The total correction of tetralogy of Fallot (TOF) after the right ventricular outflow tract construction without ventricular septal defect closure which is called central palliation is rarely reported. A case of TOF had been undergone the central palliation because of left ventricular hypoplasia in a 30 year-old woman, 19 years after Blalock-Taussig's shunt. She was performed successfuly on the total correction of TOF and pulmonary valve replacement at 35 years old, 5 years after the central palliation.

A 34-year-old man had been in a motor vehicle accident at age 21. Thirteen years later, he complained of fatigue and palpitations, and was evaluated at an outside hospital. Echocardiography revealed severe tricuspid regurgitation and the patient was referred to our institution for treatment. The anterior leaflet of the tricuspid valve was torn and the attached chorda was also torn. The torn anterior leaflet was sutured directly, and an artificial chorda was created using an e-PTFE suture. An annuloplasty was performed with a 34mm Carpentier-Edwards ring. The patient's recovery was uneventful, and postoperative echocardiography revealed no regurgitation.

SPs have made a dramatic development in medical education over 10 years, due to the influence of medical education curriculum reform and the introduction of the Objective Structured Clinical Examination. However the quality of SPs' activities varies. In order to increase the quality it is necessary to analyze the psychological needs of SPs. The purpose of this survey is to explore SPs' personal characteristics and how they feel during their activities.
1) In a nationwide survey of Japanese SPs, 332 SPs (62%) out of 532 responded.
2) Sixty percent of SPs were between the ages of 50 and 69 years and the ratio of male to female SPs was 1: 4. The ratio of workers and non-workers was 1: 2.
3) A qualitative analysis found that SP motivations were derived mainly from making a contribution to society and self-improvement. Ninety six percent of SPs were satisfied with being an SP, especially when they saw improvements in the students.
4) However, 67% of SPs expressed difficulty with the three core skills of feedback, evaluation and performance.

The role of standardized patients (SPs) has developed rapidly over the last10years because of medical education curriculum reform and the introduction of the objective structured clinical examination (OSCE). As the participation of SPs in medical education has increased, the anxieties and frustrations of SPs have also increased. We believe that an understanding of the attitudes of SPs would improve the quality of their activities. The purpose of this survey was to study the activities and psychological needs of Japanese SPs in the OSCE.
1) The response rate to the nationwide survey was62% (332of532SPs).
2) Role-playing and group discussion were the most common training methods, and the length of training varied from 0 to 40 hours.
3) The factors that SPs felt difficult were judging how much to respond in their performances (73%) and maintaining consistent standards in evaluating examinees (66%).
4) Our results suggest that SPs require more training and that the number of SP educators should be increased.

We report a case of successful graft replacement of the total aortic arch using selective cerebral perfusion for recurrent distal aortic arch aneurysm (DAAA). A 72-year-old man who had a history of patch aortoplasty for saccular DAAA was admitted to our hospital. Computed tomography and digital subtraction angiography showed recurrent saccular DAAA and coronary angiography revealed 90% stenosis of the first diagonal branch, resulting in a diagnosis of recurrent DAAA with coronary artery stenosis. A graft replacement of the total aortic arch with the aid of selective cerebral perfusion and coronary artery bypass grafting to the first diagonal branch was carried out. Postoperatively, he had no cerebral complications. One year after the operation, he had an operation for an abdominal aortic aneurysm. The patient is now leading a normal life.

Six (1.2%) of 501 patients sustained phrenic nerve injury during operation for congenital heart disease at our institutions between 1992 and 1998. The diagnosis was confirmed by percutaneous stimulation of the phrenic nerve. All but 1 patient were less than 9 months old, and the average weight was 3.6kg. All 6 patients underwent diaphragmatic plication and were extubated by 7 days after operation. Percutaneous stimulation of the phrenic nerve allowed direct assessment of phrenic nerve function which was difficult to detect by clinical and radiological evidence. This method can be non-invasively used at the bedside to facilitate early and accurate diagnosis of phrenic nerve palsy.

The retroperitoneal approach for abdominal aortic aneurysm (AAA) has been used to reduce the risk of postoperative ileus and respiratory failure. This technique is usually used in patients with non-ruptured infrarenal AAA because it has been considered to be more time consuming to approach the aorta than the normal transabdominal approach. However, we may not have sufficient information if the aneurysm is confined to the infrarenal abdominal aorta in a ruptured case. In such a situation, the retroperitoneal approach might be better than the transabdominal approach because an aortic clamp can easily be applied to the suprarenal aorta. We report three cases of ruptured AAA treated successfully by the retroperitoneal approach.

Objectives: To investigate future directions of medical interview and physical examination practice (MIPEP) with simulated patients and to clarify its educational meaning for medical students. Design: Qualitative design using 8 focus groups before and after MIPEP with simulated patients (4 pre-MIPEP and 4 post-MIPEP). Methods: Nine simulated patients and 10 medical students participated. Four physicians served as facilitators. Each student practiced consultation, including two medical interviews and physical examinations (of one male and one female simulated patient), for 15 minutes. After every consultation, students had a 15-minute feedback session with a simulated patient and a facilitator. All simulated patients and students participated in both the pre-MIPEP and post-MIPEP focus groups. Results: Through pre-MIPEP and post-MIPEP focus groups, medical students realized that an appropriate disposition and talking with patients during physical examination are helpful. MIPEP with simulated patients helps students to gain confidence before clinical practice. Simulated patients found that the value of MIPEP with simulated patients for medical students was increased by thorough course preparation and by the simulated patient's training and motivation, which was affected by the students' attitudes to MIPEP with simulated patients. Conclusion: MIPEP with simulated patients is valuable for teaching the appropriate disposition towards patients, including making physical contact and talking with patients as fellow human beings. When the students' attitudes satisfy the simulated patients, MIPEP with simulated patients can become a powerful educational method.

Introduction: Consultation simulation with simulated patients has rarely been done as a training program.
Method: Fifth-year medical students in 2 neighboring universities attended the same training program at each site. The students’ performance was evaluated.
Result: Most medical students thought that this training program was valuable and that they require more opportunity to practice. Students evaluated their own performance in both medical procedures and differential diagnosis as being poor. However, about 50% of students felt that they paid careful attention to the simulated patient during physical examination. Students thought that the consultation was extremely realistic and that the series of medical procedures they performed at the first attempt was extremely difficult but increased their motivation. They thought that the feedback they received from simulated patients was beneficial.
Discussion: This education program is highly regarded by students and is suggested to be versatile.

We reported a rare case of myxoma originating from the anterior leaflet of the mitral valve. A 65-year-old woman was admitted with sympotomes of easily fatigability and palpitation. On auscultation, a grade II/IV systolic murmur was audible at the apex. Echocardiography demonstrated a dense mass arising from the anterior mitral leaflet. The tumor (16×13×10mm in size) was resected from the anterior leaflet of the mitral valve. There was no definite evidence of a tumor stalk on the mitral valve nor valve regurgitation after the operation. Microscopically, polyhedral cells were recognized, indicating myxoma. The postoperative course was uneventful and no recurrence has been noticed during the past 6 years.