We simulated mountain climbing using walking on a treadmill in order to systematically evaluate the physical load during mountain climbing. The conditions of three types of load-(1) inclination of the walking path (walking uphill and downhill), (2) walking speed, and (3) backpack weight-were varied within the range assumed for normal mountain climbing (40 sets of conditions in total). When the three types of load were expressed as vertical work rate, energy expenditure (VO₂) during walking uphill and downhill was distributed along roughly the same curve. The following characteristics of walking uphill and downhill were observed.A. Walking uphillFor all three types of load, increase in load gave a linear increase in VO₂ and heart rate (HR). A lactate threshold (LT) appeared at an intensity of 62%VO_2max, when HR was 78% HR_max. Rating of perceived exertion (RPE) was evaluated for the “Breathlessness” and “Leg Fatigue”, and both of these increased roughly in proportion to %VO_2max.B. Walking downhillWhen walking downhill, VO₂ was 35-50% the intensity of VO₂ when walking uphill on the same slope and at the same speed. Energy expenditure did not exceed 60%VO_2max in any of the load conditions, and no LT was seen. RPE values were higher for walking downhill than walking uphill, even when %VO_2max values were the same. RPE values for the “Leg Fatigue” tended to be higher than for the “Breathlessness” at the same speed in downhill walking.Using these data, we created a table giving the intensity of exercise of mountain climbing expressed as VO₂ per unit body mass and metabolic equivalents (Mets) with vertical migration velocity and total weight (Body weight + Backpack weight) as variables. This table gives mountain climbers a systematic understanding of the physical load under various mountain climbing conditions. It is likely to be of use as a reference for mountain climbers of different levels of physical fitness when practicing mountain climbing appropriate to their individual level. The present results suggest that in downhill walking, it is insufficient to express the physical load in energy expenditure (VO₂ and Mets) alone, and the load on the leg muscles must also be judged using the RPE in the “Leg Fatigue”.

1) Anjo Kosei Hospital has nearly 40 years of history of the post-primary clinical training course.
2) More than 90% of the young doctors, passed through 2 years of the primary clinical training course, have chosen further training at Anjo Kosei Hospital. During this course they began to start the experience for their own career for specialist.
3) This education program is closely coordinated with Medical Colleges such as Nagoya University and Nagoya City College of medicine. After 4 or 5 years of training at Anjo Kosei Hospital, they continued their training at Nagoya University Hospital or Nagoya City College Hospital for the further career.

We estimated the medical expense of treating patients with diabetes mellitus under the health insurance system in Japan. The expense was summed up to 5.07 million yen for a patient who developed NIDDM at the age of 40 and died at the age of 75 without diabetic complications throughout his life. If he had diabetic retinopathy, neuropathy, hypertension and hyperlipidemia, and needed insulin injection, the cost would have increased 2.4 times to 12.32 million yen. It was also estimated at 25.22 million yen for a patient who developed IDDM at the age of 20 and died at the age of 70 without diabetic complications. If the patient had with diabetic retinopathy, neuropathy and hypertension and needed hemodialysis because of nephropathy for 20 years, the figure would have reached a whopping sum of 76.17 million yen. From the viewpoint of medical economy, more effort to prevent diabetic complications should be made.

Patients who need self-injection of insulin are educated beforehand to handle vials and syringes without bacterial contamination. However, not a few of them forget what they were told about the sterile technique during a long period of injection at home. Since 1988 a pen-typesyringe, which is considered to be more potent against bacterial contamination because of its mechanical structure, has become available in Japan. The aim of this study is to detect the percentage of contaminated vials in the patients' home and to compare traditional vials with pen-type vials in terms of potency against contamination. Two hundred eight vials were collected from 168 patients. Four traditional vials out of 163 (2.4 %) and 1 pen-type out of 45 (2.2%) were contaminated. Propionibacterium acnesgrew up from 2 vials, staphylococcus epidermidis from 2 vials and unidentified gram (+) rods from 1 vial. The patients using contaminated vials were from 30 to 65 in their age, enough skillful to handle syringes, good or poor in the control of DM and without disturbed vision. Thus, the contamination may have been derived from their technical deterioration after several years of injection at home. Therefore, re-education to keep their sterile technique should be given to them at appropriate intervals at the out-patient clinic.

Delayed hemothorax following blunt chest trauma is classified as a late presentation of hemothorax after a nearly normal chest X-ray on admission. Here, we present a case of delayed hemothorax 5 days after blunt chest trauma with ribs and sternal fracture.

A 77-year-old woman underwent percutaneous coronary intervention (PCI) for chronic total occlusion of the left anterior descending artery using a drug-eluting stent (DES). Re-stenosis, stent fracture, and aneurysm were found on follow-up coronary angiography (CAG), and thus implantation of multiple DESs was required. Surgery was indicated because CAG 48 months after first DES implantation revealed enlargement of the aneurysm with other new lesions. She successfully underwent off-pump coronary artery bypass grafting and resection of the aneurysm.

A 62-year-old woman was referred to our hospital for treatment of hemolytic anemia 10 years after total arch replacement for acute aortic dissection. The cause of hemolysis was confirmed to be mechanical damage of red blood cells at the kinked graft. Because aortic valve regurgitation and occlusion of the left subclavian artery were also found, resection of the kinked graft, aortic valve replacement and reconstruction of the left subclavian artery were carried out concomitantly at reoperation. Her postoperative course was uneventful, and hemolysis resolved soon after the operation.

A 62-year old man was referred to our hospital with endocarditis. Although the infection was improved by antibiotic therapy, he underwent surgery because of severe aortic and mitral valve regurgitation. Preoperative computed tomography revealed a pseudoaneurysm of 20 mm in diameter at the posterior wall of the ascending aorta. The non-coronary cusp was infected and there was a punched-out pseudoaneurysm at the ascending aorta adjacent to the sino-tubular junction. After resection of the aortic wall and the aortic valve, a modified Bentall operation with a composite graft and mitral valve plasty was performed. Postoperative whole body computed tomography revealed no other pseudoaneurysms. In case of endocarditis, we have to consider the possibility of aneurysm formation throughout the body.

The patient was a 68-year-old woman with chief complaints of severe lumbago, left lateral abdominal pain and high fever. Computer tomography (CT) at a local hospital showed a left psoas abscess and a low density area around the terminal aorta. Blood tests indicated a high inflammatory response and MSSA was detected in a blood culture. Control of the infection was first attempted with antibiotics, but CT showed a pseudoaneurysm at the terminal aorta, and therefore she was transferred to our hospital. We diagnosed infected abdominal aortic and left common iliac aneurysms complicated by an MSSA psoas abscess, and performed extra-anatomic reconstruction with axillo-bifemoral bypass, aneurysmectomy and omentopexy in the psoas abscess cavity. Because of massive intestinal edema and mesentery, we attempted temporary abdominal closure with the vacuum-assisted closure (VAC) technique, and finally succeeded in closing without abdominal infection in the 6th operation, 42 days after the first operation. Infected abdominal aortic aneurysm complicated by psoas abscess is extremely rare and life threatening. The VAC technique is very effective not only in avoiding abdominal compartment syndrome but also in avoiding abdominal infection.

  The patient was a woman in her 80s, who was referred to the palliative care team in our hospital for pain due to bone metastases from lung cancer. Although gabapentin and ifenprodil tartrate were administrated in addition to opioids and loxoprofen sodium, and the dose of opioids was increased, pain was not relieved remarkably. A switch from gabapentin to pregabalin brought remarkable pain relief. Before the internal use of pregabalin, the patient was often seen lyiing in bed because of pain. However, by pregabalin, she began to walk, pushing her wheelchair and smile often. Her ability to perform the basic activities of daily living was improved. The switch from gabapentin to pregabalin was one effective option when an analgesic adjuvant for cancer pain was chosen.