Between April 1990 and December 1995, a total of 32 patients underwent emergency coronary artery bypass grafting for acute refractory coronary ischemia. The IABP group (Group A) included 27 patients who could be stabilized hemodynamically only by preoperative intraaortic balloon pump support, and the PCPS group (Group B) included 5 patients who required percutaneous cardiopulmonary support as well as IABP because of profound cardiogenic shock. In addition to surgical patients, the PTCA group (Group C) included 6 patients who were managed with catheter intervention under PCPS and IABP support for acute myocardial infarction associated with severe cardiogenic shock. Patients undergoing CABG (groups/A & B) had more prevalent three-vessel disease and left main coronary artery disease than patients receiving PTCA alone. The hospital mortality was significantly lower (7.4%, 2/27) in patients of Group A. While only one of five patients in group B could be weaned from PCPS and is alive, five of six patients in group C could be weaned from PCPS, but eventually only one of them survived. Emergency CABG is beneficial for patients who have multi-vessel disease or left main coronary artery lesion with relatively small myocardial infarction. In contrast, for patients with massive irreversible myocardial damage due to acute infarction, culprit lesions should be managed with catheter interventional therapy including balloon dilatation or stent placement and elective surgery should be planned for selected patients.

The efficacy of acupuncture-moxibustion for hypertension is often experienced by many clinicians. Nevertheless the mechanism whereby the therapy improves the symptoms has been scarcely elucidated. Our present study was designed to examine some effects of acupuncture upon the organism, especially upon the renal function which is implicated in hypertension.
Experiment I
Acupuncture therapy was undertaken four times on a patient with essential hypertension who was given no hypotensive drugs. In each therapy, needles (No. 2, Seirin) were perpendicularly inserted to the depth of 1.5cm at V₂₀ Fengchi, VU₂₁ Weishu, and G₃₆ Zusanli and left there for 15 minutes. The blood samples and urine were collected three times: before the insertion, 15min. and 60min. after withdrawing the needles. At the same time, blood pressure, pulse, and the amount of urine were measured. The amount of Na, K, Cl, kallikrein, catecholamines, etc. was measured in urine. The renin activity and the concentration of aldosterone, catecholamines, and BUN were determined in the blood. Result: a marked increase was seen in the excretion of urine, Na, and Cl. An upward tendency of kallikrein excretion which is correlated with urine volume, and a downward tendency of renin in the blood were found. Blood pressure and pulse showed a slight tendency to decline. However, neither catecholamines in the blood, nor K in urine changed significantly.
Experiment II
Subjects were two healthy adult men. Urine was collected once an hour for twenty-five times by means of a balloon inserted in the bladder. Immediately after the twenty-first collection, acupuncture stimulation was given to VU₂₁ Weishu in the same manner as Exp. I. With the same measurements and determinations undertaken, a marked increase of urine, Na, and Cl excretion was observed 15min. after withdrawing the needle.
Experiment III
Subjects were three healthy adult men. Urine was collected for two days. The amount of urine and the electrolyte content were calculated on a per hour basis. Without having breakfast after rising, the subjects were given a transfusion of glucose-electrolyte solution, equivalent to the calculated urinary output, every hour for four hours. The VU₂₁ Weishu was stimulated in the same manner two hours after the onset of the first transfusion. Result: a marked increase was seen in the excretion of urine, Na, and Cl.
Conclusion
It can be seen from the above that acupuncture stimulation to the VU₂₁ Weishu facilitates the selective excretion of Na and Cl in the urinary tubule.

Perivalvular leakage (PVL) is one of the serious complications of mitral valve replacement. Between 1991 and 2006, 9 patients with mitral PVL underwent reoperation. All of them had severe hemolytic anemia before surgery. The serum lactate dehydrogenase (LDH) level decreased from 2,366±780 IU/l to 599±426 IU/l after surgery. The site of PVL was accurately defined in 7 patients by echocardiography. PVL occurred around the posterior annulus in 3 patients, anterior annulus in 2, anterolateral commissure in 1, and posteromedial commissure in 1. The most frequent cause of PVL was annular calcification in 5 patients. Infection was only noted in 1 patient. In 4 patients, the prosthesis was replaced, while the leak was repaired in 5 patients. There was one operative death, due to multiple organ failure, and 4 late deaths. The cause of late death was cerebral infarction in 1 patient, subarachnoid hemorrhage in 1, sudden death in 1, and congestive heart failure (due to persistent PVL) in 1. Reoperation for PVL due to extensive annular calcification is associated with a high mortality rate and high recurrence rate, making this procedure both challenging and frustrating for surgeons.

We evaluated the therapeutic results of cancers in the bile duct, the pancreas head region and the liver and cirrhosis.
The former two types were examined in a total of 49 cases: 10 cholecystocarcinomas, 18 cholangiocarcinomas, 6 papillocarcinomas, and 15 pancreas head cancers. Radical surgery was performed in only 9 cases: 1 cholecystocarcinoma, 1 cholangiocarcinoma, 5 papillocarcinomas and 2 pancreas head cancers. The surgical success rate was satisfactory 83%(5/6) for papillocarcinoma, yet showed 18.4% overall.
Liver cancer and cirrhosis were examined in 102 cases: 78 cirrhoses and 24 livercancers. Of the former, 15% were viral cirrhosis, 44% alcoholic, 1% specific and 40% unknown. Ofthe latter, 29% were viral liver cancer, 29% alcoholic and 42% unknown.
Treatment of these cancers, with the exception of one type, was unfavorable. To increase the surgical success rate, cancers will have to be discovered earlier using such recent, highly-advanced technological means as endoscopy, ultrasonography, angiography and computerized tomography. At the same time, radical surgery should be actively applied in a broader range of cases.
In cirrhosis, bleeding in the upper digestive tract and complicating liver cancer are increasing in frequency due to prolonged life expectancy. How to manage this increase remains subject for further study in the future.

We report a 65-year-old man with a mobile thrombus in the distal aortic arch with no previous history of thromboembolic events. There was no evidence of either aneurysmal changes or aortic dissection. Transesophageal echocardiography revealed the presence of a mobile tumor in the distal arch. The patient underwent elective resection. The mobile tumor was attached to the aortic wall, approximately 3cm distal to the left subclavian artery. Histological examination revealed an old thrombus containing calcification. He was discharged on the 22nd postoperative day with no thromboembolic complications. This is the first report of a case of mobile thrombus in the distal aortic arch in Japan.

An 87-year-old woman with unknown fever origin was admitted to our internal department. We could not determine the fever origin from clinical findings, serious blood data, urine data, bacteriological data, and images obtained by ultrasonography, computed tomography and magnetic resonance. Body inflammatory findings did not respond to several antibiotics we used. Gallium scintiphotography revealed abnormal radioisotope uptake in the bilateral inguinal region. And ultrasonography and enhanced computed tomography showed tumors in front of the bilateral femur neck. Moreover, bone scintiphotography (^99mTc) revealed abnormal radioisotope uptake in the bilateral hip joints. We performed resection of the right inguinal tumor. The tumor was solid mass 30×20×20mm in size. It was covered with an articular capsule in front of the right femur neck. We identified the mass as bilateral tuberculous granulation with Langhans-type giant cells pathologically. It was only with difficulty that we firmly diagnosed the case as tuberculous arthritis of bilateral hip joints because the fever origin was unknown. It is important to diagnose tuberculous arthritis by use of various imaging techniques. We should take tuberculous infection into consideration when we encounter a case of arthritis of unknown fever origin or a case of antibiotics resistant arthritis.

Upper gastrointestinal endoscopy is an invasive examination. Cardiovascular and respiratory adverse effects are commonly observed in patients undergoing endoscopy. We investigated prospectively the cardiovascular and respiratory changes every oneminute before, during and after routine endoscopy. Sixteen healthy adult patients were enrolled in this study. Systolic blood pressure, diastolic blood pressure, pulse rate and percutaneous arterial oxygen saturation (SpO₂) were recorded every one-minute throughout the procedure. Systolic and diastolic blood pressure increased significantly one minute after the insertion of the endoscope. Increases in pulse rate were noted after the insertion of the endoscope. Rate pressure product increased significantly one minute after the insertion of the endoscope. No significant change in SpO₂ was observed during endoscopy. Our results indicated that upper gastrointestinal endoscopy might induce cardiovascular stress and abnormality. Therefore, we should carefully insert and manipulate upper gastrointestinal endoscope.

The purpose of the present study was to obtain the insights about the roles of specialized home care clinics and the “Doctor net” in community palliative care by investigating changes in the home death rates of cancer patients in a city where both specialized home care clinics and the Doctor net are available. A region palliative care intervention study was conducted, and data on the rate of cancer patients who died at home between 2007 and 2010 in the region were collected. The rate of cancer patients who died at home increased from 7.0% in 2007 to 13.0% in 2010. In 2007, 49% of the total number of people who died at home were patients of specialized home care clinics, and the rate increased to 13.0% in 2010. However, the number of cancer patients of other clinics who died at home did not decrease, from 63 in 2007 to 98 in 2009 and 77 in 2010. The functions of specialized home care clinics and the Doctor net adopted in general clinics were not exclusive to each other, and specialized home care clinics may improve palliative care implemented for cancer patients at home by participating in the Doctor net to provide general clinics with support.

Isolated unilateral absence of the right pulmonary artery without any intracardiac anomaly is a rare congenital cardiovascular disorder. We performed a successful surgical reconstruction with autologous tissue of this anomaly. The patient was a 1-month-old boy who had been transferred to our center at 3 days of age because of tachypnea and heart murmur. Multi-detector CT and radial angiography imaging revealed isolated unilateral absence of the right pulmonary artery and left patent ductus arteriosus. Conservative treatment did not help his progressive heart failure and pulmonary hypertension due to an acute increase of pulmonary blood flow. Therefore surgical correction was determined to avoid the worsening of those symptoms. Under cardiopulmonary bypass, the right pulmonary artery branching off from the brachiocephalic artery was removed and anastomosed to the main pulmonary artery with an autologous pericardium roll. Symptoms improved postoperatively and he was discharged in good condition on the 21st of postoperative day. Cardiac catheterization, 3 months later, showed excellent results.

Between 1974 and 1991, we treated 10 aortic arch branch aneurysms in eight men and two women, who ranged in age from 17 to 81 years old (mean age, 55 years). Five patients had subclavian artery aneurysms, four had carotid artery aneurysms, and one had an inominate artery aneurysm. The chief complaint was a mass on the neck and supraclavicular fossa in five patients, rupture and an abnormal shadow on chest X-rays in two patients each, and acute artery occlusion in the upper limb in one patient. The operative method was usually excision of the aneurysm and reconstruction. The causes were arteriosclerosis in five patients, the thoracic outlet syndrome in two patients, and inflammatory, traumatic and iatrogenic in one patient each. Intraoperative hemorrhage occurred in one patient and graft occlusion in another one. The other patients have had a good course. This disease is rare, but because of complicated rupture and acute artery occlusion, it is desirable to perform surgery as soon as possible after the first diagnosis.