We examined the clinical features, 12-leads ECG, Holter ECG, monitor ECG, and electrophysiologic study (EPS) in nine consecutive paroxysmal atrioventricular block (PAVB) patients treated in our hospital between 1995 and 2000. In some of them, parasympathetic nerve stimulating maneuvers, drug administration and head-up tilt test (HUT) were performed as provocative tests. EPS documented that the sites of AV block were within the His-Purkinje system (H-PSB) in five patients, proximal to the His bundle potential (AHB) in three patients. In the remaining one patient, the His bundle potential was not recorded. The main features of the patients with H-PSB were as follows: 1) often wide QRS complex with or without axis deviation; 2) variable degrees of AV conduction disturbance in a short period; 3) sinus tachycardia, and normal length and constant PQ intervals in a daytime being apt to precede PAVB; 4) rather long ventricular asystoles leading to abrupt syncope; 5) easy induction of the block by intravenousadministration of atropine. In the other hand, the features of the patients with AHB included: 1) narrow QRS; 2) progressively increasing or decreasing in PQ intervals preceding PAVB; 3) ventricular asystole lasting about 3 to 10 seconds; 4) the failure to induce PAVB by any probale provocative tests.
Although we treated all the patients with permanent pacemakers, there might have been other management method for AHB patients who had about 3-second ventricular asystole.

A 73-year-old man was admitted to the hospital on March 31, 2000 because of nonsustained ventricular tachycardia (VT). In 1983, he was diagnosed as having apical hypertrophic cardiomyopathy (APH). Electrocardiograms showed high amplitude of R waves and giant negative T waves (GNT), and left ventriculography (LVG) revealed spade like configuration. He stopped medication without leave six months after the diagnosis. The latest ECG showed a decrease in amplitude of R waves, no signs of GNT, ST elevation in precordial leads, and an increase in QRS duration. LVG demonstrated midventricular obstruction, apical aneurysm, and the intraventricular pressure gradient in systolic phase was 56 mm Hg. No stenotic lesion was observed in coronary arteriography. Early diastolic paradoxic flow from the apical chamber toward the outflow of the left ventricle was detected by pulsed Doppler echocardiography. VT was successfully treated with beta-blocker and amiodarone, but he needed hospital treatment again one month later because of congestive heart failure. During the follow-up of APH, the decrease in amplitude of R waves and disappeasance of GNT, ST elevation, and the increase in QRS duration in electrocardiograms, and the detection of early diastolic paradoxic flow by echocardiography could be the predictors of developing apical aneurysm and/or left ventricular dysfunction.

Infectious endocarditis (IE) concomitant with patent ductus arteriosus (PDA) is now considered rare because the early treatment of PDA in infancy has become standard. We report a case of PDA with IE diagnosed by computed tomography (CT). A 51-year-old man complained of arthralgia and numbness of the left extremities. He had fever of 39°C and left hemiplegia, and was referred to our hospital. A chest X-ray film showed infiltration in both lungs. CT revealed a mass lesion in the main pulmonary artery and a tubular connection between the main pulmonary artery and the aortic arch. Multiple small infarctions were also found in the brain, lungs, kidneys and spleen. Ultrasonic cardiography revealed a bi-leaflet aortic valve, and vegetations on the aortic and mitral valves. Staphylococcus aureus was detected by culture of an intravenous catheter tip. These findings suggested IE concomitant with PDA, and we started intravenous administration of antibiotics. However, congestive heart failure occurred due to severe aortic and mitral regurgitation 2 days after hospital admission, and therefore, we performed emergency surgery. The main pulmonary artery was incised after cardiopulmonary bypass was initiated. A 20-mm length of vegetation was found on the orifice of the PDA. The vegetation was removed and the PDA directly closed. Aortic and mitral valve replacement was then performed. The post-operative course was uneventful and his neurological symptoms did not exacerbate. No sign of IE recurrence was observed 2 years after the surgery. CT clearly showed PDA and vegetation in the main pulmonary artery, although ultrasonic cardiography did not. CT was useful to make a diagnosis of PDA with IE in the present case.

A19-year-old man was admitted to the hospital because of severe congestive heart failure on 7 April 2000. In the previous year his case had been diagnosed as Churg-Strauss syndrome (allergic granulomatous angiitis, AGA) with bronchial asthma and mononeuritis multiplex. Echocardiography revealed the dilatation of the left ventricle (LVDd 74 mm) and impaired left ventricular systolic function (LVEF 20%). On the 21st hospital day, the irregularity of peripheral branches of left and right coronary arteries was detected by coronary arteriography. Right ventricular endomyocardial biopsy yielded little fibrosis and no infiltration of eosinophil. Although all the laboratory tests showed lower activity of AGA, steroid pulse therapy was tried and the use of steroids was tapered at intervals of two weeks. Left ventricular function was slowly improved (LVDd 60 mm, LVEF 36%). He was discharged on foot on the 71st hospital day.

No abstract available.
Aortic Valve Insufficiency* ; Aortic Valve* ; Echocardiography, Transesophageal ; Vena Cava, Inferior*

Background: Consideration of cultural aspects is important in medical care. We explored regional differences in cancer and palliative care among Okinawa, Tohoku, and Tokyo metropolitan area. Methods: We conducted a questionnaire survey of physicians involved in cancer medicine from September to November 2020. A total of 11 items related to physician experiences were rated using a 5-point Likert-type scale. Results: Responses were received from 553 physicians (187 in Okinawa, 219 in Tohoku, 147 in the Tokyo metropolitan area). In Okinawa, “When patients die, it is important that all family members are present at the last moment,” “Patients/family members primarily consult the elders of the family about the medical treatments,” “Family members hope the patients die at home, because the soul will not return when they die at the hospital,” “Patients/family members get advice from religious advisors about the medical treatments,” and “Family members wish to take the patient home when he/she is about to die and to confirm death at home” were significantly more frequently observed. In Tohoku, “Patients wish to be hospitalized at a specific season” was significantly more frequently reported. In Tohoku and Okinawa, “Patients hide cancer from neighbors and relatives” and “Elderly patients do not want treatment, because they cover the living expenses and education expenses for their children and grandchildren.” were significantly more frequently experienced. Conclusion: There are regional differences in cancer and palliative care in Japan. Being sensitive to the culture of the region is needed.

Students in all years, including those in lower years, were prohibited from coming to campus because of COVID-19, which began to spread in January 2020. However, we believed that a hospital tour and observership would be important practical training for first and second year medical students as part of the early exposure program, which aims to increase student motivation. Thus, we decided to conduct a virtual hospital tour and a virtual observation of medical doctors’ work. We used Zoom to conduct a virtual hospital tour for first-year students in June, and a virtual observation of physicians’ work for second-year students in December. Although this offered less of an opportunity to experience the reality of the clinic, there have been benefits in terms of increased learning content, fairness of learning opportunities delivered, and the promotion of independent learning. With regard to a “Hospital Tour” and the “Observation of Medical Doctors’ Work” , we believe that hybrid forms, which are able to skillfully combine the strengths of the two methods, would be effective.