A 70-year-old woman, who had a history of a percutaneous transvenous mitral commissurotomy for rheumatic heart disease 34 years previously, was admitted with progressive right heart failure. Massive calcification of the left wall was observed on multidetector CT. She underwent a mitral valve replacement, tricuspid annuloplasty and permanent pacemaker implantation. Massive calcification of the left atrial wall is a rare condition, and constitutes a major complication and risk to mitral valve surgery because of the difficulty in entering the left atrium, potential embolization, and impaired hemostasis.

Purpose: We developed a database that can be shared by the members of our palliative care team (PCT) before the conference and ward round (CR) to make these activities more efficient. Methods: The database was developed using Microsoft Access®. The condition of patients was evaluated using a Japanese version of the Support Team Assessment Schedule (STAS-J). The database allows any member of the team to input patient information. We also developed a form that allows us not only to share the information but to continuously observe the progress of the patients. To evaluate the advantages of the database on CR, we compared the number of patients observed in one CR and the number of CR's per patient before and after the introduction of the database. Results: The number of patients observed in one CR and the number of CR's per patient were significantly increased after the introduction of the database. Conclusion: The database had positive effects on CR by making the patient information available in advance and by allowing continuous evaluation of patients. Palliat Care Res 2011; 6(1): 209-215

A 75-year-old woman was admitted with complaints of progressive portprandial abdominal pain and weight loss. A bruit was audible in the epigastrium. Angiogram showed narrowing of the lower abdominal aorta with complete occlusion of the celiac, the superior and inferior mesenteric arteries. A 6mm Gore-Tex graft was first anastomosed from the supraceliac abdominal aorta to the superior mesenteric artery. A saphenous vein graft was then inserted proximally to the Gore-Tex graft and distally to the celiac artery. The postoperative course was uneventful. During two years of observation symptoms have disappeared and patient returned to a normal weight.

The occurrence of multiple supernumerary teeth in individuals without any associated syndrome is rare. In this report, a rare case of a 48-year-old woman who had an impacted supernumerary fourth molar in the bilateral mandibular ramus is described. She presented with a swelling in the left cheek region. Radiographic examination revealed an impacted supernumerary tooth in the left mandibular ramus with pericoronal resorption of the bone, suggesting peripheral inflammation. She also had an impacted supernumerary tooth on the right side. After administering an antibiotic and antiinflammatory drug, tooth extraction was performed under general anesthesia.

A 81-year old woman had hypertensive heart failure. She had a history of intermittent claudication for 5 years. Her ankle brachial pressure index (ABI) was 0.53 on the right and 0.58 on the left side. Coarctation of the descending aorta with severe calcification was found by a whole body CT. After medical therapy for heart failure, axillo-bifemoral artery bypass using an 8 mm ringed expanded polytetrafluoroethylene (ePTFE) graft was performed. Postoperatively, ABI improved to 0.83 on the right and 0.87 on the left side. The patient is doing well without any signs of heart failure or intermittent claudication. Although it is a palliative operation, axillo-bifemoral artery bypass is an effective and less-invasive procedure and appropriate for elderly patients.

We present here a rare case of coronary artery bypass grafting through a left thoracotomy after substernal gastric interposition for esophageal cancer. A 58-year-old man, who had undergone esophagectomy and substernal gastric interposition 11 years previously, was admitted for cerebral infarction from which he made a good recovery without any complication. At this time, the patient was diagnosed as having coronary artery disease on electrocardiogram. Cardiac catheterization revealed triple vessel disease. Coronary artery bypass grafting to the left anterior descending artery and obtuse marginal branch through a left thoracotomy was performed using a radial artery Y-graft under femorofemoral bypass. The aorta was cross-clamped and the heart was arrested with antegrade cold cardioplegic solution for the distal anastomosis of the left anterior descending artery and the obtuse marginal branch which was embedded within the myocardium. The postoperative angiography showed good coronary flow. Left thoracotomy approach provides a good exposure of the left coronary artery. This approach, therefore, is advocated as an alternative method for cases requiring coronary artery bypass but in which median sternotomy is difficult, such as the present case. The appropriate procedure for the site of thoracotomy, supporting methods, choice of graft, and the site of graft anastomosis should be selected in each patient.

Abstract:

 This study examined the ability of medical students to self-assess basic clinical competence and learning strategies including simulation-based medical education for sixth-year medical students (n=903) at nine universities in Japan. About 40% of 27 procedures to achieve clinical skills in a model curriculum were taught using simulators with or without clinical training in hospitals. We noted that significant numbers of procedures were not practiced through any learning strategies. Higher self-assessment scores were observed among students in 4 schools who had more frequent learning opportunities through simulation-based education than among those with less frequent opportunities in 5 schools.

Three-dimensional (3D) cultures are known to promote cell differentiation. Previously, we investigated the differentiation of rat dermal fibroblasts to α-smooth muscle actin (α-SMA)-positive myofibroblasts through transforming growth factor (TGF)-β production using a 3D culture model. Here, we investigated the phenotypic change from dermal mesenchymal cells (mostly fibroblasts) to osteoblast-like cells, being inspired by the roles of smooth muscle cells or fibroblasts during vascular calcification. Spindle-shaped cells that grew in heterologous populations out of dermal explants from 2-day-old Wistar rats were cultured within a collagen matrix. α-SMA and alkaline phosphatase (ALP) messenger RNA (mRNA) levels initially increased, followed by a rise in Runx2 and osteocalcin (OCN) mRNA levels without calcification. Calcium deposits were produced in the presence of a high concentration of inorganic phosphate (2.1 mM) or β-glycerophosphate (βGP, 10 mM) after 2 weeks of culture, and both were sensitive to an inhibitor of type III phosphate transporters. An ALP inhibitor decreased only βGP-induced calcification. Inhibition of TGF-β type-I receptors attenuated ALP mRNA levels and βGP-induced calcification, suggesting that endogenous TGF-β stimulates ALP activity and then βGP breakdown. An increase in the number of cells embedded in the collagen gel enhanced the mRNA levels of Runx2 and OCN, but not of ALP. Collectively, several factors are likely to promote the differentiation of dermal mesenchymal cells into osteoblast-like cells and ectopic calcification in a 3D collagen matrix, implying the utility of these cells as a potential autologous cell source for tissue engineering.
Actins ; Alkaline Phosphatase ; Animals ; Calcium ; Cell Differentiation ; Collagen ; Dermis ; Fibroblasts ; Myocytes, Smooth Muscle ; Myofibroblasts ; Osteocalcin ; Phosphate Transport Proteins ; Rats* ; Rats, Wistar ; RNA, Messenger ; Tissue Engineering ; Transforming Growth Factors ; Vascular Calcification

Six patients(3 male,3 female)aged 33-66 yr, Course of disease 6-35 days, diagnosed with spontaneous intracranial hypotemion in Sir Run Run Shaw Hospital from November 2007 to May 2008,Were treated with on epidural autologus blood patch trader X-ray guidance. According to the results of CT myelography. the puncture site Was chosen in the 1-2 vertebral interspaees below the site of a single eerebrospinal fluid leak. For patients with multiple cerebrospinal fluid leaks.the procedure was performed at the spinal cord segment of the most severe leak. The mixture of augous blood and Omnipaque(300g/100 ml)at a ratio of 2:1 was injected into the epidural space to cover the spinal cord segment of the leaks under C-arm fluoroscopic guidance.Side effects were recorded during and after the injection of autologus blood.The treatment was repeated one week later if the former one failed.One patient was treated with epidural blood patch 3 times.and the rest 5 patients were treated with epidural blood patch 1 time.During the injeetion of autologus blood,5 patients complained of pain in the purtclure site,2 experienced pain radiating to the upper limb,2 felt,numbness in the right leg and all of these syndromes could be self-relieved.No side effects were observed after the injection of autologus blood.All the patients were Cured and no recurrence was observed during a 2-6 month follow-up.

　To encourage the broad use of simulation-based medical education and establish partnerships to promote objective structured clinical examinations after clinical clerkship among medical teachers, we hosted the first team-based clinical skills competition event for medical students in Japan, named ‘Medical Students' Simlympic Games 2014'. Thirty-six (12 teams of three) open-recruited 5th or 6th grade medical students participated in this event. Student teams performed clinical tasks at 6 stations, which actively utilized the strengths of simulators or simulated patients. Contents, composition, difficulty level, and validity were tested by trainee doctors and examined by committee members in advance. In this report, we describe our concept, executive committee formation, a variety of arrangements, the outline on the day of the event, and the results of a questionnaire targeting participants. (126 words)