Two hundred five inpatients (age, 64.8±21.6 years ; mean±SD) were analyzed with respect to diagnosis, age, and complications to clarify the role of general internal medicine in large hospitals. The patients were divided into two groups: those younger than 40 years and those older than 40 years. In patients younger than 40 years, the most common diseases were viral infections, whereas a wide variety of diseases, including heart diseases, renal diseases, and neoplasms, were seen in patients older than 40 years. Disease in the older group were significantly more complicated than those in the younger group. we conclude that caring for older patients is good training for young residents learning general internal medicine.

A 45-year-old man was hospitalized with sudden-onset chest pain. He was in cardiogenic shock with a systolic pressure of 68 mmHg. His electrocardiogram (ECG) showed ST segment elevation in leads I, aVL, and V2-5. An emergency coronary angiogram (CAG) showed that the true lumens of bilateral coronary arteries were compressed, showing acute Stanford type A aortic dissection involving bilateral coronary artery. A bare metal stent was promptly implanted in the left main trunk (LMT) to restore coronary blood flow because of his hemodynamic instability. Soon afterwards, the ischemic changes on ECG disappeared and he was transferred to the operating room in a stable hemodynamic condition. We performed emergency graft replacement of the ascending aorta and coronary artery bypass grafting. The postoperative CAG showed patent bypass grafts. Implantation of LMT stent, as a bridge to surgery, should be the treatment of choice for acute type A dissection involving LMT.

We report a case of type A acute aortic dissection in a patient with situs inversus totalis. A 51-year-old man was hospitalized with sudden-onset back pain. Contrast-enhanced computed tomography revealed Stanford type A acute aortic dissection and situs inversus totalis. Total arch replacement using selective cerebral perfusion and mild hypothermic circulatory arrest was successfully performed. He was discharged home 23 days after the operation.

A 61-year-old man underwent an emergency operation for a ruptured infrarenal abdominal aortic aneurysm. Operations included bifurcated graft replacement of the abdominal aorta, oversewing of five lumbar arteries between L3 and L5, and ligation of the occluded inferior mesenteric artery. Because of the severe adhesions and arteriosclerotic changes over the bifurcation of the abdominal aorta and both common iliac arteries, prolonged aortic cross-clamp time was needed. In spite of stable his postoperative general condition, he suffered paresthesia and complete sensory loss on the left lower leg and the right sole. Moreover he was found to have paresis on the left leg and the right thigh. Knee and ankle deep-tendon reflexes were absent on the left. Lasègue's sign was positive bilaterally, which was more brisk on the left. There was no incontinence of urine and feces. EMG showed neurogenic polyphasic potentials on the lower extremities. MRI of the thoracolumbar spine and sacrum showed no evidence responsible for this neurological deficit, but IV-DSA revealed complete occlusion of the left common and internal iliac arteries. Following the active rehabilitation, he was able to walk unaided, but remained to have residual paresthesia on the left lower leg at his discharge. It was concluded that ischemic injuries to the cauda equina resulted in this rare complication, which seemed to be secondary to oversewing of critical lumbar arteries, prolonged aortic cross-clamp time, and the acute occlusion of the left common and internal iliac arteries.

Blow-out type free wall rupture is a severe complication after acute myocardial infarction and its prognosis is poor. A 68-year-old man was admitted to our hospital for extensive anterior acute myocardial infarction with cardiogenic shock. Echocardiogram and CT strongly indicated the presence of intrapericardial fluid, and we had to perform an emergency operation. Before median sternotomy, we cannulated the femoral artery and vein, and cardiopulmonary bypass was started. We resected the ruptured and necrotic left ventricular myocardium and employed the feltstrip sandwich method. Postoperative recovery of cardiac function and consciousness was satisfactory and he was discharged from hospital on the 37th postoperative day. PCPS or femoro-femoral bypass and consecutive surgical therapy can be a useful method for the treatment of left ventricular free wall blow-out rupture.

The purpose of this study is to examine the validity of muscle fatigue evaluation using maximum voluntary torque (MVT), and to identify the dependence of individual's tolerance for fatigue on the capacity to exert MVT. In 14 young male subjects (10 regular exercisers and 4 sedentary), MVT was measured during isometric knee extension, and voluntary activation (VA), which reflects motor unit activation, was evaluated using the twitch interpolation technique. In addition, the maximum endurance time (ET) was measured, and behavior of the mean power frequency (MPF) and the average rectified value (ARV) of surface EMGs from the vastus lateralis muscle were analyzed during constant force isometric contractions of 60% MVT (short-duration fatigue task; SDF task) and 20% MVT (long-duration fatigue task; LDF task) . Correlations were examined among these five variables.
The results were as follows:
1) Subjects were divided into a high voluntary activation group (HVA group) and a low voluntary activation group (LVA group) . Four sedentary subjects were included in the latter group.
2) MVT was significantly larger in the HVA group than in the LVA group (p<0.01) . A significant positive correlation (r=0.72) was found between MVT and VA (p<0.01) .
3) A significant negative correlation (r=-0.71) was found between MVT and endurance time (ET) for the LDF task (p<0.01) . The ET was significantly longer in the LVA group than in the HVA group (p<0.01) .
4) The MPF of voluntary EMG decreased consistently, as ARV increased during isometric contraction in both tasks (p<0.01), indicating the development of fatigue in the muscle. The final change of MPF relative to the initial value was significantly greater in the SDF task than in the LDF task (p<0.05) .
5) A significant correlation (r=-0.83) was seen between the relative change in MPF and ARV in the SDF task (p<0.01) .
6) For the SDF task, the final change of MPF and ARV relative to the initial value was significantly greater in the LVA group than in the HVA group (p<0.05) .
These results indicate that tolerance for local muscle fatigue usually evaluated as maximum endurance time, may depend on individual differences in VA, the VA, in turn, depending on adapta-tion to exercise, and that there appears to exist a corresponding adaptative strategy of the neuromuscular system during fatiguing contractions. Usefulness of our procedure using the twitch interpolation technique in evaluating muscle fatigue was also suggested.

A 61-year-old woman underwent a regular echocardiography in October 2008 in which a mass of 1 cm in diameter was pointed out in the left ventricle apex. It did not dcrease, in spite of anticoagulation therapy, and therefore we performed surgery. The tumor was confirmed on the septal side of the cardiac apex by intraoperative cholangioscopy, and it was excised through the mitral valve. It was diagnosed as myxoma on immediate intraoperative pathological examination, and we confirmed that there was no tumor remnants on the resected stump histologically. The patient was discharged on the 13th day after the operation and 2 years later she was alive without recurrence of the tumor. This is the 25th case of left ventricular myxoma in Japan. In these reports, an initial resection of the tumor in the left ventricle was performed in 23 cases and the approach methods were described in 20 cases. The evaluation of the resected stump, regardless of remaining tumor, was described in only 3 cases. There were no reports of relapse after the operation. There are many reports which emphasize the usefulness of echocardiography, which is very helpful not only in the diagnosis, but also in periodic evaluations after the operation.

A 76-year-old-woman, who had undergone endoscopic resection of a gastric polyp 2 years previously, had a cardiac tumor incidentaly pointed out on an abdominal ultrasonographic image. Echocardiography showed a solid round mass (34×25 mm in diameter), attached by a short stalk and which was floating on the right ventricular outflow tract and prolapsing over the pulmonary valve during systole. We suspected right ventricular myxoma. Urgent surgery was performed under cardiopulmonary bypass. After aortic clamping, the trunk of the pulmonary artery was opened near the right ventricule. The tumor was found under the pulmonary valve, attached to the anterior papillary muscle and chordae of the tricuspid valve. The tumor was completely excised with a piece of the papillary muscle and chordae. After right atriotomy, mild tricuspid regurgitation was seen on a water test. After we performed tricuspid annuloplasty and chordplasty with artificial chordae, a second water test did not show any tricuspid regurgitation. The postoperative course was uneventful, and she was discharged on the 13th postoperative day.