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.

Usefulness of balneotherapy in diabetics were discussed. Plasma glucose levels in diabetics treated with insulin decreased significantly after thirty minutes exercise under 38°C hot springs pool. There were positive relationships on plasma glucose levels between before and after exercise in hot springs. Lipids metabolism were improved during three months' balneotherapy. The ratio of VLDL·LDL-cholesterol/HDL-cholesterol decreased. Basal levels of plasma cyclic AMP decreased slightly and plasma cyclic GMP significantly increased. Intrathecal injection of vitamin B₁₂ (mecobalamin, 2500μg) was apparently effective to reduce the pain on under limb in patients with diabetic peripheral neuropathy whose subjective symptom could not improved by any medications. The effect of mecobalamin was increased by bathing in hot springs. Usually, balneotherapeutic hospitals have facilities of rehabilitation system in Japan.
In conclusion, the balneotherapy by adding physical treatment is very benefit to normalize carbohydrate and lipid metabolism. Tranquilizing function of hot springs are effective on psychological disturbance, diabetic autonomic and peripheral neuropathy.

A 77-year-old man with an abdominal aortic aneurysm, detected by abdominal ultrasonography, was referred to our hospital. Multi-detector computed tomography (MDCT) revealed an intrathoracic left subclavian artery aneurysm 30 mm in diameter and a small distal arch aortic aneurysm as well as an abdominal aortic aneurysm 40 mm in diameter. Surgery was indicated for the subclavian artery aneurysm considering the risks of rupture and distal embolism. Our choice for treatment was endovascular repair ; thoracic endovascular aortic repair (TEVAR) and coil embolism. The operation was performed successfully. Orifices of the left subclavian artery and the distal arch aneurysm were covered with a stent graft and the left subclavian artery was occluded with coils distal to the aneurysm. The operation time was 1 h and 44 min. He was extubated in the operation theater. A follow-up CT scan performed at 1 week showed the correct position of the TEVAR device, patency of the common trunk of the brachiocephalic and right common carotid arteries, and complete exclusion of the aneurysms. He was discharged on the 12th postoperative day without complication. Subclavian artery aneurysms, in particular in the intrathoracic location, are rare. Conventional surgery for this entity tends to require arch replacement to be unreasonably invasive as a therapy for peripheral artery disease. We believe this endovascular therapy can be a useful, less-invasive alternative to conventional open surgery.

A 62 year-old man presented with severe septic shock complicated by prosthetic graft infection, 7 years after aortic root replacement with a Freestyle stentless valve and graft replacement of the ascending aorta. We initially managed the patient with antimicrobial therapy for 2 months and subsequently surgery was performed, replacing the infected aortic graft with rifampicin-bonded prostheses, and added omentopexy. The infection was cured and has not recurred.

A series of cases underwent acupuncture treatment for frozen shoulder at our clinic.
1. Twenty-one cases of frozen shoulder were collected.
2. Fifteen cases (71%) Showed improvement in pain and activities of daily life (ADL) during the course of acupuncture treatment.
3. Temporary relief from pain during motion (67%), pain during rest (44%), and pain during the night (56%) was obtained after acupuncture treatment.
4. Patients whose pain was not reduced after treatment tended to drop out.
Acupuncture treatment for frozen shoulder was effective for reducing pain, and it is expected to prevent contracture when combined with exercise.

[Objective] Using a near infrared spectrometer and laser Doppler blood flowmeter, we investigated how the number of moxa applications influences blood flow at moxibustion and peripheral sites.
[Method] The subjects were nine healthy adult males, aged 25-28 years (average age 25.4). Skin blood flow was measured with a laser Doppler blood flowmeter while changes in the deep tissue (deep subcutaneous level and muscle surface course level) blood volume were measured with a near infrared spectroscopy. Each of the probes was located at the moxibustion treatment site and 20 mm away from the site.
On different days, measurements were taken from a control group not receiving stimulation, groups receiving five-cone and seven-cone moxibution (2 mg of moxa per application), respectively.
Measurements of the control group were taken for 25 minutes, while measurements for the other two groups were taken for 5 minutes before conducting moxibustion and for 20 minutes directly after completion of moxibustion.
[Results and Discussion] The skin blood flow demonstrated an further increased tendency after seven-cone moxibustion than five-cone moxibustion. This seemed to be due to the strong flare phenomenon affecting cutaneous blood flow quantity by increasing the number of moxibustion cones.
The effect of moxibustion on skin blood flow volume is suggested to be due to the strong flare phenomenon induced by increasing the number of moxibustion. The effect to the deep tissue indicated a tendency for the blood flow volume to decrease.
It is considered that further detailed experiment will be necessary in the future regarding these ambiguous points.

Reoperations after operations for acute type A aortic dissection were performed in two cases under deep hypothermic circulatory arrest. In case 1, the aortic arch replacement was performed with an inclusion technique seven years ago. The reason for reoperation was the leak from the suture lines of all anastomosis sites. Three sites of leak were closed putting sutures with pledgets. In case 2 the graft replacement of the ascending aorta was performed five years ago. The reason for reoperation was the persistent dissection from the aortic arch to the thoracic descending aorta due to the new entry formation at the site of the aortic clamp. At first the graft replacement of the thoracic descending aorta was performed, followed by arch replacement. As these conditions are preventable, we should perform the open distal anastomosis technique without using a clamp and graft replacement of aortic arch with the branched graft. Moreover, deep hypothermic circulatory arrest may appear to be a valuable adjunct for reoperation after operation on acute type A dissection.

In the future, we will have more aged patients, more cases of bilateral total hip arthroplasty (THA) and more cases of bilateral revision THA. There are not, however, many reports of long-term follow-up of bilateral revision THA. We report a case of bilateral revision THA followed up for 11 years. A 74-year-old woman presented with bilateral painful hip in 1996. She had undergone left THA in 1984 and right THA in 1986 at another hospital. Her JOA(Japan Orthopaedic Association) scores on her first visit (right/left) were 32 points/31 points. Plain radiographs revealed a clear zone in her bilateral proximal femur. We diagnosed her as having looseness of bilateral THA. She required bilateral revision THA and underwent left revision THA (Charnley) in January 1997 (14 years after the original operation) and right revision THA (Charnley) in July 1997 (12 years after the original operation). After bilateral revision THA, we were able to follow up this patient for 11 years. She had no complaints about her bilateral hip joints, and X-ray examination showed no looseness. The JOA scores and range of motion illustrate the good result achieved for this case.
Right and left ; Tacrine ; Hip ; Arthroplasty ; Serotype eleven