Aortic pseudoaneurysm is a rare but life-threatening complication after graft replacement. One of the main challenges of surgery is the appropriate and safe method of re-entering the chest cavity. Therefore, it is necessary to consider a strategy which includes cardiopulmonary bypass. The patient was a 64-year-old man who had undergone hemi-arch replacement for pseudoaneurysm of the native thoracic aorta 17 years previously. The exact surgical details of the previous operation were unknown. He experienced progressive chest pain for 1 month, and noticed a parasternal pulsatile mass. An enhanced computed tomographic scan revealed a pseudoaneurysm originating from the thoracic aortic artificial graft itself, which had eroded the left parasternum and which would possibly rupture out of the skin. Preoperative examinations suggested a high risk of bleeding if redo sternotomy was performed. Therefore, we decided to perform open surgical repair with a cardiopulmonary bypass with cannulation through the femoral artery and vein before resternotomy. In addition, we performed a transthoracic left ventricular venting and selective cerebral perfusion using bilateral axillary arteries, which enabled core cooling in case of uncontrollable hemorrhage. He successfully underwent redo graft replacement of the thoracic aorta, and his postoperative course was uneventful.

With multiple-choice questions presenting one, two, or three of five choices (types A, K or X), the expected probability of a correct answer (P) can be obtained with a five-dimensional equation for the knowledge level (q), which is the probability of discriminating correct and incorrect items. From equations for each question type, we inversely estimated the q value (the estimated knowledge level), replacing P with the raw score rate in the actual examinations for promotion. The distribution and mean value of the raw score rate of type X differed from those for types A and K. However, distributions of estimated q values for the three question types were similar. This method can be used to estimate the actual knowledge level of students without the question type affecting the raw score but cannot be used to estimate incorrect knowledge.

The objective of this study was to investigate whether isometric resistance exercise (IRE) can attenuate musculoskeletal atrophy during unloading and accelerate its recovery during reloading. Twenty-six female Fischer 344 rats, aged 16 weeks, had their hindlimbs suspended for 3 weeks (unloading) ; 12 of these rats were allowed subsequent cage activity (reloading) for 3 weeks with or without IRE. IRE (stationary support on a cylindrical grid inclined 60 or 80 degrees) was done for 30 min/day, 6 days/week, with an additional load of 30% or 50% body mass attached to the tail during the unloading and reloading periods. The tibial bone and hindlimb skeletal muscles from four experimental and two age-matched control groups were evaluated with dual-energy X-ray absorptiometry, mechanical testing, and muscle mass measurement. Bone mineral density (BMD) was measured in the whole tibia and in 7 regions divided equally along the long axis of the epiphysis from proximal (R1) to distal (R7) . After unloading, fat-free dry mass (FFDM), bone mineral content (BMC), and BMD of the whole tibia decreased by 8%, 10%, and 6%, respectively. FFDM and BMC, but not BMD, returned to the levels of age-matched controls during reloading. Unloading-induced decreases in BMD were observed in the regions from the proximal epiphysis to the diaphysis (R1 to R4) and the distal epiphysis (R7) . The rate of decrease in BMD was regionally specific and was particularly pronounced (12%) in the most proximal region (R1) . These findings indicate regional variations in responses of BMD to skeletal unloading. The BMD in R2 to R4 remained less than that in age-matched control after reloading. No significant changes were observed in maximum breaking load, energy, and deformation after unloading and reloading. Hindlimb-unloading induced loss of mass in the soleus (38%), plantaris (14%), gastrocnemius (25%), tibialis anterior (8%), extensor digitorum longus ( 8%), and rectos lemons (17%) muscles, but the mass of muscles, except for the soleus muscle, recovered during reloading. IRE ameliorated the loss of mass in the soleus and gastrocnemius muscles during unloading but did not promote the recovery of mass in any muscles during reloading. Moreover, IRE showed no effect on bone responses after unloading and reloading. This lack of beneficial effects of IRE on osteopenia may be due, in part, to insufficient exerciseinduced load. We concluded that 1) regional analysis of BMD can be used to assess local bone metabolism, 2) the response of BMD to altered loading conditions does not necessarily depend on the response of muscle mass, 3) recovery from osteopenia progresses more slowly than that from sarcopenia, and a longer time than the unloading period is required to restore BMD. Further studies are needed to develop more effective countermeasures against osteopenia and sarcopenia.

A “Okusuri-techo,” which refers to a prescription record, is utilized in medical institutions as an information tool necessary for the prevention of side effects, drug-interaction, and/or in case of emergency medication. However, the record is not shared sufficiently between patients and pharmacists and thus remains underutilized. To explore how the record could be used more effectively, a survey was conducted with the pharmacists of 73 community pharmacies that were members of the Otaru Pharmaceutical Association, and patients who received prescriptive medicines from these pharmacies. A total of 148 pharmacists and 157 patients responded. Approximately 80.9% of the patient group responded that the prescription record was useful, whereas 100% of the pharmacists answered that it was helpful. In the cross-analysis of the patients’ responses, the presentation of the prescription record to medical staff was correlated with the degree of helpfulness of the record. It was suggested that the function and effective usage of the record were rarely shared between patients and pharmacists. Sufficient understanding of the value and effective usage of such a record will therefore promote its active utilization among patients and pharmacists.

The relationships between physical activity and childhood body size, low physical fitness epidemic are still unclear. The purpose of this study was to examine the relationship between energy expenditure estimated by doubly labeled water (DLW) method and body fatness, physical fitness in children, and the relationship between physical activity levels and percent time spent in activities. 30 healthy Japanese children (20 boys and 10 girls) participated in this study. The total energy expenditure (TEE) and % body fat were measured by the DLW method over a 6-day period. The physical activity-related energy expenditure (PAEE) was calculated as (TEE × 0.90) – basal metabolic rate (BMR). The physical activity level (PAL) was also calculated as TEE/BMR. The physical fitness tests (8 items) were applied to evaluate fitness, and scores of each test were calculated as overall physical fitness score. The TEE was 2009.8 ± 272.6 kcal/day, the PAEE was 558.4 ± 206.1 kcal/day and the PAL was 1.61 ± 0.18. TEE per weight and PAEE per weight (PAEE/wt) was significantly negatively correlated with % body fat (r = - 0.626; r = - 0.400, respectively). These results suggest that increasing energy expenditure is important for achieving adequate body size. The PAEE/wt was most strongly correlated with physical fitness score (r = 0.680). The PAL was associated with percent time spent of inactivity ( r = -0.506), light-moderate activity ( r = 0.450) and vigorous activity ( r = 0.545). It was suggested that physically active lifestyle would be necessary for childhood health.

The purpose of this study was to examine the relationships between patterns of daily physical activities measured by accelerometer and physical activity level (PAL) in children. Firstly, activity intensities during incremental exercise were measured using a tri-axial accelerometer (HJA-350IT) in twenty one children aged 10.6 ± 0.9 years. As a result of receiver-operating characteristic curve analysis, the cut-off value for discrimination between walking and running activity was set at 7.2 METs of HJA-350IT. Secondly, total energy expenditure (TEE) in daily life was measured by doubly labeled water method, and durations of lifestyle, walking, and running activities were measured by the accelerometer in 6^th grade elementary school children (11 boys and 10 girls). TEE and physical activity level (PAL) were 2,021 ± 343 kcal/day and 1.56 ± 0.17, respectively. The average durations of lifestyle, walking and running activities were 188 ± 30 min/day (50.6 ± 6.0 %), 171±28 min/day (45.9 ± 5.0 %) and 13.3 ± 7.6 min/day (3.5 ± 1.8 %), respectively. The proportion of the duration of running activity was positively correlated with PAL (r = 0.615, p < 0.01), and the proportion of the duration of lifestyle activity was negatively correlated with PAL (r = -0.439, p < 0.05). There was no relationship between the proportion of the duration of walking activity and PAL (r = 0.300, n.s.). These results suggest that running activity is important to increase PAL more than ever in primary school children.

The early and mid-term survival after thoracic aortic surgery and the influence of age on operative mortality were examined in 93 consecutive patients from August 1994 to June 1999, together with assessment of postoperative quality of life (QOL). The mean age was 63.8±11.6 years old (range 26 to 84 years) and 65 patients were male. Aneurysms were atherosclerotic in 43 patients and aortic dissection was present in 50. Forty-eight (52%) required emergency operation. Operative procedures consisted of ascending aorta or hemiarch replacement in 23 patients, Bentall's operation was performed in 4, total arch replacement in 31, distal arch replacement in 9, descending aorta replacement in 13, replacement of the thoracoabdominal aorta in 6, and patch repair in 7. These patients were divided into two groups: the under 70 group (Y group, n=61) and the 70 or older group (O group, n=32). Current QOL of the survivors was assessed using the Asanoi method with a mailed questionnaire. There were 13 early deaths (14%). There were 10 late deaths (5.6%/P-Y (Patients-Years)). The actuarial survival rate of the Y group was significantly higher than that of the O group (p=0.0412). Perioperative stroke was seen in 11% of the Y group and 16% of the O group. These patients had a high mortality rate (Y group 43%, O group 100%) during early and long term follow-up periods. The postoperative NYHA category and exercise ability of the O group were better than those of the Y group. We obtained satisfactory answers concerning the results of operation in the majority of current survivors. Patients aged 70 years and older could undergo thoracic aortic surgery with reasonable risk. QOL following operation was satisfactory except in patients with merged perioperative stroke.

We present the case of a patient with primary ciliary dyskinesia who later developed clinically probable multiple system atrophy. Multiple system atrophy is a sporadic neurodegenerative disorder clinically characterised by various combinations of parkinsonism, cerebellar ataxia, autonomic failure, and pyramidal sign. Primary ciliary dyskinesia is a genetically heterogeneous disorder of motile cilia and results in chronic bronchitis, bronchiectasis, chronic rhinosinusitis, chronic otitis media, situs inversus, and male infertility. Most of the causative genes for primary ciliary dyskinesia encode proteins that are part of the heavy or intermediate chain of axonemal dynein in ciliary outer dynein arms. We hypothesised that axonemal dynein dysfunction in primary ciliary dyskinesia results in reduced autophagy, accompanied by impaired cytoplasmic dynein function, which in turn accelerates -synucleinopathy in multiple system atrophy. Furthermore, we contemplated a potential association between primary cilia and neuronal function. Although it is not yet clear if a causal link between multiple system atrophy and primary ciliary dyskinesia exists, further investigation into the relationship between axonemal dynein dysfunction in primary ciliary dyskinesia and α-synucleinopathy should be conducted.

We report 2 cases of successful treatment by percutaneous catheter drainage and irrigation for methycillin-resistant Staphylococcus aureus (MRSA) prosthetic graft infection after abdominal aortic aneurysm (AAA) repair. Case 1 was a 71-year-old man in whom MRSA graft infection was diagnosed on the basis of high fever and CT-guided taps of the perigraft fluid 11 days after AAA repair, and a percutaneous catheter was inserted into the perigraft space by the CT-guided method. Case 2 was a 77-year-old man in whom MRSA graft infection was diagnosed because of high fever and purulent discharge from the wound of retroperitoneal drainage 5 days after AAA repair. A percutaneous catheter was placed into the retroperitoneal space via an extraperitoneal route. In both cases, intermittent irrigation by 0.5% Povidone-iodine solution and saline was performed as well as systemic and local antibiotic administration. The graft infection was well controlled and both patients were discharged after 4 months. Percutaneous catheter drainage and irrigation can be one of the choices for critically ill patients with graft infection after AAA repair.

We encountered 15 cases of surgical site infection (SSI) by Methicillin-resistant Staphylococcus aureus (MRSA) among 153 patients who underwent a cardiovascular operation in 2000. SSIs consisted of 5 mediastinal infections, 9 surface wound infections and 1 artificial graft infection after an abdominal aortic surgery. All infected cases had been operated on between June and December 2000. Eighty-three cases, which underwent cardiovascular operations during this period, were divided into SSI or no-SSI groups and their clinical data were analyzed. The data included age, gender, preoperative diabetes, urgency, preoperative usage of a device like Swan-Ganz catheter or IABP, preoperative albumin level, preoperative physical state by ASA score, National Nosocominal Infections Surveillance index, duration of operation, usage of a cardiopulmonary bypass, duration of bypass, type of operation, and number of distal anastomoses in CABG operations. Multivariate analysis showed gender (male), diabetes, and emergency operation as independent risk factors for the incidence of SSI by MRSA. One patient, who suffered a mediastinal infection after CABG, had confirmed as demonstrating the colonization of MRSA in sputum preoperatively. Microbiological screening of medical staff showed 2 of the 6 surgical doctors and 3 of the 25 ward nurses exhibited colonization with MRSA. DNA analysis of MRSA, harvested from 5 infected patients, indicated at least 2 strains of MRSA and 1 of the 2 strains was identical to the MRSA that was detected in a doctor. We applied prophylactic measures with reference to the guideline for prevention of surgical site infection announced by CDC in 1999, which included the following: routine work-up of MRSA-colonization, and treatment of all MRSA colonized patients and those undergoing emergency operations with Mupirocin. Preoperative patients were isolated from MRSA-infected or colonized patients. MRSA-colonized surgical personnel were treated with Mupirocin ointment. Cephazoline was administered shortly before and after the operation as a prophylactic antibiotic. Vancomycin was added to Cephazoline in patients with a history of MRSA-colonization or infection. Through hand washing before and after daily contact with patients was emphasised to all medical staff. SSI surveillance conducted by an infection control team was implemented. After the introduction of the prophylactic measurements, one MRSA-SSI was observed among 113 cases who underwent a cardiovascular operation between January and September 2001.