We describe two repeated operations to treat ascending aortic pseudoaneurysms. The first was emergency patch closure of the ascending aorta due to impending rupture 8 years after an operation for type I aortic dissection under hypothermic circulatory arrest. The second was endovascular repair using a fenestrated stent graft 7 years after coronary artery bypass grafting. No specific guidelines have been established regarding optimal management for such patients. We believe that individualized management is safer, especially for repeated operations.

The purpose of this study was to investigate the effects of combined resistance training and aerobic training with protein intake after resistance training on body composition in obese middle-aged women. The subjects were 42 middle-aged women (age : 56.5±4.3 years, BMI : 26.6±2.3 kg/m²), who were classified into three supplementation groups: Protein group (PG), Isocalorie placebo group (IG), and Noncalorie placebo group (CG) by Double Blind Randomized Trial. The training program consisted of combined resistance training and aerobic training for 10 weeks, 5 times per week: twice a week in a university training room and 3 times per week at home. The subjects took the nutrient supplement immediately after each resistance training session. We measured body weight (Bw), body fat volume (Bf) by bioelectrical impedance analysis (BIA), and cross-sectional area (CSA) of muscle of the thigh extensor group (Te), flexor group (Tf), and psoas major (Pm) by magnetic resonance imaging (MRI) before and after the 10-week training period. Irrespective of group, Bw and Bf showed a significant decrease after the training period compared to before (p<0.001), and the CSA of Te muscle showed a significant increase after the training period (p<0.01). Moreover, the interaction of time×group was accepted in the CSA of Pm muscle (p<0.05), and the increase in muscle volume for PG was the highest increase among the three supplementation groups (p<0.05)(PG : 2.1±0.8 cm², IG : 1.3±1.0 cm², CG : 1.3±0.9 cm²). These results suggest that combined training in middle-aged obese women improves body composition, and resistance training with protein intake may increase the CSA of muscle of psoas major.

An echocardiogram revealed a mobile mass attached to the left coronary cusp of the aortic valve in an 81-year-old woman. The tumor was surgically removed without valve replacement. The tumor was whitish in color, with a sea anemone-like appearance, and it measured 10 mm in maximum dimension. It was histopathologically defined as papillary fibroelastoma (PFE), and the postoperative course was uneventful. Primary cardiac tumors are rare, and the majority are myxomas. However recent advances in noninvasive examination and surgery may increase the detection of PFE, which occurs most frequently on the endocardial surface of the cardiac valve. We report a case of cardiac PFE with a review of the pertinent literature.

We encountered a recurrent suprarenal abdominal aortic aneurysm (AAA) patient with coronary artery disease and hyperlipidemia after repair of infrareanal AAA. A 72-year-old woman complaining of an abdominal throbbing mass was admitted. Computed tomography (CT) and aortography revealed infrarenal AAA which was totally removed and Dacron graft was replaced. The patient was followed as an outpatient. At the time of initial graft replacement there was no remarkable aneurysmal change in suprarenal abdominal aorta. Five years after the initial operation, a suprarenal AAA 5cm in diameter was detected by ultra sonographic examination. CT scan and aortography confirmed suprarenal AAA involving the celiac trunk of the supramesenteric artery and renal artery. Redo AAA operation with reconstruction of these branches was performed under V-A bypass support in a thoracoabdominal approach. Slight renal and liver dysfunction occurred postoperatively. However, serum creatine GOT and GPT values normalized by the ninth postoperative day. Postoperative aortography revealed patency of all branches.

This paper aimed to summarize the current situation of prognostication for patients with an expected survival of weeks or months, and to clarify future research priorities. Prognostic information is essential for patients, their families, and medical professionals to make endof-life decisions. The clinician’s prediction of survival is often used, but this may be inaccurate and optimistic. Many prognostic tools, such as the Palliative Performance Scale, Palliative Prognostic Index, Palliative Prognostic Score, and Prognosis in Palliative Care Study, have been developed and validated to reduce the inaccuracy of the clinician’s prediction of survival. To date, there is no consensus on the most appropriate method of comparing tools that use different formats to predict survival. Therefore, the feasibility of using prognostic scales in clinical practice and the information wanted by the end users can determine the appropriate prognostic tool to use. We propose four major themes for further prognostication research: (1) functional prognosis, (2) outcomes of prognostic communication, (3) artificial intelligence, and (4) education for clinicians.

Background/Aims: Thiopurines are key drugs for inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD). Recently, NUDT15 polymorphism (R139C, c.415C > T) has been shown to be associated with thiopurineinduced adverse events in Asian populations. In patients with the C/T genotype, low-dose thiopurine treatment is recommended, but its long-term efficacy and tolerability remain unclear. This study aimed to uncover the long-term efficacy and appropriate dosage of thiopurine for IBD patients with the C/T genotype. Methods: A total of 210 patients with IBD (103 UC and 107 CD) determined to have NUDT15 R139C variants were enrolled. Clinical data were retrospectively reviewed from medical records. Results: Of 46 patients (21.9%) with the C/T genotype, 30 patients (65.2%) were treated with thiopurines. Three of whom (10.0%) discontinued thiopurine treatment due to adverse events and 27 of whom continued. The median maintenance dosage of 6-mercaptopurine was 0.25 mg/kg/day (range, 0.19–0.36 mg/kg/day), and 6-thioguanine nucleotides level was 230 (104–298) pmol/8 × 108 red blood cells. Cumulative thiopurine continuation rates for 120 months for patients with the C/C and C/T genotypes were not significantly different (P= 0.895). Cumulative non-relapse rates in the patients with UC treated with thiopurine monotherapy and surgery-free rates in CD patients treated with combination therapy (thiopurines and anti-tumor necrosis factor-α agents) for maintenance remission were not significantly different at 60 months (C/C vs. C/T, P= 0.339 and P= 0.422, respectively). Conclusions Low-dose thiopurine treatment is an effective and acceptable treatment for patients with C/T genotype.

A 40-year-old man with a family history of Marfan syndrome was admitted to our hospital because of acute Stanford type A aortic dissection. He underwent a Bentall operation with an artificial vascular graft. Postoperative computed tomography revealed a low-density area around the graft in the ascending aorta and at the left subclavian artery cannulation site. He showed no symptoms and was discharged uneventfully. Five months after the operation, a pulsatile subdermal tumor appeared in the center of the median sternotomy. Computed tomography showed low- and high density fluid accumulation surrounding the ascending aortic graft, and this was connected with a subdermal tumor. We suspected collapse of the anastomotic site and performed an emergency operation. The fluid around the aortic graft was clear and diagnosed as perigraft seroma. To prevent recurrence, we filled the space around the aortic graft with an omental pedicle graft. After the operation, perigraft seroma did not recurr. In addition, with the disappearance of the seroma in the mediastinum, fluid accumulation at the left subclavian artery cannulation site also disappeared.

Papillary fibroelastoma (PFE) is a rare primary cardiac tumor that usually involves an aortic or mitral heart valve. We encountered a case of a 32-year-old woman, who presented with syncope and was found to have multiple PFEs involving all four heart valves during surgery. The echocardiography was performed and showed two mobile masses near the tricuspid and mitral valves. Moreover, the enhanced computed tomography (CT) showed thickened aortic cusps, which may indicate the possibility of heart tumor. Intraoperatively, we first found multiple tumors at each cusp of the aortic valve, ranging in size from 5 to 10 mm which were excised without injury of aortic cusps themselves. These showed a sea anemone-like appearance and were suspected to represent PFE. We then observed the tricuspid and mitral valves, and both valves showed tumors of similar appearance in each cusp. Furthermore, we found a tumor at the pulmonary valve, even though there had been no evidence of its presence on echocardiography or CT. We confirmed that these masses were PFEs by histological study after the operation. We should keep in mind that PFE can develop in multiple valves. To the best of our knowledge, this is the first description of multiple PFEs involving all four heart valves.

Purpose: The purpose of this study was to clarify the current status of Do-Not-Resuscitate discussions (DNRd) with terminally ill cancer patients in Japan and the psychological burden on bereaved families depending on whether or not a DNRd is performed. Method: A multicenter prospective observational study of advanced cancer patients admitted to 23 palliative care units (PCUs) in Japan was conducted, and a questionnaire survey of bereaved families was also conducted after patients died. Result: 1,605 patients were included in the analysis, and 71.4% of patients had a DNRd with doctors before PCU admission, 10.8% at admission, and 11.4% during admission. In contrast, 93.3% of family members had a DNRd with doctors before PCU admission, 48.4% at admission, and 52.1% during admission. Conclusion: Although DNRd was performed between patients and physicians in 72.3% of cases at any point throughout the course of time from before PCU admission to death, there was no evidence of psychological burden such as depression or complicated grief in the bereaved families due to patient participation in DNRd.