Concomitant occurrence of acute aortic dissection and atherosclerotic aneurysm is rare. In such a circumstance, rupture of the existing aneurysm is the more likely scenario. In general, atherosclerotic plaque frequently serves to terminate the dissection process. A 65-year-old man with an abdominal aortic aneurysm was admitted due to severe back pain. Emergency CT showed acute aortic dissection (Stanford B) with a partially thrombosed pseudo-lumen and fusiform abdominal aortic aneurysm. Hemolysis occurred due to compression of the true lumen by the thrombosed pseudo-lumen. Emergency abdominal aortic graft replacement was performed successfully.

Left ventricular wall motion was evaluated after mitral valve replacement (MVR). MVR for mitral regurgitation (MR) was performed with preservation of both anterior and posterior chordae tendineae (Group I, n=12) or posterior chordae tendineae (Group II, n=9). MVR for mitral stenosis was performed with the preservation of the posterior chordae alone (MS Group, n=12). Postoperative regional wall motion was analyzed from the shortening fraction (SF) of the centerline method in 5 of antero-basal (AB), anterolateral (AL), apical (AP), diaphragmatic (DP) and posterobasal (PB) regions. The percentage of post-operative SF for preoperative value (%SF) was compared between Group I and Group II. The value of %SF improved much more in Group I than in Group II at the AL and AP regions. %EF was more significantly increased in Group I than in Group II, although postoperative ESVI and EDVI decreased in both groups. In the MS Group, EF, ESVI and EDVI did not change after surgery. The regional wall motion improved except in the calcified PB region. These results demonstrated that the preservation of both anterior and posterior chordae tendineae for MR was a useful procedure to improve postoperative LV regional wall motion. The preservation of posterior chordae for MS was sufficient to improve the regional wall motion except in the calcified submitral region.

A 72-year-old woman suffered sudden back pain 42 days after ascending aortic replacement for retrograde acute type A aortic dissection. Computed tomography (CT) revealed type B aortic dissection and a stenotic true lumen at the abdominal aorta. The celiac artery and the superior mesenteric artery (SMA) branched from the true lumen, but bilateral renal arteries were not found by DSA. Infrarenal abdominal aortic fenestration was performed at 6th day from onset, because of progressive renal dysfunction. Intestinal ischemia was not confirmed by laparotomy. After the Infrarenal aorta was clamped and transected, the proximal intima was resected in a U-shape. The proximal stump which was reinforced with teflon felt was anastomosed to an 18mm woven graft. Distal anastomosis was carried to the true lumen was carried out with closure of the false lumen. Regaining flow into the collapsed true lumen was observed by epiaortic echography. Postoperatively, continuous hemofiltration was required for several days until renal dysfunction was improved. CT showed reasonable expansion of the true lumen, and no findings of visceral ischemia except for partial infarction of the left kidney. DSA revealed that bilateral renal arteries were perfused from the true lumen through the fenestration. Neither aortic dilatation nor new ischemia have been recognized, but further close observation is necessary.

A 24-year-old man was transferred to our hospital because of traumatic rupture of the thoracic aorta suffered in a traffic accident. On admission, he had recovered from shock and was alert. Chest CT showed massive hematoma around the total extent of the descending aora and the intimal flap at the diatal descending aorta. We performed an emergency operation. Through left thoracotomy, we found dilatation of the descending aorta. Epiaortic echo revealed that the aortic intima was completely transecred between Th 10 and Th 11. The pseudoaneurysm was replaced with a Hemashield vascular graft under partial cardiopulmonary bypass. The intercostal artery was preserved. His postoperative course was uneventful and paraplegia was not seen. We reported a rare case of traumatic rupture of the distal descending thoracic aorta above the diaphragm followed by successful surgical treatment.

  A 55-year-old man visited his neighborhood general practitioner complaining of headache, fever and wet cough on July 7, 2003, but there were no sigins that his symptoms would subside. Since an abnormal shadow was found on chest X-ray on July 11, he was referred to our department and hospitalized on the same day. We started to treat him on the assumption that he had community-acquired pneumonia due-to common pathogens. However, he developed severe hypoxemia, and abnormal shadows rapidly progressed to affect both lungs, which led us to suspect that he had acute respiratory distress syndrome (ARDS). We identified the pathogen by examining urinary antigens and serum antibodies and diagnosed of his case as Legionella pneumonia. Although he suffered complications of acute renal failure and shock, the respirator was withdrawn after 11 days of controlled mechanical ventilation, as he was steadily recovering from his illness. The patient was discharged from the hospital on September 9. Although the mortality of legionella pneumonia, when complicated by ARDS, acute renal failure and shock as in the present case, has been reported to be as high as 50 to 80%, we consider that the administration of neutrophil elastase inhibitors and steroids was effective against this disorder.

A university hospital plays roles as a specific functional hospital and as a teaching hospital in primary care because most medical school graduates receive basic clinical training in this area. An important objective of primary care education for all residents is the initial treatment of patients with first-to third-level emergencies. We examined the number of patients, the level of emergency (first, second, and third level) and the diagnoses that each resident encountered. Subjects included 29 residents (3 in the first year, 4 in the second year, and 2 in the third year) who had undergone clinical training for 3 months in the department of emergency medicine at the Saga Medical School Hospital which treats 7, 000 to 8, 000 patients per year with first-to third-level emergencies. Residents were involved with 214.6 emergency cases, which included approximately 59 types of first-level emergency, 31 types of second-level emergency, and 15 types of third-level emergencies. These results were largely compatible with the Objectives of Postgraduate Basic Clinical Training proposed by the Japan Society for Medical Education. These results show that university hospitals as specific functional hospitals should accept numerous emergency patients and that residents must receive clinical training in emergency medicine to achieve the objectives of primary care education.

A 55-year-old man visited his neighborhood general practitioner complaining of headache, fever and wet cough on July 7, 2003, but there were no sigins that his symptoms would subside. Since an abnormal shadow was found on chest X-ray on July 11, he was referred to our department and hospitalized on the same day. We started to treat him on the assumption that he had community-acquired pneumonia due-to common pathogens. However, he developed severe hypoxemia, and abnormal shadows rapidly progressed to affect both lungs, which led us to suspect that he had acute respiratory distress syndrome (ARDS). We identified the pathogen by examining urinary antigens and serum antibodies and diagnosed of his case as Legionella pneumonia. Although he suffered complications of acute renal failure and shock, the respirator was withdrawn after 11 days of controlled mechanical ventilation, as he was steadily recovering from his illness. The patient was discharged from the hospital on September 9. Although the mortality of legionella pneumonia, when complicated by ARDS, acute renal failure and shock as in the present case, has been reported to be as high as 50 to 80%, we consider that the administration of neutrophil elastase inhibitors and steroids was effective against this disorder.
Shock ; Respiratory Distress Syndrome, Adult ; Pneumonia ; Kidney Failure, Acute ; Complicated