An unusual case of a 71-year-old man with massive sinuses of Valsalva presenting with coronary insufficiency was reported. Primarily, he had undergone aortic valve replacement (AVR) with a diagnosis of severe aortic regurgitation (AR) and annulo-aortic ectasia (AAE). Four years after the primary operation, he came to our hospital as an emergency admission complaining of chest pain. Electrocardiography showed sinus rhythm with ST wave elevation in limb leads of II, III and aVF and a diagnosis of acute myocardial infarction was made. Coronary angiography revealed right coronary insufficiency and aortography showed massive sinuses of Valsalva (diameter 8.5cm) with minimal functional AR. At the second operation, the right coronary artery was severely stretched and attenuated over the surface of the right coronary sinus. The ostium was found to be free of atherosclerosis. A composite reconstruction of the aortic root with a new valved conduit and reimplantation of coronary arteries were performed. The postoperative course was uneventful. Aneurysmal change of the sinus of Valsalva is rare, and it is reported that the mean maximal diameter is 5.4cm in this type of AAE. In our case, the unusual dilation of the sinuses of Valsalva resulted in right coronary insufficiency. This case reminded us that aortic root replacement must be applied in patients with AAE as the initial treatment of choice.

Objectives: The objectives of this study are to evaluate the current situation of concomitant drug use by community-dwelling elderly dementia patients, and to extract factors influencing the presence of potentially inappropriate medications (PIMs).
Method: The research subjects were patients 65 years of age or older for whom concomitant drugs were prescribed on the same prescription form as donepezil hydrochloride.  One hundred and twenty community pharmacies randomly selected from 28 of the 47 prefectures throughout Japan.  Main research topics were sex, age, the clinical department to which the prescribing physician belonged, daily dosage of donepezil, and concomitant drugs.  Concomitant drugs were evaluated using the Beers Criteria: the Japanese Version. Furthermore, to search factors influencing the presence of PIMs, logistic regression analysis was used.
Results: Data for 335 patients were extracted.  The average number of concomitant drug cases per patient were 4.2 (SD 2.6), and 109 patients (32.5%) were prescribed PIMs.  A logistic regression analysis confirmed that significant factors influencing the presence of PIMs were “the clinical department to which the prescribing physician belonged” (OR 4.80, 95%CI 1.01-22.72), “concomitant drug cases” (OR 1.26, 95%CI 1.13-1.41) and “the presence of concomitant use of central nervous system agents” (OR 5.82, 95%CI 3.35-10.11).
Conclusion: This study revealed that more than a few cases of community-dwelling elderly patients of dementia were using concomitant drugs with potential risks.  It suggested that influencing factors were “the specialty of the prescribing physician” and “the presence of concomitant use of central nervous system agents.”

X type questions have been used for the national medical licensing examination since 1997. At Tsukuba University, X type questions have been used since 1996. We compared X typeand K type questions on the basis of the percentage of correct answers and discrimination power. The average percentage of correct answers was 68.2% for K type questions and 53.1% for X type questions. However, the average discrimination power was +0.227 for K type questions and +0.257 for X type questions. These results indicate that X type questions are more difficult and are suitable for achievement tests. The estimated knowledge quantity was 2.04 for K type questions and 2.32 for X type questions. This suggests that the person writing the questions decreased the essential difficulty of X type questions.

Student self-evaluations in pediatric bedside learning based on a problem-oriented system (POS) were compared with teacher evaluations of the same items. Self-evaluations were also compared with two different methods: unsigned and signed submissions. Students evaluated themselves poorly in the ability to recall pediatric knowledge and highly in the ability to investigate and summarize suggested topics. They evaluated themselves more highly on signed submissions than on unsigned submissions left in a box. Evaluations by teachers were higher than or equal to student self-evaluations. There were few critical evaluations or complaints about POS-bedside learning, but the ratio of criticism was four-fold higher on unsigned submissions. Bedside learning based on POS was accepted willingly by students.

Objective:We successfully treated a patient suffering from pain and numbness in the waist and lower limbs with phobia. Sedative acupuncture treatment was performed in addition to somatic treatment.
Case:A 64-year-old woman complained mainly of pain and numbness in the right waist and the lower limbs and had a sense of fear. Following the postoperative pain of lumbar disk herniation (L4-L5) in X-14 year, dorsal positioning without grasping anything frequently triggered a sense of fear with a scary feeling that her body was suspended in midair, which could not be alleviated by medication. As the symptoms in the waist and lower limbs recurred due to a fall in January of X year, she consulted an orthopedist in April. She was given a diagnosis of lumbar disk hernia (L5-S1) and hospitalized. Since the symptoms sustained, she consulted the department of acupuncture attached to the Kansai University of Health Sciences Clinic in November. The sense of fear triggered by dorsal position in the acupuncture treatment interfered with the treatment. When she was referred to the department of psychosomatic medicine, the diagnosis of "Other types"of the DSM-IV "300.29 specific phobia"was given. While low-frequency acupuncture electrotherapy on the same side and the same level as the hernia was provided, we applied sedative acupuncture treatment once a week 30 times using the following acupuncture points:GV23;PC6;CV17;and CV6. Before and after every acupuncture treatment after the 10th, the symptoms were evaluated with Finger Floor Distance (FFD), Visual Analogue Scale (VAS) of pain and mood (feelings) and State-Trait Anxiety Inventory (STAI).
Results:The sense of fear during the acupuncture treatment slowly decreased after the 14th treatment. Decreases in FFD, VAS for pain and mood (feelings), and state anxiety score of STAI were observed. The pain and the numbness in the waist and the lower limbs decreased in parallel with the sense of fear. Furthermore, the dosage of hypnotic agent decreased gradually as sleep improved.
Conclusion:Pain and numbness in the waist and the lower limbs with phobia were relieved by sedative acupuncture treatment.

Between January, 1975 and June, 1990, 67 patients underwent surgical treatment for infective endocarditis at our hospital. Of 67 patients, 27 patients showed active endocarditis at the time of operation. In these 27 patients, 20 had active endocarditis of the native valve (NVE), and the seven had active prosthetic valve endocarditis (PVE). The interval between onset of infective endocarditis and operation ranged from 7 to 252 days (mean, 36 days). In the operative results, 3 of 20 patients (15%) with NVE and 2 of 5 patients (40.0%) with PVE died before discharge from the hospital. According to analysis of preoperative hemodynamic state and bacteriological data, the determinant factors of operative mortality and morbidity were preoperative NYHA functional classification, the interval between onset of infection and operation, and annular destruction (annular abscess). Patient's age, preoperative renal function, positive blood culture, the site of infection, and positive culture or stain of the surgically excised valve did not play an important role to determine operative mortality and morbidity. It is our conclusion that all patients with infective endocarditis who develop progressive congestive heart failure and echocardigraphical extravalvular infection despite medical treatment, should have prompt valve replacement.

Platelets play pivotal roles in hemostasis as well as pathological arterial thrombosis. The combination of aspirin and a P2Y₁₂ inhibitor has become the mainstay therapy in the ageing population with cardiovascular conditions, particularly during and after percutaneous coronary intervention. A number of novel P2Y₁₂ inhibitors has become available in the recent years, and they markedly vary in pharmacokinetic and pharmacodynamic properties. Perioperative physicians today face a challenge of preventing hemorrhage due to platelet inhibitors, while minimizing thrombotic risks. There are several point-of-care platelet function tests available in the peri-procedural assessment of residual platelet aggregation. However, these platelet function tests are not standardized in terms of sample processing, agonist type and potency as well as methods of detecting platelet activity. Understanding the differences in pharmacological properties of antiplatelet agents, principles of platelet function tests, and pertinent hemostatic strategies may be useful to anesthesiologists and intensivists who manage perioperative issues associated with antiplatelet agents. The objectives of this review are: 1) to discuss clinical data on aspirin and P2Y12 inhibitors relating to perioperative bleeding, 2) to outline different features of point-of-care platelet function tests, and 3) to discuss therapeutic options for the prevention and treatment of bleeding associated with antiplatelet agents.
Aspirin* ; Blood Platelets ; Hemorrhage ; Hemostasis ; Percutaneous Coronary Intervention ; Platelet Aggregation ; Platelet Aggregation Inhibitors* ; Platelet Function Tests ; Point-of-Care Systems ; Thrombosis

This study examined the effect of hot-spring bathing (40 to 41°C) on salivary secretion and salivary secretory IgA (sIgA) in healthy volunteers. Ten volunteers (10 men, average 33.6±9.3 years old) bathed in a hot-spring for 10 minutes.
Saliva samples were collected before bathing, during bathing (from 5 to 7 min), and after bathing using the Saxon test. The saliva flow rates and sIgA concentration were determined and then the sIgA secretion rates were calculated.
The saliva flow rates increased significantly during the bathing (p<0.02) and decreased after bathing. The sIgA secretion rates during bathing were significantly higher than those before and after bathing (p<0.02).
The increases in saliva flow rates and sIgA secretion rates during bathing were considered to indicate the improvement of local immunity in the oral cavity and thus considered to be useful for preventing upper respiratory tract infections.

We report 2 cases of successful treatment by percutaneous catheter drainage and irrigation for methycillin-resistant Staphylococcus aureus (MRSA) prosthetic graft infection after abdominal aortic aneurysm (AAA) repair. Case 1 was a 71-year-old man in whom MRSA graft infection was diagnosed on the basis of high fever and CT-guided taps of the perigraft fluid 11 days after AAA repair, and a percutaneous catheter was inserted into the perigraft space by the CT-guided method. Case 2 was a 77-year-old man in whom MRSA graft infection was diagnosed because of high fever and purulent discharge from the wound of retroperitoneal drainage 5 days after AAA repair. A percutaneous catheter was placed into the retroperitoneal space via an extraperitoneal route. In both cases, intermittent irrigation by 0.5% Povidone-iodine solution and saline was performed as well as systemic and local antibiotic administration. The graft infection was well controlled and both patients were discharged after 4 months. Percutaneous catheter drainage and irrigation can be one of the choices for critically ill patients with graft infection after AAA repair.