The purpose of the present investigation was to examine the relationship between the open water swimming (OW) performance and the swimming speed at 2, 3, and 4 mmol/l of blood lactate concentration (SSLA2, SSLA3, and SSLA4) or the critical swimming speed (CSS). Six male collegiate swimmers performed the 10 kilometers of OW, as well as the multi-stage graded swimming test, in order to determine the SSLA2, SSLA3, SSLA4. Furthermore, the CSS was calculated based on the personal best records for 50 to 1500 meters of free-style indoor swimming. As a result, the SSLA2, SSLA3, SSLA4, and CSS corresponded to 102±6%, 106±6%, 110±7%, and 106±5% of the average swimming speed of the OW, respectively. Thereafter, the SSLA2 did not differ significantly in comparison to the average swimming speed of the OW, whereas the SSLA3, SSLA4, and CSS differed significantly with the average swimming speed of the OW (p＜0.05). Furthermore, the average swimming speed during the OW significantly correlated with the SSLA2, SSLA3, SSLA4, and CSS, respectively (p＜0.05). These results suggest that the OW performance significantly correlated with the swimming speed at 2 to 3 mmol/l of the blood lactate concentrations and CSS. Furthermore, regarding these parameters, the SSLA2 may accurately reflect the average swimming speed of OW.

A 83-year-old woman suffered pulseless-electrical-activity (PEA) because of cardiac tamponade after acute myocardial infarction with blow-out type cardiac rupture. Immediately median sternotomy was performed and active bleeding from the postero-lateral wall was found. It was impossible to stop bleeding only by putting pressure on the aperture of the myocardium with a piece of TachoComb coated with gelatin-resorcinol-formaldehyde (GRF) glue, however, the chemical action of GRF glue made the delicate myocardium after acute infarction stronger and we managed to stop that bleeding with mattress sutures that had initially seemed to be impossible. She was discharged on POD 103 uneventfully. We think this is a useful and safe operation procedure for blow-out type cardiac rupture.

A 76-year-old woman presented because of bilateral lower-extremity edema and dyspnea. Transthoracic echocardiography revealed a mobile mass in the right atrium. A right atrial mass associated with heart failure was diagnosed. Surgery was performed. Intraoperative transesophageal echocardiography showed that the mass was contiguous with the inferior vena cava. However, the primary lesion was unclear. Therefore, only the intracardiac mass was resected. The margins of the residual tumor were marked with clips. Computed tomography performed immediately after surgery revealed a clip in structures contiguous with the region from a uterine myoma to the inferior vena cava. Intravenous leiomyomatosis was diagnosed on histopathological examination of the resected specimens. Computed tomography 6 months after surgery showed that the clip had moved from the inferior vena cava to a vein contiguous with the uterus. The tumor regressed slightly. Close follow-up is required.

At the Niigata University School of Medicine, objective structured clinical examinations (OSCEs) were performed for the first time in 2001 for 92 fourth-year medical students. The average evaluation scores students received from instructors were summarized, and the differences between scores given by different instructors were examined. We found that practice methods for the medical interview and physical examination before OSCE and the question topics and evaluation methods of OSCE were appropriate, but scores on some items were extremely low. The standardization and objectivity of the evaluation were satisfactory, perhaps because one explanatory conference and two training conferences were held for instructors before OSCE. However, some questions tended to produce differences between instructors, as did some topics, especially in the medical interview. The scores with standardized patients and those by teachers were strongly correlated, but those with the former were lower than those by the latter.

Objectives: To investigate future directions of medical interview and physical examination practice (MIPEP) with simulated patients and to clarify its educational meaning for medical students. Design: Qualitative design using 8 focus groups before and after MIPEP with simulated patients (4 pre-MIPEP and 4 post-MIPEP). Methods: Nine simulated patients and 10 medical students participated. Four physicians served as facilitators. Each student practiced consultation, including two medical interviews and physical examinations (of one male and one female simulated patient), for 15 minutes. After every consultation, students had a 15-minute feedback session with a simulated patient and a facilitator. All simulated patients and students participated in both the pre-MIPEP and post-MIPEP focus groups. Results: Through pre-MIPEP and post-MIPEP focus groups, medical students realized that an appropriate disposition and talking with patients during physical examination are helpful. MIPEP with simulated patients helps students to gain confidence before clinical practice. Simulated patients found that the value of MIPEP with simulated patients for medical students was increased by thorough course preparation and by the simulated patient's training and motivation, which was affected by the students' attitudes to MIPEP with simulated patients. Conclusion: MIPEP with simulated patients is valuable for teaching the appropriate disposition towards patients, including making physical contact and talking with patients as fellow human beings. When the students' attitudes satisfy the simulated patients, MIPEP with simulated patients can become a powerful educational method.

A 27-year-old woman was given a diagnosis of infectious endocarditis with severe tricuspid regurgitation. Despite adequate antibiotics therapy, her general condition did not improve, and moreover multiple pulmonary abscesses were detected by computed tomography. Therefore surgery was indicated. Surgery consisted of removal of vegetation and tricuspid valve plasty with autologous pericardial patch augmentation of the anterior leaflet. Tricuspid valve plasty was carried out without prosthetic materials. Her postoperative course was uneventful with only mild tricuspid regurgitation. One year after surgery, neither recurrence of infection nor worsening of tricuspid regurgitation was noted. This method could be a useful technique for young patients with severe infection.

We described a patient with free wall rupture followed by papillary muscle rupture due to acute myocardial infarction. A 69-year-old man was transferred complaining of transient unconsciousness. His clinical history, electrocardiogram, and chest CT showed myocardial infarction with free wall rupture indicated that several days had passed since the onset. Coronary angiography showed occlusion of the right coronary artery and severe stenosis of the left anterior descending artery. Since cardiac rupture was at inferior wall and hemorrhage wasn't active, repair of the rupture using fibrin glue and fibrin sheet and coronary artery bypass grafting to the left anterior descending artery was performed without cardiopulmonary bypass. On the 10th postoperative day, his arterial oxygen saturation suddenly deteriorated. Transesophageal echocardiography revealed papillary muscle rupture and severe mitral regurgitation. Emergency mitral valve replacement was performed. After two emergency operations, he gradually recovered and were discharged to home. In three months after discharge, he was admitted again due to congestive heart failure with left ventricular aneurysm at inferior wall and recovered in response of conservative treatment. Surgical experience of double rupture is rare. Based on this case, it may be necessary to perform reperfusion therapy toward even this case of recent myocardial infarction, to prevent papillary muscle rupture. It also may be better to use a patch on free wall rupture to prevent cardiac aneurysm.

A case of a 51-year old male with pulmonary valve endocarditis accompanied by aortic regurgitation, and ruptured aneurysm of Valsalva sinus was reported. Repeated blood cultures grew α-streptococcus on a single occasion. After medical treatment, resection of pulmonary valve vegetation, resection and patch closure of aneurysm, and aortic valve replacement were performed successfully. Twenty one cases of pulmonary valve endocarditis reported in Japan, including our case, were collected and reviewed. Causative organism was streptococcus in 93% of cases. No case of intravenous drug abuse was found in this series. A variety of preexisting heart diseses were found in 20 cases out of 21 (95%). All these diseases were congenital ones, such as ven-tricular septal defect, patent ductus arteriosus, pulmonary stenosis and ruptured aneurysm of Valsalva sinus. This fact means that jet lesion of pulmonary valve is a major predisposing factor of pulmonary valve endocarditis. Surgical procedures were reported in 12 cases: resection of vegetation in 4 cases, resection of pulmonary valve in 2, and pulmonary valve replacement in 5. Appropriate surgical procedures should be chosen, depending upon the activity of infective endocarditis, severity of destruction of the valve, and pulmonary vascular resistance.