We experienced a case of extensively calcified mitral annulus and severe mitral regurgitation. A 75-year-old woman underwent successful debridement of an annular calcification with a CUSA^® and replacement of mitral valve with a MIRA^TM valve in a supra-annular position. Use of CUSA^® allowed safe removal of the calcification and prevented the tearing of the A-V groove vessels. In our technique, calcification is left to a certain extent to keep annular strength. Also the MIRA^TM valve has soft and rich sewing cuff, which enhances coaptation in highly calcified annuli and accommodates even fragile tissue. This makes it possible to implant valves even in severely diseased annulus conditions.

A 68-year-old man who had undergone previous coronary artery bypass grafting was admitted with cardiac failure because of aortic valve stenosis and severe mitral valve regurgitation. Preoperative cardiac catheterization showed a patent left internal thoracic artery (LITA) and a stenotic saphenous vein graft. We performed aortic valve replacement, mitral valve repair, and coronary artery bypass grafting with repeat sternotomy, moderate hypothermia (29.3°C), aortic cross-clamping, retrograde cardioplegia and proximal occlusion of the LITA graft using a soft bulldog clamp. The proximal LITA was occluded through a supraclavicular incision without intrathoracic dissection. Although cardiopulmonary bypass (CPB) time and aortic cross-clamp time were prolonged, the patient was taken off CPB without any problem. The postoperative course was uneventful. We believe that this technique is safe and effective for establishing myocardial protection without deep hypothermia and risk of LITA injury.

  One patient was intervened by our palliative care team (PCT) to relieve neuropathic pain due to postoperative recurrence of rectal cancer. The dosage controlled-release oxycodone was increased, analgesic adjuvant drugs were changed and the administration of betamethasone were started. Furthermore, the number of times the patient took controlled-release oxycodone increased two to three times a day. These changes in medication resulted in relief of symptoms. Cetuximab therapy was given twice during the course. The other patient was intervened by the PCT for right upper limb pain and dyspnea due to postoperative recurrence of breast cancer. Morphine sulfate hydrate and analgesic adjuvant were additionally given. As pain increased three days after the administeration of transdermal fentanyl patches, the patches were changed every other day, instead of every three days. FEC100 therapy was given twice during the course. In the present two cases, the PCT was intervened with great zeal and rapid relief of symptoms resulted. In the meantime chemotherapy proceeded uneventfully. We thought that trust of the chief doctor in the PCT was most important for effective intervention.

Objective: To investigate whether postgraduate education through evidence-based medicine can affect the knowledge and behavior of residents.
Design: Self-controlled and externally controlled trial.
Setting: University hospital.
Participants: Fifteen residents specializing in family medicine.
Intervention: Four 2-hour seminars and weekly evidence-based medicine-style journal club meetings.
Main outcome measures: Scores from a test of knowledge of evidence-based medicine and the number of MEDLINE searches conducted each month.
Results: All residents improved their knowledge of evidence-based medicine and conducted more MEDLINE searches each month than did other medical residents or residents of our department last year.
Conclusion: Postgraduate education through evidence-based medicine is effective in improving residents' knowledge and behavior.

Nusa Tengara Barat (NTB) province consists of two main islands, Lombok and Sumbawa, to the east of Bali Island, Indonesia. Most of the area is known to be moderately malaria endemic, but the exact malaria epidemiology has not been elucidated. At least 30 deaths per year are thought to be caused by falciparum malaria in Lombok alone, judging from the hospital data. According to the Gebrak Malaria Team in West Lombok, the annual incidence in the district of West Lombok from 1996 to 1999 was consistently over 40‰.
In the present report, we describe the small malaria endemic foci in the West Lombok and Sumbawa districts. Falciparum malaria is predominant over vivax malaria and other types of malaria. There are 11 species of Anopheles vector, but three of these species, An. subpictus, An. maculates and An. barbirostris, are of primary importance in malaria transmission and An. sundaicus and An. aconitus are of secondary importance. Our data from Sekotong, West Lombok, and Sumbawa supported the importance of An. subpictus in coastal areas but suggested the existence of different transmission peaks according to environmental conditions. The usual transmission peak comes in the dry season but is affected by climatic and geographical conditions. Although there were many malaria endemic foci along the coast, the width and grade of the foci varied widely. The presence of malaria endemic foci inland, although likely, has not been definitively reported to date.

OBJECTIVEPrevious studies on the association between physical activity (PA) and neighborhood environments (NE) focused on either objectively measuring the NE or the residents' perception of NE. Here, we investigate which actual or perceived NE is associated with residents' PA in Japan.

METHODSTwo regions with an objectively assessed high and low residential density, land use mix-diversity, and street connectivity, respectively, were identified in one city. The subjects were selected using a stratified random sampling method by sex and age in each region. The NE of the subjects was objectively measured using the Geographic Information System (GIS), and the subjects' perception of the NE was assessed using a questionnaire. The daily total number of walking steps was measured with an accelerometer, and walking and cycling time were assessed by a questionnaire.

RESULTSFor the female subjects, the mean cycling time, subjectively assessed as a means of transport, was significantly longer in the group with a high GIS score for the number of land use types, while the score for total number of walking steps was significantly higher among those who were aware of places to walk to, and cycling time for transport was longer for those who perceived an accessibility to post offices, banks/credit unions, gymnasiums/fitness facilities, and amusement facilities in their neighborhood. For the male subjects, the score for walking time for leisure was longer for those who perceived aesthetics and an accessibility to parks, and the score for total walking steps was significantly higher for those who perceived an accessibility to bookstores or rental video stores in their neighborhood.

CONCLUSIONSThe results to this study demonstrate that daily PA was high among female subjects living in a NE with land use mix-diversity, and who had an awareness of places to walk to and the accessibility to facilities for daily necessities in their neighborhood. For male subjects, daily PA was high among those who perceived the aesthetics of and accessibility to facilities for pleasure in their neighborhood. Further research is needed to determine the association between PA and NE on the basis of sex differences.

In some molecular targeted therapies, skin disorders including acne-like rashes or maculopapular rashes frequently appear, which are often clinically problematic. In Kampo medicine, it has been reported that the combination of jumihaidokuto and orengedokuto (hereinafter called JHT + OGT) is effective for acne. In this study, we report the experiences of JHT + OGT for the treatment of rashes caused by molecular targeted therapies. We extracted patients from June 2013 to June 2017 who took molecular targeted therapies and the treatment with JHT + OGT for skin rashes. The primary endpoint was severity of rashes before and after treatment by JHT + OGT (judged by CTCAE v4.0). In 22 patients (14 males and 8 females), the rashes after treatment with JHT + OGT significantly improved compared with those before treatment (from the median grade of 2 to 1 [p = 0.011]), with 14 cases of improvement, 6 cases of no change, and 2 cases of deterioration. It was suggested that JHT + OGT for skin rashes caused by molecular targeted therapies could be one of the treatment options.