We simulated mountain climbing using walking on a treadmill in order to systematically evaluate the physical load during mountain climbing. The conditions of three types of load-(1) inclination of the walking path (walking uphill and downhill), (2) walking speed, and (3) backpack weight-were varied within the range assumed for normal mountain climbing (40 sets of conditions in total). When the three types of load were expressed as vertical work rate, energy expenditure (VO₂) during walking uphill and downhill was distributed along roughly the same curve. The following characteristics of walking uphill and downhill were observed.A. Walking uphillFor all three types of load, increase in load gave a linear increase in VO₂ and heart rate (HR). A lactate threshold (LT) appeared at an intensity of 62%VO_2max, when HR was 78% HR_max. Rating of perceived exertion (RPE) was evaluated for the “Breathlessness” and “Leg Fatigue”, and both of these increased roughly in proportion to %VO_2max.B. Walking downhillWhen walking downhill, VO₂ was 35-50% the intensity of VO₂ when walking uphill on the same slope and at the same speed. Energy expenditure did not exceed 60%VO_2max in any of the load conditions, and no LT was seen. RPE values were higher for walking downhill than walking uphill, even when %VO_2max values were the same. RPE values for the “Leg Fatigue” tended to be higher than for the “Breathlessness” at the same speed in downhill walking.Using these data, we created a table giving the intensity of exercise of mountain climbing expressed as VO₂ per unit body mass and metabolic equivalents (Mets) with vertical migration velocity and total weight (Body weight + Backpack weight) as variables. This table gives mountain climbers a systematic understanding of the physical load under various mountain climbing conditions. It is likely to be of use as a reference for mountain climbers of different levels of physical fitness when practicing mountain climbing appropriate to their individual level. The present results suggest that in downhill walking, it is insufficient to express the physical load in energy expenditure (VO₂ and Mets) alone, and the load on the leg muscles must also be judged using the RPE in the “Leg Fatigue”.

1) Anjo Kosei Hospital has nearly 40 years of history of the post-primary clinical training course.
2) More than 90% of the young doctors, passed through 2 years of the primary clinical training course, have chosen further training at Anjo Kosei Hospital. During this course they began to start the experience for their own career for specialist.
3) This education program is closely coordinated with Medical Colleges such as Nagoya University and Nagoya City College of medicine. After 4 or 5 years of training at Anjo Kosei Hospital, they continued their training at Nagoya University Hospital or Nagoya City College Hospital for the further career.

Patients who need self-injection of insulin are educated beforehand to handle vials and syringes without bacterial contamination. However, not a few of them forget what they were told about the sterile technique during a long period of injection at home. Since 1988 a pen-typesyringe, which is considered to be more potent against bacterial contamination because of its mechanical structure, has become available in Japan. The aim of this study is to detect the percentage of contaminated vials in the patients' home and to compare traditional vials with pen-type vials in terms of potency against contamination. Two hundred eight vials were collected from 168 patients. Four traditional vials out of 163 (2.4 %) and 1 pen-type out of 45 (2.2%) were contaminated. Propionibacterium acnesgrew up from 2 vials, staphylococcus epidermidis from 2 vials and unidentified gram (+) rods from 1 vial. The patients using contaminated vials were from 30 to 65 in their age, enough skillful to handle syringes, good or poor in the control of DM and without disturbed vision. Thus, the contamination may have been derived from their technical deterioration after several years of injection at home. Therefore, re-education to keep their sterile technique should be given to them at appropriate intervals at the out-patient clinic.

We estimated the medical expense of treating patients with diabetes mellitus under the health insurance system in Japan. The expense was summed up to 5.07 million yen for a patient who developed NIDDM at the age of 40 and died at the age of 75 without diabetic complications throughout his life. If he had diabetic retinopathy, neuropathy, hypertension and hyperlipidemia, and needed insulin injection, the cost would have increased 2.4 times to 12.32 million yen. It was also estimated at 25.22 million yen for a patient who developed IDDM at the age of 20 and died at the age of 70 without diabetic complications. If the patient had with diabetic retinopathy, neuropathy and hypertension and needed hemodialysis because of nephropathy for 20 years, the figure would have reached a whopping sum of 76.17 million yen. From the viewpoint of medical economy, more effort to prevent diabetic complications should be made.

Delayed hemothorax following blunt chest trauma is classified as a late presentation of hemothorax after a nearly normal chest X-ray on admission. Here, we present a case of delayed hemothorax 5 days after blunt chest trauma with ribs and sternal fracture.

A 77-year-old woman underwent percutaneous coronary intervention (PCI) for chronic total occlusion of the left anterior descending artery using a drug-eluting stent (DES). Re-stenosis, stent fracture, and aneurysm were found on follow-up coronary angiography (CAG), and thus implantation of multiple DESs was required. Surgery was indicated because CAG 48 months after first DES implantation revealed enlargement of the aneurysm with other new lesions. She successfully underwent off-pump coronary artery bypass grafting and resection of the aneurysm.

A 62-year-old woman was referred to our hospital for treatment of hemolytic anemia 10 years after total arch replacement for acute aortic dissection. The cause of hemolysis was confirmed to be mechanical damage of red blood cells at the kinked graft. Because aortic valve regurgitation and occlusion of the left subclavian artery were also found, resection of the kinked graft, aortic valve replacement and reconstruction of the left subclavian artery were carried out concomitantly at reoperation. Her postoperative course was uneventful, and hemolysis resolved soon after the operation.

Aneurysms of the inferior left ventricular wall comprise only a small fraction of all aneurysms that have been reported in surgical series. Pseudo-false ventricular aneurysm is very rare and communicates with the left ventricule through a small orifice, and its wall contains myocardial tissue, unlike false ventricular aneurysm. A 53-year-old man was admitted to our hospital with chest pain. Echocardiography revealed left ventricular aneurysm, and the coronary arteriography subsequently revealed a complete occlusion of right coronary #2 and 75% and 90% stenosis of left anterior descending artery #7 and #8, respectively. Left ventriculography revealed an aneurysm of the inferior left ventricular wall, which communicated with the left ventricle through a small orifice and exhibited contraction. Surgical repair was indicated. Endoventricular circular patch repair (Dor operation) of the aneurysm of the inferior left ventricular wall and coronary artery bypass grafting to the left anterior descending artery and the right coronary artery were simultaneously performed under cardiopulmonary bypass with moderate hypothermia. The postoperative course was uneventful and the patient was discharged on the 22th day after surgery. Pseudo-false ventricular aneurysm of the inferior left ventricular wall was diagnosed by pathologic examination.

To evaluate a comparison for endovascular repair (EVAR) versus open repair (OR) for the treatment of abdominal aortic aneurysm (AAA). Data of all patients with infrarenal AAA treated electively, both with OR (107 cases) and EVAR (24 cases), at our institute between January 1999 and March 2004 were retrospectively reviewed. No difference was found between the 2 groups for sex, age, and AAA size. Cases of chronic obstructive pulmonary disease (20.8% vs 6.5%, p<0.04) and frequencies of laparotomy (25% vs 2.8%, p<0.001) were significantly more in the EVAR group than the OR group. In the initial results, deployment of the stent grafts was successful in all cases and complete thrombosis of the aneurysm was achieved in 21 cases (87.5%). One graft occlusion and a wound infection occurred in the EVAR group. OR was successfully performed in all cases. These were 6 cases of paralytic ileus, 1 of re-operation for hemorrhage, 1 of respiratory failure, and 1 of ischemic colitis in the OR group. One hospital death occurred in each group. Mean blood transfusion (0ml vs 238±345ml) and operation time (131±53min vs 250±76min) were significantly less in the EVAR group than the OR group. In the long term results, the cumulative survival rate was 88.0±6.5% at 1 and 2 years, 80.6±9.2% at 3 years in the EVAR group; 99.0±0.9% at 1 year, 94.1±2.6% at 2 years, 87.7±3.9% at 3 years in the OR group, with no difference between the 2 groups regarding survival rate. Four new endoleak and 3 graft infections were encountered in the EVAR group. Freedom from stent graft-related complications was 81.3±8.5% at 1 year, 61.4±11.9% at 2 years, 47.8±12.6% at 3 years in the EVAR group, but 100% at 1, 2 and 3 years in the OR group. Freedom from procedure-related complications in the EVAR group was significantly lower than that in OR group. In the long term results, EVAR was associated with more procedure-related complications. This finding may justify reappraisal of currently accepted EVAR for AAA management strategies.

There is disagreement regarding the indications of surgery for cases of severe aortic stenosis (AS) with a decrease in left ventricular ejection fraction (EF) and a low aortic pressure gradient (PG), since there is a high perioperative risk associated with this condition. Hence, we investigated the surgical outcome of AS cases with impaired left ventricular function. Our department performed 144 aortic valve replacements (AVRs) for cases of AS and AS-dominant mild regurgitation (ASr) between January 2000 and September 2005. Among these cases, 9 patients had an EF under 35%, and these patients were selected as subjects and compared with a control group with an EF of more than 35%. Patients with accompanying coronary artery diseases that required treatment were excluded to avoid confounding effects on cardiac function. The mean age of the 9 subjects (4 men and 5 women) was 67.8±10.8 years old, with a range from 53 to 80 years old, and the subjects had the following mean background data: EF, 34.4±0.5%; left ventricular end-diastolic dimension (LVDd), 57.3±5.8mm; left ventricular end-systolic dimension (LVDs), 49.3±5.7mm; interventricular septum thickness (IVSth), 11.9±1.9mm; and left ventricular posterior wall thickness (LVPWth), 11.1±2.6mm. Characteristics such as left ventricular dilatation and thinning of the left ventricle myocardium were noted in these data. The cases were classified as severe AS because the mean aortic valve area (AVA) was 0.58±0.2cm², but the peak aortic pressure gradient (peak PG) (65.2±32.7mmHg) in the 9 subjects was lower than that of the control group (97.0±65.2mmHg). All 9 subjects underwent aortic valve replacements (AVRs), with simultaneous mitral annuloplasty (MAP) in 3 cases, mitral valve replacement (MVR) in 1 case and performance of a Maze procedure in 1 case. No deaths occurred while the patients were in hospital. Postoperative complications included 2 cases of transient atrial fibrillation and 1 case of postoperative bleeding requiring rethoracotomy for hemostasis. The EF in the late postoperative period showed improvement in 8 cases and was unchanged in the remaining case; the mean postoperative EF was 56.9% for the 9 subjects. All cases were rated as improved based on the NYHA classification of cardiac performance, and the significant improvement in EF in 8 of the 9 cases suggests that surgery is safe and can improve prognosis for patients with advanced AS with myocardium thinning and decreased EF.