A 64-year-old man with a history of abdominal aortic occlusion was admitted because of anterior chest pain. Angina pectoris with ischemic mitral regurgitation were diagnosed by transthoracic echocardiography and coronary artery angiography. He underwent coronary artery bypass grafting and mitral valve annuloplasty with a 26-mm Physio-ring. Because of difficulty in weaning from cardiopulmonary bypass, he required IABP support which was introduced via the ascending aorta. On the 2nd postoperative day, IABP was discontinued and the sternum was closed. His postoperative course thereafter was uneventful without any neurological complications. Postoperative echocardiogram showed good mitral valve function. He was discharged 16 days after surgery.

We report a rare case of a 73-year-old man with abdominal and thoracic aortic aneurysms complicated with Buerger's disease. He complained of abdominal pain, nausea and an abdominal pulsatile mass. Computed tomography and angiography revealed an abdominal aortic aneurysm (58mm in diameter) and a thoracic aortic aneurysm (47mm in diameter). Y graft replacement was performed for abdominal aortic aneurysm. The size of the thoracic aortic aneurysm increased from 47mm to 60mm in 3 years, and hoarseness appeared. We then performed graft replacement of the thoracic aorta. In cases of Buerger's disease, we have to consider perfusion of the extremities when we need extracorporeal circulation, and we must shorten ischemic interval.

Background: Development in internet technology enables e-learning at the higher education level. We have developed the Internet PBL-Tutorial System/Rakuichi that allows multi-directional communication among participants with web-based bulletin boards. Although this system has been successful in medical education at the undergraduate level, we sought to encourage “readonly members” to participate more fully in the program. Methods: To this end, we compared the posting frequency among three strategies: (1) students and tutors had an off-site meeting to promote face-to-face communication during the course, (2) several classes were allowed to watch the discussion in other classes in the second half of the course, (3) three classes (5 – 6 students each) in one topic were combined into one class (16 students) in the second half. Results: No meaningful effects were observed for strategies (1) or (2). However, the posting frequency increased 50 % for strategy (3). Conclusion: Facilitation of communication among participants was achieved by increasing the number of student participants. We predicted that an optimal number of students in each class in internet-based PBL would be ~20 people.

Recently, with the advent of medical devices and minimally invasive operations, endoscopic saphenous vein harvesting (EVH) in coronary artery bypass grafting has been widely accepted. Although EVH has short-term advantages of less wound morbidity and better cosmetic results compared with open vein harvesting (OVH), several studies have demonstrated that the mid- and long-term patency rate of EVH veins is significantly lower than that of OVH veins, therefore the role of EVH is currently controversial. The purpose of this study was to investigate the early results of EVH compared with the OVH group. Between April 2011 and December 2012, 115 consecutive patients underwent coronary artery bypass grafting (CABG) in our institution. Of these, EVH was performed in 62 patients and OVH in 53. In EVH groups, all 50 patients were men, and mean age was 71.3±7.8 years. A total of 211 coronary anastomoses, 109 SVGs anastomoses were assessed for patency postoperatively by angiography or enhanced computed tomography before discharge. The mean vein harvesting time was 26.0±8.1 min, and the mean number of ostial branch tear was 0.34±0.59. The overall SVG patency rates at discharge were 95.4% in EVH and 92% in OVH, respectively (p=0.24). There was a significant reduction in the incidence of leg wound complications in the EVH group (EVH : 1.6% ; OVH : 13.2% ; p=0.038). In conclusion, the short-term result of EVH was satisfactory. EVH reduces leg wound complications compared with OVH.

Recent advances in both diagnostic and therapeutic technologies have caused dramatic changes in treatment strategy for esophageal cancer patients. In this lecture, we will introduce the advances in multimodal treatment for esophageal cancer, based on our own experiences. 1. Neoadjuvant chemotherapy (NAC) with Docetaxel/Cisplatin/5-fluorouracil (DCF) for node-positive esophageal cancer. Recently, in Japan, an efficacy of NAC for resectable advanced squamous cell carcinoma of the esophagus has been reported. DCF is expected to be a powerful alternative to cisplatin/5-fluorouracil. Our experience on neoadjuvant or induction DCF will be demonstrated. 2. Efficacy and safety of salvage esophagectomy after dCRT. Salvage esophagectomy is an almost only method to cure the patients with local failure after dCRT, although high mortality and morbidity rates have been reported. We performed 40 cases of salvage esophagectomy during the last 7 years and no hospital mortality has been experienced. Benefit of salvage surgery and procedures to decrease surgical risk will be discussed. 3. Basic research for individualized treatment. If an individualized treatment strategy can be established based on some predictive markers, both improved survival and preserved quality of life will be realized. We will demonstrate the possibility of epigenetic analysis (e.g., LINE-1 methylation level) as biomarkers to predict patient prognosis.

The Young Primary Care Doctors' Organization of the Japan Primary Care Association (JPCA) launched the "Generalist 80 Universities Angya Project" in 2011 to increase contact between generalists and medical students or residents interested in general hospital medicine, family medicine and primary care. The project targeted students interested in family medicine, primary care and hospital general medicine who do not participate in nationwide seminars. The project helps medical students and residents hold voluntary seminars at their university campus about family medicine, primary care and hospital general medicine. From 2011 to 2016, the project supported 129 seminars attended by 3,569 people at 63 universities. A questionnaire survey on 11 seminars between September 2013 and February 2014 revealed that 66% of medical students had never participated in JPCA family medicine summer seminars for students and residents. By holding seminars at university campuses, we targeted different participants from those at the nationwide seminar.

A 55-year-old man visited his neighborhood general practitioner complaining of headache, fever and wet cough on July 7, 2003, but there were no sigins that his symptoms would subside. Since an abnormal shadow was found on chest X-ray on July 11, he was referred to our department and hospitalized on the same day. We started to treat him on the assumption that he had community-acquired pneumonia due-to common pathogens. However, he developed severe hypoxemia, and abnormal shadows rapidly progressed to affect both lungs, which led us to suspect that he had acute respiratory distress syndrome (ARDS). We identified the pathogen by examining urinary antigens and serum antibodies and diagnosed of his case as Legionella pneumonia. Although he suffered complications of acute renal failure and shock, the respirator was withdrawn after 11 days of controlled mechanical ventilation, as he was steadily recovering from his illness. The patient was discharged from the hospital on September 9. Although the mortality of legionella pneumonia, when complicated by ARDS, acute renal failure and shock as in the present case, has been reported to be as high as 50 to 80%, we consider that the administration of neutrophil elastase inhibitors and steroids was effective against this disorder.
Shock ; Respiratory Distress Syndrome, Adult ; Pneumonia ; Kidney Failure, Acute ; Complicated

We encountered 15 cases of surgical site infection (SSI) by Methicillin-resistant Staphylococcus aureus (MRSA) among 153 patients who underwent a cardiovascular operation in 2000. SSIs consisted of 5 mediastinal infections, 9 surface wound infections and 1 artificial graft infection after an abdominal aortic surgery. All infected cases had been operated on between June and December 2000. Eighty-three cases, which underwent cardiovascular operations during this period, were divided into SSI or no-SSI groups and their clinical data were analyzed. The data included age, gender, preoperative diabetes, urgency, preoperative usage of a device like Swan-Ganz catheter or IABP, preoperative albumin level, preoperative physical state by ASA score, National Nosocominal Infections Surveillance index, duration of operation, usage of a cardiopulmonary bypass, duration of bypass, type of operation, and number of distal anastomoses in CABG operations. Multivariate analysis showed gender (male), diabetes, and emergency operation as independent risk factors for the incidence of SSI by MRSA. One patient, who suffered a mediastinal infection after CABG, had confirmed as demonstrating the colonization of MRSA in sputum preoperatively. Microbiological screening of medical staff showed 2 of the 6 surgical doctors and 3 of the 25 ward nurses exhibited colonization with MRSA. DNA analysis of MRSA, harvested from 5 infected patients, indicated at least 2 strains of MRSA and 1 of the 2 strains was identical to the MRSA that was detected in a doctor. We applied prophylactic measures with reference to the guideline for prevention of surgical site infection announced by CDC in 1999, which included the following: routine work-up of MRSA-colonization, and treatment of all MRSA colonized patients and those undergoing emergency operations with Mupirocin. Preoperative patients were isolated from MRSA-infected or colonized patients. MRSA-colonized surgical personnel were treated with Mupirocin ointment. Cephazoline was administered shortly before and after the operation as a prophylactic antibiotic. Vancomycin was added to Cephazoline in patients with a history of MRSA-colonization or infection. Through hand washing before and after daily contact with patients was emphasised to all medical staff. SSI surveillance conducted by an infection control team was implemented. After the introduction of the prophylactic measurements, one MRSA-SSI was observed among 113 cases who underwent a cardiovascular operation between January and September 2001.

  A 55-year-old man visited his neighborhood general practitioner complaining of headache, fever and wet cough on July 7, 2003, but there were no sigins that his symptoms would subside. Since an abnormal shadow was found on chest X-ray on July 11, he was referred to our department and hospitalized on the same day. We started to treat him on the assumption that he had community-acquired pneumonia due-to common pathogens. However, he developed severe hypoxemia, and abnormal shadows rapidly progressed to affect both lungs, which led us to suspect that he had acute respiratory distress syndrome (ARDS). We identified the pathogen by examining urinary antigens and serum antibodies and diagnosed of his case as Legionella pneumonia. Although he suffered complications of acute renal failure and shock, the respirator was withdrawn after 11 days of controlled mechanical ventilation, as he was steadily recovering from his illness. The patient was discharged from the hospital on September 9. Although the mortality of legionella pneumonia, when complicated by ARDS, acute renal failure and shock as in the present case, has been reported to be as high as 50 to 80%, we consider that the administration of neutrophil elastase inhibitors and steroids was effective against this disorder.