Since January, 1981 to December, 1990, eight patients (one male, 7 female) of Stanford A type aortic dissection underwent surgical treatments with deep hypothermic circulatory arrest. The average was age 59.6 years (range 50 to 72 years). All of them were diagnosed with UCG and/or CT before operation. Two cases had already been in shock state due to cardiac tamponade. Three cases had aortic insufficiency and one had neurological deficit. After median sternotomy, right atrial-femoral artery bypass was established. Right atrium was incised and coronary sinus was cannulated. Then retrograde coronary infusion of cardioplegic solution was employed at a continuous flow rate of 20ml/kg/hr. The mean rectal temperature was 19.6°C and the mean circulatory arrest time was 35.5min (22-58min). Two of eight cases died, because of DIC followed by necrotizing enteritis at 28th postoperative day, and prolonged shock state before operation. The rest were all survived without any neurological deficits. There were no severe complications related to deep hypothermia. We concluded that deep hypothermic arrest is safe and simple method, allows good inspection of operative field and makes it easier to repair the dissected aorta.

We report 18 cases of thoracoabdominal aortic aneurysm repair. Most causes of the thoracoabdominal aortic aneurysm were atherosclerotic lesions (56%) or inflammatory changes (39%), such as Takayasu's aortitis and Behçet's disease. The Crawford procedure was performed in 13 patients, patch aortoplasty in 3, the Hardy procedure in 1 and extra-anatomic bypass in 1. As an adjunct, temporary bypass was employed in 8 patients and F-F bypass in 7 patients. Visceral arteries were perfused selectively during aortic cross-clamp. A total of 39% of all patients required emergency surgery for rupture, and among inflammatory aneurysms 86% of them ruptured. The early mortality rate was 0% in non-ruptured thoracoabdominal aneurysms, 42.9% in ruptured and 16.7% overall. There were 3 severe post-operative complications including one each of paraplegia, non-occlusive intestinal ischemia and rupture. All of them turned resulted in in-hospital death and the in-hospital mortality rate was 33.3%. There was no late death among atherosclerotic thoracoabdominal aortic aneurysms. However both Behçet's disease cases required re-operation for rupture at the anastomotic site in the late postoperative period and one patient died. One Marfan's syndrome patient also died 3 years postoperatively. We conclude that the Crawford procedure with F-F bypass is an effective and safe approach to thoracoabdominal aortic aneurysm repair and yields good clinical results.

The aim of this study is to clarify the present situation of activities of continuing medical education (CME) for the primary care physicians to whom the leading hospitals, such as universities and clinical trainee hospitals perform CME in their regions. A questionaire was designed for main 4 parts, as following: 1) On the purpose of CME for the physicians. 2) On the organization (office) managing CME in the hospitals. 3) On the strategies of CME. 4) On the evaluation of CME. Answers to a questionaire were replied from 234 institutions (58.1%). Analyzing the results, we recognized that the leading hospitals actively carried out CME for the primary care physicians in the community. Furthermore, conversion to experiential learning from passive learning and establishment of evaluation methods should be promoted in CME.

Nine patients with type IIIb dissecting aortic aneurysm underwent graft replacement of the thoracic and abdominal aorta between 1988 and 1992. The spiral opening method was used to expose the thoracic and abdominal aorta. Temporal bypass was employed in 2 patients and F-F bypass in 7 patients. Visceral arteries were perfused selectively during aortic cross-clamp. The entire descending thoracic aorta and abdominal aorta was reconstructed in 6 patients and the proximal descending thoracic aorta to renal arteries in 3 patients. The Crawford graft inclusion technique was used in all cases. Three patients required emergency surgery for rupture in one and impending rupture in 2. Operative deaths occurred in 2 patients (22.2%). Morbidity included renal failure (2), bleeding requiring reoperation (2), arrythmia (1), paraplegia (1), paraparesis (1), respiratory failure (1) and ileus (1). In the past two years, we operated on 5 cases of type IIIb dissecting aneurysms and there was neither operative death nor paraplegia.

Because new media have come onstage in the information technology period, also self-learning methods have been diversified. Recently, small group discussion such as clinical conference using the mailing list is lively performed among the primary care physicians, and it is considered to be useful for continuing medical education. To promote the mailing list for continuing medical education, we present as follows; 1) present situation: to show a good example of TFC-ML (total family care-mailing list), 2) usefulness: to know new medical knowledge, new medical information and literatures etc., to discuss clinical cases. 3) issues: a role of moderator, excess of information, correspondence with slander, 4) future: to reevaluate usefulness for continuing medical education. We would like to expect effectiveness of mailing list for continuing medical education.

Objective: Glycemic control varies based on lifestyle factors and stress coping mechanisms, which are influenced by personality. The psychological factors associated with glycemic control have not yet been established in patients with type 2 diabetes mellitus (T2DM). The relationship between a 5-factor model of personality and glycemic control was evaluated in individuals with T2DM. Methods: The subjects were 503 Japanese outpatients with T2DM. Glycated hemoglobin A1c (HbA1c) levels, depressive status, insomnia and personality traits were assessed. Lifestyle factors of the patients, such as habitual alcohol consumption and smoking, were also included in the analyses. Results: Because the influence of insulin therapy on HbA1c is so strong, we stratified the patients according to insulin use. Simple regression analysis showed a significant correlation between HbA1c and neuroticism in patients who did not use insulin. After adjustment for confounders, multiple regression analyses revealed that none of the personality factors, including neuroticism, were found to be associated with HbA1c. Conclusion These findings suggest that personality traits do not have a large impact on glycemic control. Further studies are required to confirm the relationships between psychological factors and glycemic control using a longitudinal study design.

A 73-year-old woman was diagnosed with coronary artery aneurysms associated with coronary-pulmonary arterial fistula in a preoperative examination for transverse colon cancer. One of the aneurysms (28 mm) originated from a branch of the right coronary artery and the other two (16 and 12 mm) originated from a branch of the left coronary artery. We performed surgery to prevent their rupture because the right coronary artery aneurysm showed a tendency to enlarge. Surgery was performed through a median sternotomy under cardiopulmonary bypass. Suture closure of the inflow and outflow of the aneurysm was performed. The coronary-pulmonary arterial fistula was ligated. In addition, suture closure of the outflow of the coronary-pulmonary artery fistula into the pulmonary artery was performed, under direct view after incision of the pulmonary trunk. No residual shunt blood flow in the coronary-pulmonary arterial fistula was observed on postoperative echocardiography. Furthermore, no coronary aneurysm and coronary-pulmonary arterial fistula was recognized on postoperative coronary computed tomography. The patient made an uneventful recovery and was discharged from the hospital on postoperative day 12.