A 28-year-old woman with no underlying health issues was injured in a motorcycle accident and taken to our hospital by ambulance when she was 26 years old. Though she was diagnosed with multiple trauma, upon arrival at the hospital neither cardiac murmurs nor cardiac abnormalities on transthoracic echocardiography were detected. She was managed conservatively, and discharged on hospital day 16. She experienced dyspnea upon mild effort, and an early diastolic murmur appeared. She was again referred to our hospital, and diagnosed with severe aortic regurgitation. We scheduled an aortic valve replacement using an bioprosthetic valve because she intended to give birth. We also considered simultaneous aortic root enlargement as her aortic annulus was small. We performed the surgery 2 years after the initial motorcycle accident. Perioperatively, we noticed that her non-coronary cusp was torn. We converted the procedure to an aortic valve repair using an autologous pericardial patch. Her aortic regurgitation disappeared after the operation, and she was discharged on postoperative day 14. We successfully preserved the aortic valve cusps and avoided the need for anticoagulant therapy.

A 79-year-old man, who had undergone aortic valve replacement due to severe aortic stenosis 2.5 years previously and permanent pacemaker implantation for sick sinus syndrome 2 months after aortic valve replacement, was admitted for congestive heart failure and suspicion of prosthetic valve endocarditis. However, he had a fever in spite of medical therapy, and transthoracic echocardiography revealed a 20 mm vegetation on the posterior mitral valve leaflet. He underwent emergency surgery on a diagnosis of infective endocarditis. The intraoperative examination showed annular abscess on the calcified mitral annulus, and a part of abscess had disintegrated, from which the vegetation arose. We performed maximal possible debridement of the infected tissue and mitral annulus reconstruction with a bovine pericardium. Subsequently, mitral valve replacement and annulus reinforcement with a prosthetic valve collared with a bovine pericardium were performed to prevent perivalvular leakage. The patient showed no recurrence of infection and perivalvular leakage at 1.5 years of follow-up.

We report a patient displaying several symptoms of myelitis associated with atopic dermatitis. The patient, a 35-year-old female, initially suffered from gait titubation that gradually developed into motor disturbance. She underwent many tests (blood, cerebrospinal fluid, electromyography, and brain, cervical, and lumbar spinal cord and muscle MRIs) at several hospitals, including a university institution, over the course of two years until she finally came to our hospital. However, her disease was never identified by these tests, and she was referred to our hospital to start rehabilitation for her disability which was believed to be caused by disuse syndrome. On first examination, muscle hypertonia of both legs, hypoesthesia of all extremities, difficulty sitting, and a low performance level of ADL were observed. Judging by the factors (e.g. age, neurological symptoms), we considered that the patient was not suffering disuse syndrome, and recommended that she attend another medical college hospital for a thorough investigation. The disease was finally diagnosed as atopic myelitis, as indicated by the test results (e.g. hyperIgEemia). She could sit without a back rest and undertake gait training between parallel bars after steroid pulse therapy at the hospital. While she undertook rehabilitation at our hospital, we applied some approaches to adapt to her fluctuating symptoms (e.g. making short leg braces for both legs, injection of botulinum toxin A (BOTOX^®) in the leg). We recognized we should gather as much information as possible given the rarity of the disease.

This study was a nonrandomized controlled trial, aimed to identify the effects of a walking program designed to improve the physical functions of elderly people requiring support or low-level care and receiving rehabilitation services at day care centers. Participants were 28 elderly people (mean age: 77.9±7.5 years). Twelve participants agreed to wear a physical activity monitoring device. Their daily walking goals were updated every week. Sixteen subjects designated as a control group only underwent personalized rehabilitation programs. The gait functions of all subjects were evaluated by several gait parameters before and after the 4-week intervention. ADL and QOL were assessed using the Tokyo Metropolitan Institute Gerontology Index of Competence and 8-Item Short-Form Health Survey (SF-8), respectively. The step length, walking angle, the stance phase ratio and the double-support phase ratio significantly improved in the intervention group after the walking program. Interaction effects of the stance phase ratio, the double-support phase ratio and QOL (mental component summery) were observed between the two groups. The walking program, combined with rehabilitation services, showed favorable effects on the gait functions, and QOL of elderly people, suggesting that it may be useful for preventing functional deterioration of the elderly requiring support or low-level care.

Objective：To assess the risk for hyperkalemia caused by treatment with angiotensin Ⅱ Type 1 receptor blockers （ARB） in clinical practice with Japanese medical database.Design：A cohort study in patients treated with ARB alone and those treated with calcium channel blockers （CCB） alone as control.Methods：The Diagnosis Procedure Combination （DPC） database provided by Medical Data Vision Co., Ltd. was used to identify patients who received a diagnosis of hypertension (ICD-10 codes, I10 to I15) and were treated with ARB or CCB from April 2008 to June 2017. A logistic regression model was applied to estimate adjusted odds ratios （OR） and their 95％ confidence intervals （CI） in these patients. The outcome in the logistic model was hyperkalemia （serum potassium≧5.5 mEq/L） and the covariates were sex, age, renal insufficiency, hepatic insufficiency, and baseline serum potassium levels. And, subgroup analysis was also performed in patients with and without renal insufficiency.Results：The incidence of hyperkalemia （per 1000 person-years） with ARB was 39.4 and that with CCB was 32.6. And, median periods from the index date to the date of occurrence of hyperkalemia for both exposure and control groups were 36 days （Min-Max：12-85） and 51.5 days（Min-Max：8-88）respectively. However, treatment with ARB was not associated with occurrence of hyperkalemia （OR 1.26, 95％CI： 0.58-2.75). The risk for hyperkalemia among those with renal insufficiency was higher （OR 3.31, 95％CI： 1.39-7.88）and as baseline serum potassium increased, the risk increased as well （OR 9.20, 95％CI： 3.52-24.10). And, the subgroup analysis also showed that rare occurrence of hyperkalemia by ARB and elevation risk for hyperkalemia by baseline serum potassium.Conclusion：The clinical data showed rare occurrence of hyperkalemia caused by ARB, indicating that renal insufficiency and baseline serum potassium levels affected the onset of the disease in clinical practice. Previous studies also reported the effects of renal insufficiency and other factors on the onset of hyperkalemia. ARB should be prescribed carefully in patients with these factors, as is conventionally done.

Background and Aims: The gastrointestinal motility effects by carbonated water have not yet been sufficiently investigated. The aim of this study was to determine whether single pre-prandial carbonated water administration might have an effect on the rate of liquid gastric emptying using the 13C-acetic acid breath test. Methods: Eight healthy volunteers (F/M; 3/5) participated in this randomized, 3-way crossover study. The subjects fasted overnight and were randomly assigned to receive 200mL of carbonated water before ingestion of the liquid test meal (200 kcal per 200 mL, containing 100 mg 13C acetate) or 200mL of carbonated water before the test meal or the test meal alone. Under all conditions, breath samples were collected for 150 min following the meal. Liquid gastric emptying was estimated by the values of the following parameters: T1/2, Tlag, the gastric emptying coefficient (GEC) and the regression-estimated constants (β and κ), calculated using the 13CO2 breath excretion curve using the conventional formulae. The parameters between the 3 test conditions were compared statistically. Results: Carbonated water significantly decreased k and beta, but T1/2, Tlag and GEC remained unchanged. Conclusions: The present study revealed that carbonated water has dual effects on liquid emptying: an initial acceleration with a subsequent deceleration in asymptomatic volunteers.