We present a very rare case of abdominal aortic aneurysm associated with paraplegia. A 68-year-old man developed paraplegia following resection of a infrarenal abdominal aortic aneurysm. The aorta was clamped just below the renal arteries. In this case interruption of the radicular artery magna (RAM; Adamkiewicz artery) might have caused serious ischemia of the spinal cord. Spinal cord ischemia is a very rare and unpredictable complication in surgery of infrarenal abdominal aortic aneurysms because the spinal cord is generally protected from irreversible ischemia during infrarenal aortic occlusion by the presence of the RAM which arises above the renal artery (Even if RAM interruption might arise, the lower renal artery, and other radicular arteries are usually present above the renal arteries). We feel that reducing aortic cross-clamping time as short as possible and avoiding intra- and postoperative hypotensive episodes to keep adequate blood flow of collaterals seem to be the most important factors to prevent spinal cord ischemia.

Higher brain dysfunction generally refers to cognitive and/or behavioral changes resulting from stroke, traumatic head injury, hypoxic encephalopathy, or any other of a number of cerebrovascular events. In 2004, the Ministry of Health, Labour and Welfare of Japan released a provisional figure of the probable prevalence of higher brain dysfunction in Japan as some 300,000 individuals. The aim of this study was to provide an estimate of the number of people with higher brain dysfunction in Tokyo. All 651 hospitals in Tokyo were surveyed between January 7, 2008 and January 20, 2008 by questionnaire. Analysis of the data showed 118 incidents of brain damage which resulted in higher brain dysfunction. This roughly converts to 3,010 incidents per year in Tokyo. Taking life expectancy into consideration, we estimate the current number of higher brain dysfunction survivors to be 49,508 (male : 33,936, female : 15,572) in Tokyo. The social impact of higher brain dysfunction has recently emerged amid growing recognition that disturbances of attention, memory, and behavior overshadow the contribution of focal motor deficits to chronic dependency. Our data provide information about the number of people that may require appropriate provision in the community.

Purpose: This study aimed to identify the teaching competencies of medical residents. Methods: A modified Delphi study was conducted from January to March 2017. Twenty-four panelists (six medical educators, program directors, chief residents, and residents each) from various facilities in Japan participated in the study. The consensus criterion for this study was that more than 80% of the panelists gave a rating of 6 or higher on the 7-point Likert scale (“not at all important” to “extremely important”) without any comments. The modified Delphi approach resulted in a list of 27 resident teaching competencies after three rounds. These competencies were categorized based on Harden and Crosby’s 12 roles of medical teachers. Results: Our study revealed that, of the 12 roles, residents were primarily viewed as “clinical or practical teachers,” “teaching role models,” “on-the-job role models,” “learning facilitators,” and “student assessors.” Conclusion The 27 resident teaching competencies indicate the importance of educational proximity for residents as teachers. It is expected that this finding will contribute to competency-based resident-as-teacher education.

[Background] Surgical septal myectomy is the gold-standard therapy for hypertrophic obstructive cardiomyopathy (HOCM) in Europe and America. However, few cases underwent surgical septal myectomy in Japan. We have performed the surgical transaortic extended left ventricular myectomy (LV myectomy) as a first choice in HOCM patients unresponsive to pharmacologic therapy. We report the short and medium term clinical outcomes. Methods : From May 2012 to September 2014, 9 patients underwent extended LV myectomy without other accompanying procedures. All cases were symptomatic and peak left ventricular outflow tract pressure gradients (LVOTG) were 50 mmHg or more. We assessed clinical and echocardiographic outcomes at the short and medium term, intra-operative findings and cardiomyocyte pathological findings. Results : All patients (mean age 64.3 years, 56% female) underwent transaortic LV myectomy with no obvious complications. Postoperative LVOTG were controlled within 10 mmHg or less. SAM disappeared completely in all patients and MR decreased to mild or less. LVOTG sustained good control of 10 mmHg or less under low-dose dobutamine stress echocardiography at the medium term. Conclusion : Our transaortic extended LV myectomy procedure is effective in decreasing LVOTG, SAM and MR with low operative morbidity and mortality.

We present a case of Marfan's syndrome with acute aortic dissection during the trimester of her pregnancy, who underwent a Bentall operation 2 days after emergency cesarean section. A 24-year-old woman during the 31st week of pregnancy visited our emergency room due to sudden onset of chest and back pain, though she had no abnormality until this event. Because of her tall height, spider fingers, positive wrist sign, visual disorder and scoliosis, she was given a diagnosis of Marfan's syndrome. Enhanced CT and cardiac ultrasonography revealed that she was suffering from acute aortic dissection with annulo-aortic ectasia. Since it was difficult for her to continue with her pregnancy, she underwent emergency cesarean section and gave birth to a male baby weighted 1, 706g. Although there was little likelifood of early thrombus formation in the false lumen or significant aortic regurgitation indicating an emergency operation, fear of massive bleeding from her uterus and the exfoliated surface of the placenta after cesarean section required an observation period of 2 days. We performed a Bentall operation successfully after careful sedation, ventilation and blood pressure control for 2 days.

Protein C (PC) deficiency is an inherited thrombotic disorder with a prevalence of 0.19% among the general population. PC deficiency is associated with an increased risk of thrombosis when other risk factors are present, such as trauma, surgery, or infection, and is an important cause of mechanical valve thrombosis. We performed tricuspid valve replacement with a 29mm Carpentier-Edwards Perimount valve in a 20-year-old man with PC deficiency. The patient had corrected transposition of the great vessels with severe tricuspid insufficiency, as well as a history of cerebral infarction. In the perioperative period, we used only heparin sodium as the anticoagulant. When we restarted administration of warfarin, changing over from heparin, transient increases of serum plasmin inhibitor-plasmin complex (PIC) and thrombin antithrombin complex (TAT) levels were observed. Despite an increased dose of heparin, an appropriate activated partial thromboplastin time (APTT) was not obtained. This suggested a hypercoagulatory state, but the postoperative course was uneventful. Management of perioperative anticoagulation, prevention of late thrombotic events, and prosthetic valve selection in this particular situation are discussed.

Objectives : To investigate the prevalence of rubella HI antibody among pregnant women in relation to changes in the recommended age for rubella-containing vaccination.
Methods : A total of 659 primiparous women were included in this study. All subjects were ≥20 years old at the time of delivery in our hospital during the 5-year period from January 2008 to December 2012. Rubella HI antibody titers were measured. Subjects were divided into four groups according to their date of birth and retrospectively analyzed : i) single-dose mass vaccination in junior high school generation ; ii) “interim measures generation” ; iii) single-dose vaccination in infancy generation ; and iv) infancy plus catch-up MR two-dose vaccination generation. HI antibody titers ≤1 : 16 was defined as a low antibody titer.
Results : The percentage of cases with low antibody titers in the total study population was 20.2%. The percentages of cases with low antibody titers in each group were : i) 20.4%, ii) 18.2%, iii) 30.6%, and iv) 31.6%.
Conclusion : The percentage of low antibody titers among all cases was comparable to other reports. The results suggested that rubella seroprevalence was low among those in the generation including and subsequent to the single-dose vaccination in infancy generation.

Objectives : In Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV), full scale intelligence quotient (FSIQ) and the index scores are thought to be solely important and supplemental subtests are not taken into account in the score.However, in assessment by intelligent tests it is required that we analyze the result from many directions. Accordingly, the factor of “Cancellation” was taken up and the importance of adding a focus on the qualitative side of the test results was examined. Methods : Some 412 children who received WISC-IV in our developmental evaluation center were divided into three groups according to their intellectual level, and of these, 30 persons were assigned to each group [total of 90] selected at random to comprise the sample. By comparing the index scores and the scaled scores for each group,we have classified the procedures of deletion into six types. Results : The more the intellectual level increases, the lower the “Cancellation” scaled score becomes compared to the other subtests. Further, the scaled score was lower in the type of deletion procedure such as systematic linear strategy. Conclusion : In the high intellect level group, the scaled “Cancellation” score was lower than the other subtests, it was thought to be because there were many “order type” subjects using a systematic linear strategy. It was also considered that attention to the qualitative aspects as well as quantitative is important in “Cancellation”. Therefore, when assessing high intellect children with developmental disabilities in the future, a clinical examination that incorporates “Cancellation” to detect executive function disabilities such as persistence or poor planning ability is desirable.

Background: Although there is a growing momentum in Japan to expect residents to play an educational role, the guidelines are still unclear. Objective: The purpose of this study is to examine the characteristics and contents of teaching roles for residents in the new curriculum of each specialty program and uncover current issues. Methods: Two researchers independently searched for and determined the wording related to teaching in the program for all 19 specialties. The research team extracted the relevant issues. Results: Seventeen of the 19 programs included a statement on educational roles for their residents, but almost all of the programs did not include educational competencies and any specific strategy to achieve it. Discussion: The definition of educational competencies and the development of methods to acquire the competencies are issues for the future. It is necessary to develop and expand programs for the Residents-as-Teachers program in Japan.