Injury to the thoracic aorta is often fatal. We encountered a case of aortic rupture caused by a traffic accident. A 20-year-old man was transferred to our hospital because of right elbow fracture and enlargement of the upper mediastinum on X-ray. We diagnosed aortic isthmus rupture by chest CT with enhancement. He did not have chest pain, but complained of severe pain in the right elbow. His hemodynamic condition was stable, but his right arm become swollen with increasing sensory disturbance. Chest CT and blood cell count showed no interval change between results at a previous hospital and ours. So we decided to operate on his right arm before aortic rupture. After the open reduction of his fractured elbow, pleural effusion increased although his hemodynamic condition was stable. Then the descending aorta was replaced under partial cardio-pulmonary bypass. His post-operative course was uneventful.

The first trial of common achievement test-computer-based testing was held from January through August 2002. The number of examinees was 5, 693, of whom 5, 676 were analyzed. Single-best-answer, five-choice questions were used. The highest score was 92 points, the lowest score was 19 points, and the average score was 55.9±10.2 points (standard deviation). Scores were distributed normally. The test sets did not differ significantly in difficulty, although test-set items differed for each student. The percentage of correct answers, the ∅-coefficient, and the point-biserial correlation coefficient were calculated for each category of the model core curriculum. The percentage of correct answers was highest in category A of the model core curriculum, and percentages of correct answers were similar in categories B, C, D, E, and F. The ∅-coefficient and the correlation coefficient were low in categories A and F and were highest in category C. Although the percentage of correct answers in this trial was lower than expected, many test items had discriminatory power. The Test Items Evaluation Subcommittee is now evaluating test items, determining pool items, and revising new test items for the second trial and expect to compile a useful item bank.

1) The faculty development at each medical school from 2003 through 2005 was analysed.
2) The major themes in faculty development were problem based learning, tutorial, computer based testing, and clinical training.
3) Faculty development is considered an effective way to enhance the contributions of faculty members to medical education.

A 72-year-old woman was admitted to our department with a diagnosis of severe aortic stenosis was also diagnosed Inherited antithrombin deficiency was also diagnosed after she suffered from a pulmonary thromboembolic event 10 years previously and had been taking warfarin since then. On admission, her antithrombin activity was 53% of normal, and her PT-INR level was maintained around 2.5. Preoperative management of anticoagulation therapy included discontinuation of warfarin, and supplementation of antithrombin with heparin infusion. On the day of operation, antithrombin activity was maintained above 80% by administering antithrombin, and aortic valve replacement with a mechanical valve prosthesis was carried out under standard cardiopulmonary bypass support using heparin. Heparin infusion was continued with antithrombin supplementation until PT-INR recovered to round 2.5 with warfarin. Her intra- and postoperative courses did not show any thromboembolic events, and she was discharged 14 days after the surgery.

This is a report on a case of delirium due to a small amount of ketamine with voriconazole. A 58 year old male was treated for multiple myeloma and hip pain due to an extramedullary tumor following the administration of oxycodone, and voriconazole was administrated for his suspected mycotic pneumonia. His pain was refractory, so we started the administration of a small dose of ketamine (4 mg/hr) for analgesia, added to oxycodone. About 30 hours later, the delirium appeared but he complained of worsening hip pain, so we added 2 mg of ketamine rapidly. Immediately after the additional administration of ketamine, his delirium became more serious. We think the reason why a small amount of ketamine induced delirium is an interaction of ketamine and voriconazole. Ketamine is metabolized to norketamine, which is thought to be more harmless than ketamine, by cytochrome P 450 (CYP) (a part of by CYP3A4) and voriconazole is an inhibitor of CYP3A4. In cases of patients treated with voriconazole, ketamine should be more carefully administrated.

Bacteremia from dental disease is the most important cause of infective endocarditis in patients with heart valve disease. However, the prevalence of dental disease in patients undergoing valve surgery has not been clarified. One hundred thirty-seven patients had a dental check-up before heart valve surgery, 82 patients (59.9%) had significant dental disease which could have caused bacteremia. All patients with the dental disease underwent extraction preoperatively. There was neither complication in extraction nor any influence on heart valve surgery. Postoperative hospital stay was not prolonged due to the extraction. During the mean follow-up period of 30 months, no infective endocarditis was seen. The prevalence of dental disease was high in patients undergoing heart valve surgery. Preoperative treatment of dental disease did not have a negative impact on the postoperative course and hospital stay in heart valve surgery.

Five patients with isolated stenosis of the left main coronary artery or stenotic ostial lesions underwent direct coronary artery surgery. These surgical approaches included vein patch angioplasty in 2 cases, punch out endarterectomy in 1 case, and resection of the thickened aortic wall and transaortic endarterectomy in 2 cases. Early results were satisfactory, except for one case who died due to severe LOS and MOF. In the late postoperative period, one case of vein patch angioplasty died due to cerebral bleeding, and in the other case, stenosis existed in position of distal patch anastomosis. Since direct coronary artery surgery was successful in both early and late postoperative fidings, it is believed to be useful and safe technique if the candidates are selected properly.

A 24-year-old woman with patent ductus arteriosus underwent division of the ductus. On the fifth postoperative day (POD 5), MRSA was detected in pus from the wound. On POD 8, an emergency operation was performed for left tension hemothorax due to a ruptured aorta with MRSA infection. The bleeding site in the descending aorta was covered with a viable omental flap under deep hypothermic circulatory arrest. Although MRSA was detected in the pleural effusion and the aortic wall, the patient recovered from pyothorax, and pneumonia caused by Pseudomonas aeruginosas and acute renal failure. On POD 37, a pseudoaneurysm of the descending aorta was found and graft replacement was performed on POD 56 due to enlargement of the aneurysm. However, MRSA was not detected in the left pleural effusion. The postoperative course was uneventful. Omental transfer should be considered for the treatment of severe aortic wall infection, even in the presense of MRSA infection.

A minimally invasive approach to coronary artery revascularization without cardiopulmonary bypass has been performed recently and its feasibility and effectiveness have been proved. However, occlusion of the coronary artery during anastomosis in the beating heart is liable to cause myocardial ischemia or infarction. To prevent these and to perform minimally invasive coronary artery bypass on the beating heart safely, intra-coronary shunt was developed and applied in animal experiments. Materials and methods: The left internal mammary artery was harvested endoscopically and anastomosed to the left anterior descending coronary artery in the beating heart without cardiopulmonary bypass in seven pigs. Three of them utilized intracoronary shunt tubes (group S) and the other did not (group C). Results: Use of an intracoronary shunt tube facilitated non-blood exposure of the coronary artery during anastomosis. In group C, three pigs out of four had ventricular fibrillation during occlusion for the anastomosis. In group S the anastomosis was accomplished without change of ECG except one case and without any elevation of CPK-MB and Troponin T during and after the anastomosis. Conclusion: These results showed that an intra-coronary shunt can prevent myocardial ischemia and may be very useful especially to those who do not develop collateral branches from other coronary arteries.

　　A 48-year-old man with jaundice was referred to our hospital. Endoscopic retrograde cholangiography showed primary sclerosing cholangitis. Endoscopic biliary drainage was not successful because of highly viscous bile, so we performed percutaneous trans-gallbladder drainage (PTGBD), which was able to reduce the total serum bilirubin level from 8 to 10mg/ml. Subsequently, an indwelling drainage catheter was placed in the gallbladder for 13 months. However, liver atrophy worsened with the gradual progression of hepatic failure. Twelve months later, he complained of dyspnea. Computed abdominal tomography showed that the drainage catheter had perforated the diaphragm and become exposed to the chest cavity. In spite of intensive care, the patient died of liver failure while waiting for a liver transplant. Careful attention should be paid to the possibility of this serious complication in such patients.