Because Japanese high school graduates have poor basic English skills they have difficulty acquiringduring the 6 years of medical school English skills sufficient to write medical papers in easily understood English and to converse with foreign medical researchers at international medical conferences in fluent English. In an attempt to improve English teaching in medical schools we analyzed the structures of sentences in high school English textbooks and compared them with those of sentences in more advanced English, as in the journals Science and Nature. We found that the English in high school textbooks has significantly lower subordination ratios. Thus, we propose that English with higher subordination ratios be taught in the 1st year of medical school.

Objective (1)To study the change of fetal middle cerebral artery pulsatility index (PI_MCA) in twin pregnancy; (2)To compare the singleton and twin pregnancies with regard of changes in PI_MCA over the course of the pregnancy. Methods Fetal middle cerebral artery flow velocity waveforms were measured in 34 cases of normal twin pregnancies and 176 cases of normal singleton pregnancies from 23～35 gestational weeks. Results PI_MCA in twin pregnancies exhibited a decrease trend toward the gestation. Before 29 weeks' gestation the PI_MCA in twin pregnancies was lower than that of the singleton pregnancies,and it was rather higher than that of the singleton pregnances after 29 weeks'gestation. Conclusions The vascular resistance in middle cerebral artery after 29 weeks of gestation was higher in twin pregnancies than that of the singleton pregnancies.

Between May in 1988 and October in 1990, simultaneous coronary artery bypass grafting (CABG) and valve surgery was performed in 14 patients. Nine patients received arterial graft conduit for CABG (AG group) and only saphenous vein graft (SVG) was used in 5 patients (SVG group). In AG group, mean age was 63.3 years and the number of distal anastomosis was 2.2/patient. In valve operation, valve replacement was performed in 5 and valve plasty was in 4, and the mean aortic cross clamping time was 116min. As AG, internal thoracic artery (ITA) was used in 8 and right gastroepiploic artery (RGEA) was in 4. Among them concomitant use of ITA and RGEA was in 3, and the use of SVG was in 5. In two patients, the AG pedicle did not reach to either left anterior descending or obtuse marginal artery and the SVG was used as a graft conduit. Between AG group and SVG group, there were no significances in the age and aortic cross clamping time. However, postoperative use of cathecholamin was in three (33%) in AG group and three (60%) in SVG group and there were significant differences between them. In AG group, there were no operative deaths and the late NYHA improved to class I in 4 and class II in 5. In simultaneous CABG with AG and valve surgery, the improvement of symptom was good and stable operative result was obtained, however, the length of the pedicled graft should be carefully considered for coronary anastomosis.

A 50-year-old man was diagnosed as having aortic valve insufficiency, complete occlusion of the right coronary artery and 75% stenosis of the left main trunk due to syphilitic aortitis. Aortic valve replacement and coronary artery bypass grafting to three vessels were successfully performed. The selection of surgical procedures for the coronary lesion with syphilitic aortitis should be made carefully, since the progression of aortic root inflammation in the acute phase and the development of atherosclerotic changes are not preventable in the future. It is most important to select effective and safe surgical interventions, especially for patients with such a low cardiac function as our patient.

We studied possible factors to cause left ventricular rupture after mitral valve replacement and the prevention in eight patients of 1, 046 receiving mitral valve replacement between September, 1965 and August, 1991. The age at operation ranged from 43 to 67 years old (average 58 years old), and there were one man and seven women. According to the Treasure and Miller's classification, the type of rupture was type I in 5, type II in 2, and type III in 3. The onset time of rupture was immediately after cardiopulmonary bypass in 3 and at the time of chest closure in one. In four patients it occurred 11 hours, 14 hours, 18 hours and 25 hours after operation, respectively. In 8 patients, repair was performed with external closure under heart beating and in five patients with both internal and external closure during cardiac arrest under cardiopulmonary bypass. Two patients under cardiopulmonary bypass were successful for hemostasis, however, they died with low cardiac output syndrome, following to multiple organ failure 2 or 44 days after operation, respectively. The repair was not successful in 6 patients. In four patients the left ventricular rupture occurred immediately after hypertension and pathological findings showed severe myocardial degeneration of left ventricular muscle in all of them. These findings may suggest that hypertension after the operation is one of major factors to cause left ventricular rupture and thus the careful management of the systemic blood pressure after mitral valve replacement is effective to prevent the left ventricular rupture.

Surgical interventions for aorto-iliac obstructive diseases were studied through the operative results. Eighteen patients underwent aorto-femeral bypass (AOF) and 23 who were over 70 years of age or who had serious preoperative complications had axillofemoral bypass (AXF). No perioperative death occurred in AOF patients, while the mortality rate of AXF patients was 8%. Postoperative ankle pressure indexes were significantly higher in AOF patients than in AXF patients. Follow-up graft patency rate was 100% in AOF patients at 54 months (mean), and 85% in AXF patients at 44 months respectively. AOF should be the first choice for patients with aorto-iliac obstructive disease, and AXF is suitable only for high-risk patients.

In a consecutive series of abdominal aortic aneurysm repairs, a non-washing autotransfusion unit system was used in 47 patients, and was not used in 25. In the 47 patients treated with the autotransfusion unit, the average amount of autotransfused blood was 1, 109±131ml in elective cases. The amount of banked blood transfusion was significantly smaller in autotransfused patients (mean; 712ml), compared to non-autotransfused patients (mean; 1, 405ml). Postoperative levels of serum bilirubin were higher in patients with greater autotransfused blood volumes than those with smaller volumes. The combination of preoperative autologous blood donation (2-3 units) and intraoperative autotransfusion is necessary to perform abdominal aortic aneurysm repair without homologous blood transfusion.

Surgical results in eight octogenarians who were operated upon for abdominal aortic aneurysms were compared to those of 42 patients under 80 years of age. Seven of eight octogenarians were operated on an emergency basis, and four of them were ruptured aneurysms. The size of the ruptured aneurysms was over 6cm in all cases of both groups. Postoperative complications occurred more frequently and postoperative mortality were significantly higher in octogenarians than in patients under 80. Early surgical intervention is recommended for elderly cases with large abdominal aortic aneurysms.

Blood oxygen saturation, keton boby ratio and endotoxin concentration of arterial and hepatic venous blood were measured in 12 adult patients before, during and after extracorporeal circulation (ECC). When rectal temperature returned to 32°C during ECC, the levels of hepatic venous blood oxygen saturation (ShvO₂) and arterial keton body ratio, hepatic venous keton body ratio decreased. The serum level of endotoxin concentration was within normal limits on the operative day and increased at the first and second day after surgery. In three patients in whom the level of ShvO₂ was under 50% at 60 minutes after ECC, postoperative liver dysfunction occurred frequently. Endotoxin changes on the first day after surgery is probably due to recovery differences between hepatic and gastrointestinal circulations.

A 78-year-old man underwent successful removal of a contaminated pacemaker in a case of methicillin-resistant Staphylococcus aureus (MRSA) septicemia. Septicemia was due to a subcutaneous abscess at the site of old cut electrodes. Following debridement of the infected pacemaker pocket, residual leads and the pacemaker system were removed under cardiopulmonary bypass. Bacterial examination of arterial blood and vegetation attached to the leads showed septicemia caused by MRSA. After the operation, antibiotic therapy with vancomycin, arbekacin and minocycline was performed for several weeks. His postoperative course was uneventful without the recurrence of infection. In cases of pacemaker contamination, with septicemia, total removal of the pacemaker system and adequate antibiotic therapy are necessary.