Objective : To examine the association between the combination therapy of calcium antagonists with angiotensin converting enzyme (ACE) inhibitors and underlying diseases for hypertensive patients.
Design : Cross-sectional survey of the drug utilization.
Methods : This survey included 603 hypertensive patients who had visited Toyama Medical and Pharmaceutical University Hospital, Toyama, Japan more than twice from January to June in 1996 and received the prescriptions of calcium antagonists and/or ACE inhibitors. Main outcome measure was the combined medication of calcium antagonists with ACE inhibitors. Underlying diseases under consideration were diabetes mellitus (DM), hyperlipidemia (LIPID), ischemic heart disease (IHD), chronic heart failure (CHF), and ischemic stroke (STROKE).
Results : Out of 603 hypertensive patients, 57.5% received only calcium antagonists, 23.7% received only ACE inhibitors, and 18.7% received both of them. Patients with either IHD or CHF tended to receive the combination therapy as compared to DM or LIPID. Although men tended to receive the combination therapy, a gender effect might be a confounder for the association. Logistic regression showed a 33% increase (P=0.265) in frequency of the combination therapy in patients with IHD after adjusting for age and gender.
Conclusion : Some underlying diseases were associated with more frequent prescriptions of the combination therapy for hypertensive patients, especially with ischemic heart diseases. This result should be regarded as an exploratory stage although the pattern of antihypertensive drug use could be reasonably explained from the pharmacological sense.

A shortage of physicians in rural areas has become a serious problem of the new residency training program in Japan. To address this problem, we propose a model for attracting physicians to rural areas by improving residency training programs and by evaluating a curriculum introduced at Kainan Hospital, a community hospital. In this first paper, we describe the short-term evaluation of the curriculum.1) We introduced clinical teams in which residents were able to actively participate in clinical practice as team members by being supervised by senior physicians. We also introduced teaching rounds and case conferences for residents.2) Focus-group interviews of residents showed that "giving educational opportunities to residents" and "an explicit policy of the hospital to improve the residency training program" are examples of ways to improve residency programs.3) The number of residents working at Kainan Hospital increased. The residency training program was somewhat improved.4) An effective and easily generalized way to provide residents with more learning opportunities is to involve clinicians in teaching residents in hospitals.

A 79-year-old man was admitted for thoracoabdominal aortic aneurysm repair. He had already twice undergone coronary artery bypass grafting, 19 and 2 years previously. The value of the ejection fraction of the left ventricle was 36%, measured by ventriculography; and transthoracic echocardiography revealed moderate aortic valve regurgitation. In the presence of aortic valve regurgitation or coronary artery disease, myocardial perfusion under hypothermic fibrillatory arrest may be significantly impaired. Therefore, to maintain a beating heart we used separate perfusions of the upper and lower body that enabled individual temperature control of each organ. The femoral and axillary arteries were cannulated, and a long cannula was inserted into the right common femoral vein and positioned in the right atrium. Cardiopulmonary bypass was established, and the upper body was mildly cooled until the pharyngeal temperature was 33°C, while the lower body was cooled until the bladder temperature reached 20°C. Mild hypothermia of the upper body maintained the beating heart, and deep hypothermia in the lower body provided adequate protection to the spinal cord. Furthermore, in a case of aortic valve regurgitation and low left ventricular function, left ventricular venting is essential for the heart. However, it was difficult to insert the venting tube through the apex of the left ventricle or through the left inferior pulmonary vein; therefore, we selected the left main pulmonary artery for left ventricular venting, and maintained a non-working beating heart. After cardiopulmonary bypass was discontinued, cardiac function was good although a bleeding tendency became apparent. Postoperatively, the maximum dose of dopamine we needed was only 3γ. There were no remarkable complications and the patient was discharged on postoperative day 30. This experience suggests that pulmonary artery venting and separate perfusion of the upper and lower body to individually control organ temperatures is a useful procedure for thoracoabdominal aortic aneurysm repair in patients with low left ventricular function.