A 78-year-old man consulted our hospital with complaint of abdominal mass. Blood examination indicated a inflammatory reaction. An abdominal aortic aneurysm, 5.5cm in size, was found by CT scanning examination. Its wall quite thick (mantle sign), and enhanced by contrast medium. Y graft replacement was carried out. Microscopic hiatological examination of the aneurysmal wall indicated severe inflammation being assisted of chronic inflammatory cells, like lymphocytes and plasma cells at the adventitia. Ten cases of inflammatory abdominal aortic aneurysm reported in Japan so far are reviewed and features of this disease are discussed.

Recently, objective structured clinical examinations (OSCEs) have been used to assess the clinical skills of medical trainees. We introduced an OSCE station for heart disease to assess clinical competence at the completion of bedside learning. The station involved students performing a 15-minute focused interview and physical examination of a simulated patient with mitral regurgitation and congestive heart failure. The physical examination included listening to a tape recording of a heart murmur. Each student was evaluated by three examiners. The average scores for the interview and physical examination were 22.3±4.0 points (perfect score, 34 points) and 15.2±2.9 points (perfect score, 22 points), respectively. Kappa statistics, which evaluate variability among examiners, revealed moderate to substantial agreement in the results for both the interview and the physical examination. This study suggests that our OSCE station is useful for assessing clinical competence at the end of bedside learning.

Two cases of blue toe syndrome were effectively treated by PGE1. Case 1 was an 80-year-old man who had an ulcer lesion of the 5th toe. Angiography indicated the symptoms were caused by microemboli from an extended lesion of the aorta and iliac artery. The wound was healed by lipo PGE1 (10μg×30 days). Case 2 was a 54-year-old man who had dull pain and skin color change of the 3rd and 4th fingers. A thrombus could not be detected by transthoracic echocardiography, but was found by transesophageal echocardiography. The symptoms improved by PGE1 (60μg×20days). Blue toe syndrome is induced by a microembolism in the peripheral arteries, and thus the conventional treatment has been the administration of fibrinolysins and anticoagulants. PGE1 was used in this study for the first time in consideration of its vasodilating effect on the collateral circulation and to prevent a secondary thrombus by inhibiting platelet aggregation.

This is a rare case of abdominal apoplexy encountered in a 50-year-old man who had aortic and mitral valve replacement due to dominant regurgitation resulting from infective eneocarditis. On the 4th day after the operation, retroperitoneal bleeding, probably due to rupture of the splenic artery aneurysm, occurred and he developed shock. On the 28th day, there was bleeding in the digestive tract and blood pressure was low, probably due to rupture of the microaneurysm of the small artery distributing to the ileum. Rupture of an abdominal vessel without a recognizable external cause is called abdominal apoplexy, and our case was caused by mycotic aneurysm caused by infective endocarditis. Angiography facilitated the accurate diagnosis.

Objective. We investigated whether the aging-related decrease in gap junction expression affects myocardial response against ischemia-reperfusion injury of the rabbit myocardium. Methods. Isolated aged (≥135 weeks) or mature (15-20 weeks) rabbit hearts were perfused with Krebs-Henseleit solution via a Langendorff apparatus, and were divided into five groups as follows: 7 mature hearts served as mature controls (Group A), 7 mature hearts underwent ischemic preconditioning (IPC) consisting of two cycles of global ischemia for 5min followed by reperfusion for 5min (Group B), 7 aged hearts served as aged control (Group C), 7 aged hearts underwent IPC (Group D) and 7 mature hearts received 1mM of gap junction uncoupler heptanol for 5min (Group E). Then, all hearts were subjected to 1h of left anterior descending coronary artery occlusion followed by 1h of reperfusion. Left ventricular pressure, ischemic zone monophasic action potential and coronary flow were measured throughout the experiment and the infarct size (IS) was determined at the end of the experiment. Gap junction expression was investigated by the electron microscopy. Results. The IS of Group A was 39.1±3.8 (%) and that of Group B was 26.9±3.8 (%)^* (^*p<0.05 vs. Group A). The IS of Group C was 19.3± 1.6(%)^*. That of Group D was 43.6±5.8 (%)^# (^#p<0.05 vs. Group C). IS of Group E was 24.3±1.6 (%)^*. Electron microscopic findings demonstrated that gap junction expression in aged hearts was less prominent than in mature ones. Conclusion. These data suggested that aged myocardium might be more tolerant of ischemic insult than that of mature heart, and that the mechanism might be related to the aging-related change of gap junction expression.

Patients who underwent the bypass operation during 5 years from 1987 to 1992 in the 1st Department of Surgery, Hiroshima University School of Medicine, were divided into 2 groups; AIOD group (51 cases) had lesions in the aorta and iliac artery, and FPOD group (46 cases) had lesions in the femoral artery and popliteal artery. A comparative study of these two groups was made. There was no significant difference in age, sex, symptom severity, smoking history, serum cholesterol level, serum triglyceride level. The complication rate of peripheral lesions of the AIOD group was 24% and of the FPOD group was 57%. The cumulative patency rate for 5 years of the AIDO group was 100% and of the FPOD group was 61%. The AIOD group exhibited better patency. In addition to the lower complication rate of peripheral lesions, all the AIOD group had underwent reconstruction operation for peripheral lesions simultaneously. The run-off state of the peripheral region may thus possibly be related to patency.

Fifty-one cases which underwent surgery for arteriosclerosis obliterans in the aorta and iliac artery at the First Department of Surgery, Hiroshima University School of Medicine were divided into two groups. The EAB group (18 cases) underwent extra-anatomic bypass operation, and the AB group (33 cases) underwent anatomic bypass operation. A comparative study showed the mean age of the EAB group to be 10 years higher than that of the AB group, and the former group exhibited severer symptoms. Renal and pulmonary function declined in the EAB group, and the occurrence rate of complications such as cerebral infarction was also higher At operation, the following approaches were employed; long-term administration of PGE-1 before and after operation, operation with a better visual field under light general anesthesia, simultaneous reconstructive operation in peripheral lesions, artificial vessels of externally supported velour knitted Dacron. There was no case of obstruction in the past 5 years. Extra-anatomic bypass operation therefore provides as good postoperative patency as anatomic operation.

A 74-year-old man presented with swelling in both lower limbs and fatigue. Venography indicated nozzle-like stenosis of the inferior vena cava that appeared during the inspiratory phase but disappeared during the expiratory phase. A large pressure gradient between the upper and lower portion of the stenosis was observed during the expiratory phase. Stenosis during the inspiratory phase was relieved by percutaneous transluminal angioplasty, and symptoms and signs disappeared. Although stenosis occurred only during the inspiratory phase, our patient exhibited symptoms characteristic of Budd-Chiari syndrome. We believe that this patient originally had stenosis of the diaphragmatic portion of the inferior vena cava, and that his symptoms derived from the formation of a parietal thrombus.

In Akita Prefecture, there are nine hospitals established by the Akita Prefectural Federation of Agricultural Cooperatives for Health and Welfare (Koseiren). Half of the stroke patients in the prefecture were treated in these Koseiren hospitals, and half of the mass screening projects for the prevention of cardio vascular diseases were undertaken by these hospitals. A retrospective cohort study was done using mass-screening data (age, sex, past history of diabetes mellitus, blood pressure, body mass index, smoking and drinking habits) of 175,033 cases stored at these hospitals from 1988 to 1999, and the prefecture-wide stroke data of 2,520 initial stroke events registered from 1988 to 2003. The number of stroke cases was broken down into 1,428 cases of cerebral infarction (57%, CI), 693 cases of cerebral hemorrhage (27%, CH) and 399 cases of subarachnoid hemorrhage (16%, SAH). The subjects were also divided into five age groups:30-49, 50-59, 60-69, 70-79 and 80-89. Blood pressure (BP) was classified into six categories according to the JNC 6 criteria. Risk factors were determined using the Cox analysis. The hazard ratio for CI and CH was increasing with advancing age. CI showed a higher hazard ratio in men than women (hazard ratio for men was 1.8). The hazard ratio was increasing as BP became higher in any of three stroke subtypes, and especially CH showed the strongest correlation with BP. Uncontrollable risk factors were very closely associated with the attack of CI. On the other hand, BP (controllable risk) was closely linked with the attack of CH. Our results showed the prevention of CI was not easy. Controlling BP may be the most effective strategy for preventing hemorrhagic stroke (CH and SAH).
Cerebrovascular accident ; Cephalic index ; Blood pressure determination ; hazard ; Risk Factors