A 47-year-old man, having undergone mitral valve replacement in another hospital 9 years ago, suffered from sudden dyspnea and was transferred to our hospital immediately. On admission, disturbance of consciousness, severe dyspnea, marked hypotension (60/40) and hypo-oxygenation were noted. Under assisted ventilation with endotracheal intubation, diagnosis was confirmed by chest X-ray. The patient was transferred to the operation room after initiation of percutaneous cardiopulmonary support (PCPS). The emergency re-operation was started 7 hours after the onset of the symptoms. Left atriotomy was performed following total cardiopulmonary bypass and cardioplegic solution infusion. The pyrolite disc and the minor strut were missing and could not be found in the cardiac cavity. The fractured prosthesis was removed and replaced with a 29mm Carbomedics prosthesis. He was weaned from cardiopulmonary bypass with large doses of pressor amines. The disc and the strut were removed from the abdominal aorta and right deep femoral artery respectively 4 weeks after re-MVR surgery. The patient was discharged after 8 weeks' admission, and has been doing well so far. Although it is obvious that prompt diagnosis and early operation to replace the fractured prosthesis are essential for patient survival, percutaneous cardio-pulmonary support is helpful to maintain patient's hemodynamics during rediagnosis and preparation for surgery.

Thirty (n=30) seven week old male Sprague-Dawley rats were divided into six groups of five rats (n=5) in each group. The groups were designated Sc=sea level controls; St=sea level trained; Fc=hypoxic exposed (16% O₂) controls; Ft =hypoxic exposed (16% O₂) trained; Pc=intermittent hypoxic exposed (18%, 16%, 14%, 16%, 18% O₂ for two days each) controls; and Pt=intermittent hypoxic exercise trained. Exercise training consisted of 45min/day running on a rat treadwheel for 24 consecutive days. Fiber type distribution, succinate dehydrogenase (SDH) activity and glycogen content of the soleus muscle and the oxidative enzyme activity of the motoneurons of the soleus were measured in each group after the 24 days of hypoxic exposure and exercise training. In comparison to each training group's control the glycogen concentration of the soleus muscle was increased (P<0.05) regardless of hypoxic exposure. Only the intermittently hypoxic exercise trained group (Pt) demonstrated a fiber type shift of slow-twitch oxidative to fast-twitch oxidative glycolytic fibers. Neither hypoxia or exercise training altered the oxidative enzyme capacity of the soleus motoneurons.

Malignant pericardial mesothelioma was successfully resected in a 70-year-old man, who had been admitted complaining of palpitation. Chest X-ray films showed slight cardiac enlargement. A moderate amount of pericardial effusion was noted by echocardiography. Chest X-ray commputed tomography and MRI revealed a localized pericardial tumor. Total excision of the tumor was accomplished through a left thoracotomy approach because the tumor showed neither invasion to the myocardium nor dissemination to the pericardium. The patient was discharged following an uneventful postoperative course. No sign of recurrence has been encountered for nine months after surgery. However careful observation is needed.

An 81-year-old-woman was successfully treated with simultaneous minimally invasive direct coronary artery bypass (MIDCAB) and colectomy. The patient complained of effort angina and tarry stool and had a combination of Bormann type II transverse colon cancer with oozing bleeding and long segmental stenosis of the left anterior descending coronary artery (LAD). Angiography suggested that the anastomotic site on the LAD extramusclarly presented on the tortours LAD. We therefore carried out one-stage operation of MIDCAB and colectomy. First, MIDCAB to the LAD using the left internal thoracic artery was performed via left anterior thoracotomy. After closing the left thoracic wall, we carried out transverse colectomy with lymph node resection via upper median laparotomy. The total operation time was 3hr 30min, 2hr 10min for MIDCAB and 1hr 20min for Colectomy respectively. Postoperative coronary angiography showed good patency of the LITA. The resected colon specimen showed moderately differentiated adenocarcinoma: ss, n1, Po, Mo stage 3a. She was discharged 15 days after the operation.

A 68-year-old man was admitted to our hospital with dyspnea and general fatigue. At first, pulmonary embolism was diagnosed by electrocardiography and pulmonary scintigram. X-ray CT scans and echocardiography revealed a tumor occupying the right atrial cavity. To prevent further pulmonary embolism, he underwent tumor resection. In surgery, two venous drainage cannulas were inserted directly to the superior vena cava and to the inferior vena cava via the right femoral vein, in order to avoid the direct contact with the right atrium prior to institution of extra-corporeal circulation. The tumor was carefully removed together with the atrial wall around the site where the tumor originated. A pathological study showed that the specimens were myxoma in the right atrium. His post-operative course has been uneventful until now, however, long-term observation with respect to the metastasis and/or recurrence of this tumor will be carried out.

A 73-year-old man suddenly felt severe back pain. Computed tomography showed acute type B dissection. The false lumen existed from the distal arch to the right common femoral artery and was patent. The true lumen was severely compressed by the false lumen and his right leg was cold. In spite of limb ischemia, we started conservative therapy because he had severe airway stenosis due to obesity and obstructive sleep apnea syndrome (OSAS) and we thought surgical intervention very risky. We thought OSAS also involved a risk of high blood pressure and started continuous positive airway pressure. His blood pressure went down along with the improvement of respiratory conditon. After 12 days from the onset he evacuated bloody stool and gastrointestinal fiberscopy revealed giant gastric ulcer bleeding. Platelet counts and prothrombin time began to increase 2 days later. Computed tomography 14 days after onset showed a patent false lumen and severely compressed true lumen. Computed tomography 39 days after onset showed thrombosis of the false lumen and considerable dilatation of the true lumen. Hypercoagulability after bleeding from gastric ulcer and treatment of OSAS were important in this successful conservative therapy.

Obstructive sleep apnea syndrome (OSAS) has symptoms such as severe snoring, apneic attack, and daytime hypersomnia due to repeated obstruction of the upper respiratory tract during sleep. The mortality rate due to cardiovascular complications in severe OSAS. We reported 5 cases of OSAS among the acute aortic dissection cases we treated. They were 2 cases of DeBakey I (cases 1, 2) and 3 cases of III b (cases 3, 4, 5). Organ ischemia was recognized in 4 among 5 cases of dissection combined with OSAS. There was 1 case of renal ischemia (case 1), 2 cases of limb ischemia (cases 3, 4), 1 case of visceral and spinal ischemia (case 5). Case 4 was III b type dissection with severely compressed true lumen and limb ischemia. The false lumen occluded by combining antihypertensive therapy and continuous positive airway pressure used to OSAS. Case 5 also had a severely compressed true lumen, and visceral ischemia 4 days after the onset. Angiography showed a severly compressed orifice of the true lumen of the celiac artery and superior mesentric artery due to the occluded false lumen. We placed a stent into the orifice of celiac artery transluminally and then patient recovered. There were many dangerous situations such as organ ischemia, and severely compressed true lumen among the cases of dissection combined with OSAS. Marked changes of intrathoracic pressure in apneic attacks may place stress on the thoracic aorta.

We report a successful open heart reoperation of a 14-year-old girl with Alagille syndrome. The patient underwent a living related donor liver transplantation at the age of 9 years in another hospital because of liver failure due to a paucity of interlobular bile ducts. Two years later, because of progression of her aortic valve stenosis, Ross operation and CABG were performed in the same hospital. Afterwards, her neoaortic valve regurgitation developed due to aortic root dilatation and myocardial ischemia developed by anastomosis site stenosis. She started to experience frequent angina attacks. She underwent AVR and redo CABG in our institution in April 2002. Her pre- and postoperative liver function was normal and no special procedure for the liver was needed, and she was discharged on the 18th postoperative day with no complications. In this country, few open heart surgeries for liver transplant recipient have been performed, and no case of reoperation has yet been reported. If pre- and postoperative liver function are normal, pre- and postoperative management of open heart surgery for a transplant may be perfomed conventionally.

To introduce problem-based learning (PBL) in small groups to medical education in Japan, a questionnaire was sent to 10 foreign medical schools where PBL has been used. Five schools in the United States and one each in the United Kingdom, Canada, and Australia responded to all 15 questions concerning their educational system, faculty training, faculty evaluation, and student evaluation. The faculty is trained in 7 medical schools, retrained in 4, and self-trained in 5. The faculty is objectively evaluated by students and a faculty committee in seven schools and the results are returned to the faculty. The students are evaluated by self-evaluation, written tests, and oral examination in al schools, and also by peer-evaluation in one school. The evaluation of students directly affects their promotion in all schools but one. Such effective evaluation and feedback systems, including evaluations of the students' learning skills and their attitude toward learning, play important roles in effective PBL.

OBJECTIVETo analyze the upstream region of radiation-induced junB gene.

METHODSFour plasmids containing 250 bp, 590 bp, 900 bp and 1650 bp, and CAT reporter gene were constructed separately and introduced to L8704 cells. The cells were irradiated with 2 Gy X-rays and incubated at different intervals. Total RNA was extracted from the cells and fluctuation of the CAT mRNA level was assessed by the RNA ratio of CAT/beta-actin measured by quantitative Northern blot hybridization.

RESULTSCAT mRNA expression containing 900 bp and 1560 bp junB promoter remarkably and rapidly increased, and reached its peak 30 min after 2 Gy X-ray irradiation.

CONCLUSIONS590-900 bp fragments located in the upstream region of junB gene play an important role in the early process of cells against radiation.

Actins ; analysis ; metabolism ; Animals ; Blotting, Northern ; Cells, Cultured ; Chloramphenicol O-Acetyltransferase ; genetics ; Gene Expression Regulation ; radiation effects ; Genes, Reporter ; Genes, jun ; genetics ; radiation effects ; In Situ Hybridization ; Mice ; Mice, Inbred BALB C ; Plasmids ; analysis ; genetics ; RNA ; isolation & purification ; metabolism ; RNA, Messenger ; analysis ; metabolism ; Time Factors ; X-Rays