A 59-year-old man with myocardial infarction underwent 4-vessel coronary artery bypass grafting. After operation, on the 9th hospital day, fever, dehiscence of the median wound, and pus discharge were observed. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in the wound, and median wound curettage and removal of the sternal bone wire were performed. The infection also involved the substernal area and anterior mediastinum, and a diagnosis of mediastinitis was made. After wound cleansing and antibiotic (vancomycin) administration, inflammatory reactions decreased, and MRSA disappeared from the wound. The wound spontaneously closed, and complete closure required 60 days. On the 75th hospital day, pain from the right shoulder to the neck and numbness in the upper limbs suddenly developed. MRI revealed vertebral body destruction at C5-6, and a diagnosis of cervical osteomyelitis was made. The spinal cord was compressed, and there was a risk of spinal cord injury below the cervical spine. After consultation with orthopedic surgeons, cervical anteroposterior fixation was performed, he improved, and was discharged. We report a patient with MRSA mediastinitis complicated by cervical osteomyelitis who required emergency surgery.

Background: The aim of this study was to clarify the decadal trends in the structure and usage status of palliative care units in Japan and the association with length of stay. Methods: We conducted a secondary analysis of data from nationwide surveys of palliative care units conducted by Hospice Palliative Care Japan from 2002 to 2012. Length of stay was divided into three categories (within 30 days, 31 to 60 days, and 61 days or more). Results: Significant decadal trends in usage status were observed: the mean annual number of admitted patients (119±55 persons in 2001, 163.0±77.7 in 2011, p＜0.001), and deaths (99±44, 136±58, p＜0.001) increased and the mean length of stay in a palliative care unit (8±15 days, 39±15, p＜0.001) decreased. Palliative care units with a shorter mean length of stay had significantly more admitted patients, and more discharged patients, and a significantly lower mean ratio of death to discharge, and a lower bed availability rate. In contrast, length of stay was not significantly associated with the structure of palliative care units, including the type of units, number of inpatient beds, percentage of private rooms, and number of staff. Conclusion: The features of decadal trends in the structure and usage status of palliative care units in Japan were a shortening of length of stay, and an increase in the number of patients. Palliative care units with a shorter mean length of stay cared for a larger number of terminally ill patients.

The authors examined the frequency of thromboembolism and bleeding complications in cases of mechanical valve replacement during the past 5 years in the Tokyo area. There were 21 cases of thromboembolism and 15 cases of bleeding complications. Analyzing these cases with regard to anticoagulant therapy, 71% of the thromboembolism cases and 47% of the bleeding complication cases had 10∼25% result on the thrombotest at the time of the event. Consequently, in cases of mechanical valve replacement it is necessary to reevaluate the therapeutic range of the thrombotest results. This was a retrospective study of a TAS (The Tokyo area anticoagulation study for cardiac valve replacement by using PT-INR) trial and we intend to carry out a prospective study on the therapeutic range of the thrombotest and PT-INR.

A 61-year-old woman who presented with symptoms of dysphagia was hospitalized after right subclavian artery aneurysm was diagnosed. A selective right subclavian arteriogram revealed the presence of two large subclavian arterial aneurysms. The operative procedure consisted of aneurysmectomy through a right supuraclavian incision followed by the reconstruction of the blood vessel by end-to-end anastomosis of the right subclavian artery. The postoperative course was uneventful. Multiple subclavian artery aneurysms are rare among peripheral aneurysms. This case was found by the symptoms of dysphagia caused by compression of the esophagus. The etiology of this case is unclear, but most likely was due to trauma.

A 50-year-old man who had coronary artery bypass grafting (LITA-LAD, RA-RCA, SVG-OM-PL) 6 years previously was admitted with acute dissection of the aorta (DeBakey type I). Preoperative computed tomography showed that all coronary bypass grafts were patent. We replaced the graft of the ascending aorta and reconstructed the coronary artery bypass by re-sternotomy, circulatory arrest (rectal temperature: 23.6°C), retrograde cerebral perfusion, and intermittent retrograde cardioplegia. Because a radial artery (RA) graft and a saphenous vein graft (SVG) each had intact orifices, we detached them together and attached the grafts back to the aortic graft wall. He was weaned successfully from cardiopulmonary bypass without difficulty and postoperative transthoracic echocardiography (TTE) showed good left ventricle (LV) function. Postoperative multidetector-row computed tomography (MDCT) showed that the RA graft and SVG were patent. By performing circulatory arrest and intermittent retrograde cardioplegia, we successfully protected the myocardial function of a patient with acute aorta dissection after a CABG and we reconstructed the graft without needing further coronary anastomosis.

Aneurysms of the inferior left ventricular wall comprise only a small fraction of all aneurysms that have been reported in surgical series. Pseudo-false ventricular aneurysm is very rare and communicates with the left ventricule through a small orifice, and its wall contains myocardial tissue, unlike false ventricular aneurysm. A 53-year-old man was admitted to our hospital with chest pain. Echocardiography revealed left ventricular aneurysm, and the coronary arteriography subsequently revealed a complete occlusion of right coronary #2 and 75% and 90% stenosis of left anterior descending artery #7 and #8, respectively. Left ventriculography revealed an aneurysm of the inferior left ventricular wall, which communicated with the left ventricle through a small orifice and exhibited contraction. Surgical repair was indicated. Endoventricular circular patch repair (Dor operation) of the aneurysm of the inferior left ventricular wall and coronary artery bypass grafting to the left anterior descending artery and the right coronary artery were simultaneously performed under cardiopulmonary bypass with moderate hypothermia. The postoperative course was uneventful and the patient was discharged on the 22th day after surgery. Pseudo-false ventricular aneurysm of the inferior left ventricular wall was diagnosed by pathologic examination.

A 71-year-old man had been repeatedly admitted to our hospital with congestive heart failure, cerebral infarction and pneumonia. Under a diagnosis of mitral regurgitation and tricuspid regurgitation by echocardiography and catheter examination, mitral valve replacement and tricuspid annuloplasty were performed. Pathohistological study revealed a direct insertion of the papillary muscle into the anterior mitral leaflet (DPM) in addition to post-rheumatic valvular disease. These findings suggest that the increased rigidity of the scarring valve leaflets in combination with direct insertion of DPM lead to inadequate leaflet coaptation and apposition. This is the first report of mitral valve replacement for mitral regurgitation due to post-inflammatory valvular disease with DPM.

Purpose: The aim of this study was to clarify the factors contributing to the evaluation of perceived care in inpatient palliative care services from the aspect of informal caregiver after their loss of the patient to cancer. Method: A questionnaire was mailed to 9,684 bereaved subjects who had lost family members at one of 103 palliative care units in Japan to evaluate their sociodemographic characteristics and the evaluation of perceived care. An institution survey was performed to collect organization-related variables. The evaluation of perceived care was rated by the Care Evalutaion Scale (CES), the Good Death Inventory (GDI) and single item of overall satisfation. Result: A total of 5,810 responses were analyzed (response rate＝60％). Uni-variate and multivariate analysis was performed to clarify the determinants of each scale. Significant determinants of the score in the evaluation of care identified were: the rate of private room (100％), independent facility, palliative care physician being night-time duty, the number of nurses at night (＞0.1 per bed), sending a letter to every bereaved family, holding a memorial services for every bereaved family and having a religious background. Conclusion: In conclusion, the evaluation of palliative care from the aspect of informal caregiver was influenced by various organization-related variables.

Based on two years working of “the enlarged working group for the curriculum of chemistry for medical education”, a provisional plan of the curriculum of chemistry for medical students is proposed. The article is consist of four sections; namely A: general problems, B: “chemistry” as a general education, C: purpose and specific problems of the general education for medical students, D: a provisional plan of the curriculum of chemistry for medical students.
The main part D is consist of three subsections: namely (1) a plan of the curriculum of physical and inorganic chemistry, (2) a plan of the curriculum of organic chemistry, (3) a plan of the curriculum of experiments.

BACKGROUND/AIMS: Postoperative endoscopic recurrence (PER) occurs in nearly 80% of patients 1 year after ileocecal resection in patients with Crohn's disease (CD). Biological agents were more effective in reducing the rates of PER in comparison with conventional therapy, in prospective trials. The aim of this study was to compare the PER rates of biological versus conventional therapy after ileocecal resections in patients with CD in real-world practice. METHODS: The MULTIPER (Multicenter International Postoperative Endoscopic Recurrence) database is a retrospective analysis of PER rates in CD patients after ileocecal resection, from 7 referral centers in 3 different countries. All consecutive patients who underwent ileocecal resections between 2008 and 2012 and in whom colonoscopies had been performed up to 12 months after surgery, were included. Recurrence was defined as Rutgeerts' score > or =i2. The patients were allocated to either biological or conventional therapy after surgery, and PER rates were compared between the groups. RESULTS: Initially, 231 patients were evaluated, and 63 were excluded. Of the 168 patients in the database, 96 received anti-tumor necrosis factor agents and 72 were treated with conventional therapy after resection. The groups were comparable regarding age, gender, and perianal disease. There was longer disease duration, more previous resections, and more open surgical procedures in patients on biologicals postoperatively. PER was identified in 25/96 (26%) patients on biological therapy and in 24/72 (33.3%) patients on conventional therapy (P=0.310). CONCLUSIONS: In this retrospective observational analysis from an international database, no difference was observed between biological and conventional therapy in preventing PER after ileocecal resections in CD patients.
Biological Factors ; Biological Therapy* ; Colonoscopy ; Crohn Disease* ; Humans ; Necrosis ; Observational Study* ; Recurrence* ; Referral and Consultation ; Retrospective Studies ; Tumor Necrosis Factor-alpha