We demonstrated two patients with fibromyalgia syndrome (FMS), successfully treated with Kampo medicine, and considered the resemblance between the clinical manifestation of FMS and SHO for Kanzo-bushi-to.The first case was a 52-year-old women who consulted a local hospital in 2001 due to althralgia and myalgia in the left hand, bilateral elbows, shoulders and foot. Her condition was diagnosed as FMS without abnormal findings in the thorough medical examination. Treatment with NSAIDs was not effective, so she consulted our department in 2004. She was treated with Keishi-ni-eppi-itto-ka-ryojutsu-ka-boi-ogi-kakkon. After two mouths, her symptoms had reduced to 50% by visual analog scale (VAS). By March 2006, her symptoms had significantly decreased to 20% by VAS and NSAIDs became unnecessary.The second case was a 58-year-old woman who had suffered from tolerable pain in her right elbow for 10 years. In 2004, she visited the Department of Orthology at her local hospital due to pain in the neck, bilateral arms and shoulders. There were no findings on cervical X-ray or neurological examination, and NSAIDs were administered. Her symptoms did not resolve, therefore, she consulted our department in 2005. She was diagnosed with FMS, based on fulfilling the diagnostic criteria for FMS of ACR (American college of rheumatology) in 1990. She was treated with Kanzo-bushi-to. After 3 months, her symptoms had reduced to 30% by VAS. By Mar. 2006, her pain had redused to 25% by VAS and she was physically fit enough for a daily life.
CSF1-R ; symptoms <1> ; Medicine, Kampo ; Pain ; Fibromyalgia

Extracorporeal shock wave lithotripsy (ESWL) represents the preferred treatment for most upper ureteric and renal calculi. Complication rates associated with ESWL are low, justifying the enthusiasm and acceptance of this treatment modality. We report a case of abdominal aortic pseudoaneurysm due to ESWL. A 47-year-old man had undergone ESWL treatment for ureteric calculi since 1990. He was admitted to our hospital because of lumbar pain. Physical examination revealed a pulsatile mass in his abdomen. Abdominal CT scan showed an abdominal aortic aneurysm (5.3cm in diameter). Angiography showed a fusiform aneurysm of the infrarenal abdominal aorta. Y-graft replacement was performed after aneurysm resection. Histological examination revealed that it was a pseudoaneurysm. The patient had no history of trauma, inflammation or operation except ESWL. This is the first report of abdominal aortic pseudoaneurysm due to ESWL.

A 53-year-old woman underwent mitral valve replacement for congestive heart failure due to mitral stenosis and regurgitation. She had been receiving hemodialysis because of diabetic nephropathy since 1993, and had had congestive heart failure since 1999. Echocardiography demonstrated mitral stenosis (MVA; 1.10cm²) and regurgitation with a severely calcified mitral annulus. Annular calcification extended to the posterior wall of the left ventricle and the base of bilateral papillary muscles. After removing all calcium from the mitral annulus to the base of the papillary muscle, the left ventricular posterior wall and mitral annulus were reconstructed by glutaraldehyde-preserved autologous pericardium. Then, a Carbo-Medics mechanical valve was placed at the mitral annulus using everting mattress sutures. Although her hemodynamics were stable, bacteremia and multi-organ failure developed 3 months after surgery and she died. Autopsy showed that the reconstructed left ventricular posterior wall and mitral annulus using glutaraldehyde preserved autologous pericardium were in excellent condition without any thrombus. No dehiscence was found at the suture line of the mechanical valve. Mitral annulus reconstruction with glutaraldehyde preserved autologous pericardium is thought to be effective for patients with calcified mitral annulus who require mitral valve surgery.

Infected femoral artery aneurysm is difficult to treat because of the risk of reinfection and anastomosis. The treatment of choice has been a topic of much controversy. Revascularization is mandatory for limb salvage after excision of infected grafts. Revascularization requires various ingenious techniques such as retro-sartorius bypass and obturator bypass. We treated a patient with suspected infection of an aorta-femoral graft, using femoro-femoral crossover bypass in front of the pubis and inside of the thigh muscle. We performed complete debridement of infected tissue. After resterilization of the operative field once more and exchange of all the instruments we performed revascularization detouring around areas of focal infection, using autogenious vein graft through the front of the pubis and inside of the thigh muscle to reach the left superficial femoral artery.

The saphenopopliteal junction (SPJ) is found at various levels and has various patterns compared with the saphenofemoral junction. Although this can cause difficulty in the surgical treatment of varicose veins and affect the outcome, there have been few reports on preoperative assessment of the small saphenous vein (SSV) regarding this point. This study was undertaken to evaluate three-dimensional CT venography with dual-route injection for the preoperative assessment of a small saphenous-type varicose vein. We examined a total of 15 legs in 15 patients with a small saphenous-type varicose vein, which were preoperatively evaluated by CT venography and then surgically treated. The patients included 4 men and 11 women with ages ranging from 50 to 80 years old (mean age, 66 years). The grading of varicose veins according to the CEAP classification was C2, C3, C4, and C5 in 3, 4, 6 and 2 legs, respectively. The CT imaging was performed with contrast medium diluted ten-fold, which was injected into the great and small saphenous veins simultaneously. CT venography clearly visualized the lower extremity veins. Whereas the popliteal vein coursed deep above the level of the femoral intercondylar groove, it followed a shallow course below the level of the knee joint. In 11 legs (74%), the SPJ was located in the shallow portion, whereas it was in the deep portion in 4 legs (26%). Among the former group, the SSV was connected to the great saphenous vein via the Giacomini vein in 2 cases, and the gastrocnemius vein was connected to the SSV before the SPJ in 3 cases. Among the latter group, a localized large venous aneurysm with thrombus before its termination was found in one case. In another case, the SSV showed branched termination in the deep portion. Our three-dimensional CT venography with dual-route injection provides more accurate information on venous anatomy in the lower extremity. The accuracy of images acquired by CT venography with dual-route injection was verified by intraoperative findings. Although Doppler ultrasound is essential for examining the presence of regurgitation in the veins and locating the course of a varicose vein in the surgical field, all 15 cases had scheduled surgery under local anesthesia based on accurate preoperative diagnosis. This study suggests that CT venography with dual-route injection is beneficial in preventing undesired complications during surgery and avoiding additional procedures for recurrent varicose veins.

Under scheduled anticoagulation therapy, surgery for abdominal aortic aneurysm was performed in 4 patients who had undergone heart valve surgery and implantation of a mechanical prosthesis. Warfarin and antiplatelet agents were prescribed in all cases preoperatively. Antiplatelet agents were discontinued from seven to 10 days before operation. Warfarin was stopped from two to three days before operation and heparin (200IU/kg/day) was administered by continuous intravenous infusion to produce an activated clotting time of around 150 seconds. Bolus intravenous heparin of 3, 000 IU was added before aortic crossclamp. Oral anticoagulants were resumed from the beginning of oral intake, and heparin was stopped when the prothrombin time reached therapeutic levels (% PT=40%). In three patients perioperative courses were uneventful. Intraperitoneal hemorrhage occurred in one patient who simultaneously underwent cholecystectomy and aneurysmectomy with Y-grafting. He required blood transfusion and interruption of anticoagulation. Brain thromboembolism occurred in this patient 26 days after the operation. We believe that scheduled anticoagulation for the operation of abdominal aortic aneurysm is safe and useful in patients with prior prosthetic heart valve surgery. However, the coexistence of coagulopathy requires more intensive anticoagulation therapy.