Scimitar syndrome is a rare congenital cardiac anomaly with anomalous right pulmonary veins draining to the inferior caval vein. Currently, it is widely accepted that there are 2 forms of presentation with either an infantile manifestation or an adult form. Patients in the latter category are usually less severely affected and frequently asymptomatic on diagnosis. A 16-year-old boy who had been given a diagnosis of scimitar syndrome was observed for years because of his unwillingness to undergo surgery. However, since the latest catheter examination demonstrated an elevated pulmonary-to-systemic flow ratio of 2.39, he consented to undergo surgical treatment. Preoperative studies demonstrated an intact atrial septum and abnormal bronchial arborization of the right lung. Pulmonary angiography demonstrated abnormal right pulmonary veins that converged to a single venous trunk, the so-called scimitar vein, and drained into the inferior caval vein at the level of diaphragma. Because of the morphological abnormalities including a wide distance between the pulmonary veno-caval junction and interatrial septum, counterclockwise rotation of the heart, and a small left atrium, surgical management was performed with a novel approach, consisting of relocation of the scimitar vein to the anterolateral wall of the right atrium, total excision of the oval fossa, and intra-atrial baffle rerouting with the pulmonary venous blood being conveyed to the left atrium through the atrial septal defect. During the cardiopulmonary bypass vacuum assisted venous drainage through a femoral venous cannula was highly effective to secure a clear operative field without occlusion of the inferior caval vein. Postoperative recovery was uneventful and the repeat Doppler echocardiography demonstrated an unobstructed flow through the baffle. This experience indicates that the above novel approach is a promising surgical option for the management of scimitar syndrome.

It is known that lactic anions and hydrogen ions (H⁺) produced during intense exercise are partly transported or diffused from muscle to blood resulting in the production of non-metabolic CO₂ through the bicarbonate buffering system. The purpose of the present study was to examine the reliability of the estimation of non-metabolic CO₂ output using respiratory gas analysis during incremental exercise. Six healthy subjects underwent an incremental pedaling exercise test accompanied by respiratory gas and arterial blood sampling. The rate of non-metabolic CO₂ output (VCO₂-NM) was calculated by subtracting projected metabolic VCO₂ from actual VCO₂ after CO₂ threshold (CT) . CT was determined using a modified V-Slope method. Bicarbonate (HCO₃^-), pH, CO₂ partial pressure and lactate concentration were measured from arterial blood samples using automatic analyzers. The kinetics of VCO₂-NM and HCO₂^- were compared throughout the exercise test. VCO₂-NM was significantly correlated with HCO₃^-decrease after CT (r=0.976, p<0.001) and the kinetics of VCO₂-NM and HCO₃^- decrease were similar during exercise. Furthermore, the amount of non-metabolic CO₂ output (NM-CO₂) calculated integrating VCO₂-NM above CT was significantly correlated with the difference in HCO₃^-between CT and exhaustion (r=0.929, p<0.01) and with the difference in arterial blood pH between rest and exhaustion (r=0.863, p<0.05) . However, NM-CO₂ was not significantly related to maximum ventilation (r=0.111, ns) . These results suggest that the estimation of non-metabolic CO₂ output during incremental exercise proposed in the present study is reliable. It was also suggested that the primary factor which influenced nonmetabolic CO₂ output during incremental exercise was the addition of H⁺ into blood and not hyperventilation.

We investigated the effects of low-intensity brief exercise on lymphocyte functions and plasma cytokine concentrations. Six young sedentary women performed 30-min walking exercise (6 km/h, 50–65% HR max) per day for 3 weeks. Each subject’s peripheral blood was sampled before training, 1 week and 3 weeks after training, and analyzed for natural killer (NK) cell activity, T cell proliferation activity, granzyme B, interleukin-2 (IL-2), IL-6, IL-10, IL-12p40 and interferon.γ (IFN-γ). Lymphocyte functions did not change significantly following training, but plasma concentrations of IL-12p40 decreased significantly. These results suggest that cytokine balance towards significant Th1>Th2 is induced by low-intensity training.

The present study was to evaluate endothelial nitric oxide synthase (eNOS) protein expression and hemodynamics of pulmonary circulation in rats of "Living high and Training low" (LH+TL). The Sprague Dawley strain of male rats were used at the age of 9 weeks. They were divided according to four conditions of a living low (LL) group, living low and training low (LL+TL) group, living high (LH) group and LH+TL group, for 10 days. We assessed the effects of LH+TL on exercise-induced pulmonary arterial pressure and blood lactic acids under sea-level altitude in catheter-implanted conscious rats. Also, we measured the pulmonary artery under anesthesia and analyzed eNOS protein expression by western blot analysis. The blood lactate levels in the LH+TL rats decreased after maximal treadmill running compared to LL, LL+TL and LH rats (p<0.05). The increase in pulmonary arterial blood pressure with exercise was significantly lower in the LH+TL group than in the LL group (p<0.05). The eNOS protein expressions of pulmonary artery were higher in the LH+TL group than in the LL group (p<0.05). This study indicates that LH+TL reduced the increase of pulmonary arterial blood pressure with exercise at below sea-level altitude. In addition, eNOS protein expressions were enhanced in the pulmonary arteries of LH+TL rats. Thus, we conclude that the high altitude training of LH+TL was a useful method for improvement of endurance exercise ability and this improvement may be associated with pulmonary arterial response.

The purpose of this study was to estimate the postoperative growth of untreated segments of the dissected aorta with non-thrombotic communicating false lumen, and also to evaluate the clinical outcome in relation to the aortic enlargement after surgery. Nineteen patients who underwent surgical treatment of aortic dissection were studied with enhanced CT scans and angiograms during the postoperative follow-up period. In Stanford type A patients, mean aortic dilatation rate calculated at the segment showing maximal dilatation was 5.1mm/year during 13-82 months (average, 41 months) after surgery, as a sequela of enlargement of the false lumen. Differences in the aortic dilatation rates between the different segments of the aorta were observed and these were per annum 4.8mm in the ascending aorta, 5.4mm in the transverse aortic arch, 4.3mm in the proximal descending aorta, 2.7mm in the distal descending aorta and 2.4mm in the abdominal aorta. In all patients, major communications were detected at the perianastomotic sites on angiography. In Stanford type B patients, false lumens with small communications were observed to show gradual thrombotic occlusion, but no significant aortic dilatation was detected during the follow-up period (13-70 months, average: 44 months), except three cases of sudden death who had major communications. Nine late events related to dissection, consisting of 4 sudden deaths suspected to be due to aortic rupture, 2 intestinal necroses and 3 cerebral infarctions, occured in 6 patients (32%), among which three patients had undergone arterial fenestration, one of whom had double barrel anastomosis. In the remaining two, major leakages were recognized at distal aortic anastomotic sites on postoperative angiography. The results of this study, we stress the importance of periodic check-ups using enhanced CT scan and if necessary, angiography after surgery of the patients having communicating false lumen. Early detection of progressive aneurysm formation and timely surgical reintervention can yield a good prognosis.

Since the model core curriculum was shown in public, the discussion about the medical education is getting hot in every medical school. In the model core curriculum, the integrated course is designed with the basic sciences and the clinical medicine via pathophysiology, which will be educated by the PBL tutorial. Thus, the model core curriculum is suitable for growing up better clinician. The problem involved in the context is the lower recognition to the basic sciences and also the missing of the next generation in the teaching staff of the basic sciences. The introduction of the information technology to the medical education should be much progressive. The new integrated course with the structure and function should be designed with the information technology, which will fit to the new medical education in the 21st century.

1) We reported recent movement to graduate entry program (GEP) of medical education curriculum in the UK by both interviewing faculty members who are in charge of GEP and doing literature review.
2) In GEP, we may be able to make better doctors in short term.However, as long term outcome is not known so far, further discussion is necessary.
3) Many contents can be improved by just curriculum change, not by introducing GEP.Besides it can be said that GEP can make diverse doctors.

This study examined cytokine responses to cold exposure together with the effects of exercise and thermal adaptation. Ten male short-track skaters who had adapted to a cold environment, and ten male inline skaters who had not, were each assigned to two experimental conditions. For the cold condition, subjects sat for 60 min at 5–8°C, then exercised on a cycle ergometer for 60 min at 65% maximal oxygen uptake (at 5–8°C), and finally sat again for 120 min at room temperature (20–25°C). In the control condition, subjects participated in the same protocol as the above but at room temperature (20–25°C). Blood samples were collected at pre-cold exposure, post-cold exposure (pre-exercise), post-exercise, post-30 min, post-60 min, and post-120 min, and analyzed for plasma concentrations of interleukin (IL)-1 receptor antagonist (IL-1ra), IL-8, IL-10, IL-12p40, soluble tumor necrosis factor receptor I (sTNFR-I), cortisol, and myoglobin by using enzyme-linked immunosorbent assay (ELISA). 60-min cycle ergometer exercise induced significant increases in plasma IL-1ra, IL-10 and IL-12p40 at room temperature in short-track skaters adapted to the cold, but significant decreases in these cytokines were observed with exposure to cold. These results indicate that acute cold exposure has a suppressive effect on cytokine response during exercise, suggesting the possibility of preventive effects on immunosuppression, heat stroke and allergy induced by exercise.