, three kinds of commercially available collagen hemostats, cotton type (Integran^®), microfibrillar type (Avitene^®), and sheet type (TachoComb^®), were examined. A rabbit ear chamber (REC), a system for viewing materials in vivo, was applied to the auricle of male Japanese white rabbits. The REC was designed to leave a 50-μm-thick and 6.4mm-diameter chamber, and 0.5mg of each specimen (Integran; n=8, Avitene; n=6, TachoComb; n=6) was placed in the chamber. Macroscopic and microscopic observations were performed every week up to 5 weeks without anesthetizing or stressing the animal. In the Integran group, capillaries infiltrated between the collagen fibers, and the vasculature in the REC field was complete in 6 out of 8 animals at 5 weeks. Cotton type collagen fibers of Integran became thinner every week without effusion. In the TachoComb group, capillaries were directed toward the effusion at 2 weeks, while in the Avitene group, a similar phenomenon was not observed. The vasculature was incomplete, with either effusion or infection at 5 weeks in the Avitene and TachoComb groups. Material was recognized up to 4 weeks in the TachoComb group, whereas the space occupied by material remained vacant without vasculature in the Avitene group. Our results suggest that cotton type configuration is excellent as a collagen hemostat, with smooth capillary infiltration, rapid resorption of material and promotion of the healing process.

When local hemostatic agents are used in surgery, rapid dissolution followed by prompt absorption without adverse effect after successful hemostasis are essential qualities. Residual hemostatic materials greatly influence host cells during the wound healing process. Biocompatibility of material is also essential. Furthermore, hemostatic agents also should be free of cytotoxicity that may block mitosis and migration of host cells, so that wound healing can proceed smoothly. For the evaluation of biocompatibility and cytotoxicity, 4 commercially available hemostatic agents; oxidized regenerated cellulose (Surgicel^®), gelatin sponge (Spongel^®), microfibrillar collagen (Avitene^®) and cotton type collagen (Integran^®) were tested in vitro and in vivo. The hydrogen ion concentration (pH) of culture medium containing hemostatic agents was measured. Fibroblasts were cultured with the hemostatic agents in petri dishes for 5 days. A rabbit ear chamber (REC) model was used to evaluate tissue compatibility and the healing process. Each hemostatic agent was placed in the REC and evaluated macroscopically once a week up to 5 weeks. At 72h, the pH of the culture medium containing Surgicel was low at 7.2, while they stayed between 7.7-7.8 with the other agents. In the fibroblast culture containing Surgicel, cell detachment occurred and the cell numbers decreased, while no particular changes occurred with other hemostatic agents. In the REC model, after 5 weeks Surgicel was dissolved and remained in the effusion, and the healing process was disturbed by inflammation. Spongel was dissolved and absorbed, with normal vasculature. Avitene was dissolved and remained in the effusion, but did not induce strong inflammation. With Integran, the healing process was prompt but the material was still recognizable at 5 weeks. The 4 hemostatic materials tested showed differences in biocompatibility and cytotoxicity. The ability of hemostasis is important; however, after hemostasis is achieved, unused hemostatic material should be eliminated, leaving as little hemostatic agent as possible to avoid postoperative complications.

We encountered two patients complaining of hiccups following the resection of subaural tumor or subarachnoid hemorrhage. In one patient, we measured the autunomic nerves of Ryodoraku, and placed grains of silver on Ryodoraku points which showed abnormal values. We also used the in situ needle technique on acupoints which were considered to be closely related to the phrenic nerve. Furthermore, we inserted round-head subcutaneous needles in auricular acupoints such as “Kaku”, “Shinmon”, “Hishitsuka”, and “Jichu”. After repeating the above treatment twice, the hiccups disappeared completely. In the other patient who had difficulty even taking off clothes, a subcutaneous needle was inserted into “Kaku”, which was repeated twice a week. After five months, the hiccups disappeared completely.
Based on our experience with the two patients above, we had the impression that auricular acupuncture is particularly effective. “Kaku” was the main acupoint used, which is believed to influence the diaphragm. We believe that this technique can therefore be used clinically in the future.