It is well known that individual differences exist in exercise capacity or trainability. Several studies have shown that these individual differences are brought about by environmental effects such as life-style, diet and genetics. The potential of several specific genes to cause individual differences in endurance capacity or trainability has been investigated. The angiotensin-converting enzyme (ACE) gene, which has insertion (I) /deletion (D) polymorphism, is one of the most studied genes. Montgomery et al. reported that elite high-altitude mountaineers had higher I allele frequency of the ACE gene than did sedentary males. Moreover, they reported that subjects with II homozygotes showed higher trainability during a 10-week endurance training program than did individuals with ID heterozygotes or DD homozygotes. However, the results reported by Rankinen et al. did not support their results in terms of the relation between ACE genotype and cardiorespiratory endurance. Although numerous studies have reported a relationship between these two items, it remains controversial. Furthermore, mitochondrial DNA (mtDNA), the creative kinase and the Na⁺-K⁺-ATPase ∂2 genes have been studied as genes that may dictate individual differences in endurance capacity or trainability. We are going to report about the relation between these genes and exercise capacity and trainability.

A 53-year-old woman was admitted with cardiac failure due to aortic regurgitation (AR) and pseudocoarctation of the aorta associated with Takayasu's aortitis. It was revealed that her hypertension of upper extremities was based on Takayasu's aortitis at her 37-year-old age. But at that time there was no sign of inflammation, only drug therapy for hypertension had been employed. She started to complaint of dyspnea on exertion and palpitation when 47 years old, ultrasonic echocardiography and cardiac catheterization revealed that her symptoms were based on pseudocoarctation and AR. Despite of drug therapy, her symptoms progressed and reached NYHA class III. Detailed examination showed progressed AR and occurrence of mitral regurgitation (MR). Surgical treatment, ascending aorto-terminal aortic bypass, aortic valve replacement (AVR), and mitral valvuloplasty was performed at the age of 53 years old. In instituting the extracorporeal circulation, an arterial cannula was placed in the graft that anastomosed to the terminal aorta, in addition to the arterial cannula to the ascending aorta, to prevent low perfusion of the organs distal to the pseudocoarctation. The postoperative course was uneventful. Special attention should be paid to prevent low perfusion of the organs in such case with presence of pressure gradient in the aorta.

A 22-year-old woman was admitted to our hospital with high fever and lumbar pain. Echocardiography revealed mitral regurgitation due to prolapse of the anterior mitral leaflet. On admission, her white blood cell count was high and results for C-reactive protein were positive. The blood culture was positive for hemolytic streptococcus. After the white blood cell count and C-reactive protein level were normalized, and the blood culture had become negative following treatment by multiple antibiotics, she underwent valvular surgery. Because the infectious lesion was limited to the mitral leaflet and chordae, mitral valvuloplasty was performed with a satisfactory postoperative result. The operative technique consisted of resection of the infected valvular tissue, implantation of artificial chordae with e-PTFE, and suture annuloplasty. To conclude, mitral valvuloplasty should be the operative method of choice in patients with infective endocarditis, especially in young women with the potential of future pregnancy and labor.

Case：A 57 year-old man, who had received home oxygen therapy and noninvasive ventilation（NIV）as outpatient, was admitted to our hospital because he felt shortness of breath. He could not eat meals because he was required to receive NIV in all days. He therefore was admitted to our palliative care unit（PCU）on a permanent basis in order to improve the quality of his life. In the PCU, he could take a bath, eat meals and appreciate local folk songs while receiving NIV. Complications were only desaturation and feeling shortness of breath while bathing or eating. Conclusions：NIV may be a useful device for the patients with terminal respiratory failure.

Abnormalities of the skeleton and joint as well as ophthalmic symptoms and cardiovascular abnormalities are found in Marfan's syndrome, one of the connective tissue diseases associated with autosomal dominant inheritance. A 34-year-old man was operated on for Stanford type A acute aortic dissection that developed 13 years after sternal turnover surgery for funnel chest. After approaching by median incision made on the sternum, composite graft replacement and aortic arch replacement were performed. After surgery, the sternum at the site of reflections became unsteady, causing flail chest, which required internal fixation with an artificial respirator for 15 days. A patient with Marfan's syndrome may undergo cardiovascular operation twice or more throughout his lifetime. Where a longitudinal incision is made on the sternum after operation on the funnel chest, care should be exercised even if it is a long time after surgery. In this sense, minimal invasive surgery with a steel bar inserted percutaneously, a surgical technique that has come to be used recently, should be useful.

Introduction: Recently, community-based medical education has become widespread in Japanese medical schools, but the current status is not clear on a national level. A second survey of community-based medical education at all Japanese medical schools was conducted. The first survey was done in 2011. Methods: Members of the Council made and distributed a questionnaire to medical schools in order to assess the situation of community-based medical education as of April 2014. Results: A total of eighty schools responded. The number of schools which had community medicine programs was seventy-eight. In the first survey, the number was seventy-three. Seventy-seven schools gave community-based clinical clerkships. Discussion: The number of medical schools that had curriculum about community medicine was more than indicated in the first survey. Further research about the contents or implementation system of community-based clerkships is needed.