Objective: This study aimed to clarify changes in planter pressure at the 1, 2, 5 metatarsal head, and muscle activities resulting from exercise of the peroneus longus (PL) or tibialis posterior (TP) muscles. Method: Nine subjects (3 male, 6 female) were recruited. Before and after exercise, planter pressure at the metatarsal heads and the activities of PL, TP, tibialis anterior, and soleus muscles were recorded during heel raising using electromyography and a foot sensor. The first exercise was a maximal isometric contraction of the PL and peroneus brevis (PB). The second was contraction of the TP, and the third was of all three, the PL, PB, and TP. Result: The amount of planter pressure at the first metatarsal head increased after PL exercise. The standard deviation at the second metatarsal head decreased after PL and TP exercise, but showed no change after PL exercise. Conclusion: After PL and TP exercise, heel raises were possible with few perturbations at the metatarsal head. After PL exercise, the amount of planter pressure at the first metatarsal head increased, but there was no change in perturbations. The results show that it is necessary to consider the effect of short time exercise.

In grip strength a subject being ordered to show one-third, one-second and twothird of his own maximum value after checking his maximum, the value he shows is not always the same as the ordered value. The Discrepancy Index was determined by the grade of the difference between the ordered value mentioned above and the value showed actually.
For 2117 subjects composed of both sexes our experiment was performed.
1) The possibility of training effect for one-third and two-third of their own maximum value existed but little for one-second.
2) Up to 16 years of age the training effect increased with their physical development, but after 17 years remarkable change of their grading ability was not found.
3) There existed no relation between the experimental results of one-third value and two-third, between the left hands and the right, and between the Discrepancy Index of pre-training and post-training.
4) The larger maximum value of grip strength became, the smaller the Discrepancy Index was. Sometimes in the individuals who have larger maximum value, the more training effect was recognized.
5) The champions of weight-lifting, Kendo and volleyball showed better results than those of the control groups.

[Objectives] It has been demonstrated that HMG-CoA reductase inhibitors (statins) effectively reduce the low-density lipoprotein cholesterol (LDL-C) and total cholesterol levels in the blood, and currently, statins are most widely used for the treatment of hyperlipidemia.  On the other hand, it has been demonstrated that fibrates more effectively reduce the blood triglyceride level (TG).  However, concomitant use of statins and fibrates is contraindicated.
  Therefore, practical and situational use of fenofibrate (fibrate therapy) and atorvastatin (statin therapy) was investigated in patients with high TG and LDL-C levels in consideration of cost effectiveness.
[Method] Baseline TG and LDL-C levels were stratified, and a table of combination was prepared for TG and LDL-C values.  Effectiveness was measured by the number of patients who were able to achieve treatment targets.  Treatment targets were set referring to the reduction rate of serum lipid levels in dose finding studies of fenofibrate and atorvastatin and the target lipid levels identified in 2007 Japan Atherosclerosis Society Guidelines for Prevention of Atherosclerotic Cardiovascular Diseases.  Costs were measured by annual drug treatment costs, and the incremental cost effectiveness ratio of atorvastatin to fenofibrate was then estimated.  According to the actual patient distribution, the incremental cost effectiveness ratio of atorvastatin to fenofibrate in patients with TG level over 150 mg and LDL level over 140 mg was also estimated.
[Results] Fenofibrate was dominant over atorvastatin where effectiveness was higher and costs were lower in fenofibrate treatment in two patient groups; patients with LDL-C level under 160 mg patients with TG level over 170 mg and LDL-C level between 160 mg and 170 mg patients with TG level over 190 mg and LDL-C level between 170 mg and 180 mg patients with TG level over 230 mg and LDL-C level between 180 mg and 190 mg patients with TG level over 250 mg and LDL-C level between 190 mg and 200 mg patients with TG level over 290 mg and LDL-C level between 200 mg and 210 mg patients with TG level over 350 mg and LDL-C level over 210 mg.  In an analysis made according to the actual patient distribution, 571 fenofibrate patients and 534 atorvastatin patients were able to achieve the treatment targets, and fenofibrate was dominant over atorvastatin where effectiveness was higher and costs were lower in fenofibrate treatment.

A 32-year-old woman was referred to our hospital during the 35th week of pregnancy because of chest pain and dyspnea. The cesarean section was performed and a healthy infant was delivered. On the 16th hospital day, she developed heart failure. Echocardiograms revealed protrusion of the mitral valve into the left atrium in systole, vegetation and worsening of mitral regurgitation. CT showed splenic infarction. Mitral valve replacement was performed after inflammatory findings were improved by antibiotics. We reported here a case of infective endocarditis during the perinatal period.

A 22-year-old woman had been treated with a Ross operation for aortic root aneurysm and aortic regurgitation 10 years previously. In the initial Ross operation, a handmade tri-leaflet conduit was used for the right ventricle outflow tract (RVOT) reconstruction. The conduit was prepared preoperatively, by sewing a folded 0.1 mm expanded polytetrafluoroethylene (ePTFE) membrane onto the luminal cavity of the 24 mm woven double velour vascular graft, thereby creating a tri-leaflet valve. During ambulatory follow up after discharge, dilation of the pulmonary autograft had been observed, and its maximal diameter reached 60 mm. Furthermore, preoperative a pressure study revealed a 25 mmHg pressure gradient between the right ventricle and the pulmonary artery. At the time of reoperation, we performed an aortic root replacement combined with RVOT conduit replacement. A 24-mm woven double velour vascular graft integrating a 21-mm On-X mechanical prosthesis was used for aortic root replacement. A handmade ePTFE tri-leaflet conduit, 26 mm in size, was used to replace the previous RVOT conduit. The operation was successful, and the postoperative course was uneventful. The explanted conduit was sent for microscopic examination, which revealed that the graft was covered by a fibrocollagenous membrane. On the contrary, no surface membrane was found on the ePTFE valve. Moreover the microscopic examination showed cystic medionecrosis of the pulmonary autograft. Both dilatation of the pulmonary autograft and RVOT conduit failure were successfully treated at the second operation. However this young patient will require follow-up of the mechanical prosthesis and RVOT conduit for the rest of her life.

Objective: We have used therapeutic drug monitoring (TDM) analysis software to set the initial dose of vancomycin in our hospital.  In contrast, the TDM guideline, in which the initial dose of vancomycin per body weight was set, was published in 2012.  We looked forward with utilizing the TDM guideline in the clinical setting, after which we conducted multiple surveys to determine the important points of the TDM guideline.
Methods: We surveyed patients treated with vancomycin, in whom the initial dose was set using the TDM analysis software and the concordance rate between the vancomycin dose set with the software and that set with the TDM guideline.
Results: The concordance rate of vancomycin dose was 42.1%.  The mean age of the high-dose group (vancomycin dose higher than that recommended by the TDM guideline), was younger than that of the recommended-dose group.  Additionally, the mean body weight of the high-dose group was significantly lower than that of the recommended-dose group.  The corrected creatinine clearance of the low-dose group was significantly lower than that of the recommended-dose group.
Conclusion: Our results suggest that when the initial dose is set after referring the TDM guideline in patients who are not very high age, and having low body weight and decreased renal function, the dose may differ from the dose set by using TDM analysis software.  In addition, since the recommended dose per body weight is a range and not a single value, setting the dose appropriate to target trough concentration is necessary.

Reconstruction of the right ventriclar outflow tract (RVOT) in congenital heart disease often requires implantation of a valved conduit. A hand-made expanded polytetrafluoroethylene (ePTFE) trileaflet Dacron graft conduit has been used at our center since 1997, and has been implanted in 31 patients. Midterm results of this conduit were investigated in 30 of the patients who have been followed at our outpatient clinic. There were 16 males and 14 females. The mean age and body weight were 16.4±7.2 (range, 3.4-33.4) years and 41.7±13.3 (range, 13.0-64.0)kg, respectively. Diagnoses were tetralogy of Fallot with pulmonary atresia in 14 patients, RVOT reconstruction associated with Ross procedure in 8, transposition with pulmonary stenosis in 3, pulmonary atresia with intact ventricular septum in 2, tetralogy with absent pulmonary valve syndrome in 1, pulmonary regurgitation developed after tetralogy repair in 1, and hemitruncus in 1. The median size of the graft was 22 (range, 20-26)mm. All patients were in NYHA functional class I at the time of the latest follow-up. The pressure gradient across the conduit was 11.0±5.8mmHg during the same hospitalization and 13.8±6.5mmHg on the latest echocardiogram (Interval, 2.4±1.5 years, p=0.85). The valve function was well maintained in all patients, with the regurgitation graded as non-trivial in 22 patients, mild in 7, and moderate in only 1. Midterm results of hand-made ePTFE trileaflet valved cunduit was satisfactory. A longer follow-up is mandatory to assess its actual durability.

During the period of two years from 2001 to 2003, we treated nine cases of takotsubo-type myocardiopathy. In this paper, the clinical characteristics and patients' conditions are described, and the mechanisms leading to dyskinesia of the muscular walls of the heart are discussed. All the cases were female. The mean age was 73 years. Physiological as well as psychological stress was implicated as a major cause of the disease, with onset occurring when some members of their family were suddenly taken ill or when they started quarreling with others. Echocardiograms revealed sigmoid septa in almost half of the nine patients. The prognosis was good. Only one patient had cardiac insufficiency as a sequela, but her condition improved. No one died.Eight patients got over dyskinesia of the left ventricular walls in two weeks. From our experience and studies of literature, we ruled out the possibility of the involvement of circulatory disorder and myocarditis in the onset of the disease. Women of advanced age are apt to have sigmoid septa and left ventricular walls thinning. When the old patient in this condition suffer psychosomatic stress, catecholamines will be released, causing the hypercontraction of the left ventricle, the pressure difference in the chamber, and the collapse of the apical of the heart. We concluded that these physiopathological states may be responsible for the abnormal movements of the muscular walls of the heart peculiar to the disease taken up in this study.
Heart ; Patients ; Dyskinetic syndrome ; Age, NOS ; Heart insufficiency

1)The purpose of this study was to evaluate a role–playing class for informed consent with fifth–year students playing the role of physicians and first–year students playing the role of patients.
2)The first–year students were competent as simulated patients for the informed consent role–playing and were a worthy educational human resource.
3)This role–playing was effective for helping both first–year and fifth–year students understand informed consent and the mentality of patients and to motivate students to study informed consent. This joint class also allowed fifth–year students to review their progress over time and gave first–year students a chance to meet role models.