When serious emergency patients come to a 3rd-level emergency hospital, they are able to obtain optimal medical treatment for their condition. However, the emergency room of general hospitals are extremely crowded with many kinds of patients, ranging from 1st-to 3rd-level emergencies. Thus, a good training program in triage is necessary for emergency medicine doctors because of the risk of inappropriate management of patients.
In this study, we examined the number of 2nd-and 3rd-level emergency patients who came to our emergency room initially as walk-in 1st-level emergency patients in 1991 and 1992. Our results indicate that the education for emergency medicine doctors needs to cover a wide range of medical fields dealing with 1st-to 3rd-level emergency patients, and that ideal training in emergency medicine must be organized in hospitals that accept 1st-to 3rd-level emergency patients.

The purpose of this study was to confirm the causal structure model of muscle, motor and living functions utilizing structural equation modeling (SEM) . As subjects, 103 community-dwelling older men and women, aged 65.7±6.9years of age, participated in the study to measure muscle cross-sectional area, maximum voluntary contractions, muscle power, 4 physical performance tests, and 16 questionnaires regarding ability of activities of daily living. The causal structure model of muscle, motor and living functions was hypothesized to be a hierarchical causal structure. The causal structure model of muscle function was hypothesized to be a hierarchical causal structure consisting of 3 sub-domains of muscle mass, muscle strength, and muscle power. Data analysis procedures were as follows : a) testing of construct validity of muscle function variables using confirmatory factor analysis (CFA) in SEM ; b) testing of causal structure using SEM ; c) testing of factor invariance using multi-group analysis for gender. The highest goodness of fit indices was obtained in the causal structure model of muscle, motor and living functions (NFI= .928, CFI= .978, RMSEA =.061) . The causal coefficient of muscle function to motor function was .98 (p<.05), followed by.34 for motor function to living function. From the results of multi-group analysis, the measurement invariance model indicated the highest goodness of fit indices (TLI=.968, CFI .977) . It was concluded that the hierarchical causal relation was among muscle, motor and living functions, and in which muscle function was consisted of 3 sub-domains.

The purpose of this study was to confirm the reliability and validity of a physical fitness questionnaire (PFQ) with self-rating for elderly people applying structural equation modeling (SEM) . As subjects, 105 community-dwelling older men and women aged 67.1±6.1 years participated in the study to measure 13 PFQ items and 13 performance tests. The data analysis procedures were as follows : a) testing reliability of PFQ ; b) testing of construct validity of PFQ using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) ; c) testing of criterion-related validity of PFQ to the performance tests using SEM ; d) testing of correlations of the PFQ to walking ability using SEM. Cronbaeh's alpha coefficient for consistency reliability of the PFQ was .83. Four common factors of muscle strength-power, endurance, coordination, and flexibility were extracted in EFA. The high and enough goodness of fit indices were obtained in the confirmatory factor structure model, and in each sub-domain of criterion-related validity to performance tests and correlation to walking ability models. The criterion-related validity coefficient of muscle strength and power was .77, followed by .66 for endurance, .59 for coordination and .82 for flexibility. The correlation coefficient of muscle strength and power to walking ability was -.51, followed by -.58 for coordination, - .43 for endurance and - . 28 for flexibility. These results indicated that the PFQ consisting of 13 items and 4 sub-domains satisfied reliability and construct validity although criterion related validity to performance tests was insufficient. It was concluded that the PFQ is of useful for physical fitness checking of elderly people.

The purpose of this study was to confirm the causal effect model of strength on walking ability development as a result of exercise participation among elderly people in a community, utilizing the latent curve model (LCM) in structural equation modeling (SEM) . Twenty-six male and 57 female subjects, 83 in total, aged 67.8±5.7, 63.9±7.1 and 65.1±6.9 in a pooled sample participated in the exercise program which lasted for two years. Grip strength and sit-ups used in the Japan Fitness Test were measured for muscular strength, 10-m hurdle walk and 6-min walk for walking ability, and the fitness test score for physical ability. The data analysis procedures were as follows : a) analysis of test-retest reliability and construct validity of measurement items, b) analysis of causal structure model of aging, muscular strength and walking ability, c) analysis of variance for repeated measurement of walking performance by sex, age and year, d) analysis of LCM for walking performance development. The highest goodness-of-fit indices of SEM were obtained in the LCM of 10-m hurdle walk performance development (GFI=0.989, AGFI=0.920, CFI=0.998, RMSEA=0.038) . The path coefficient of sit-ups at pre-test effect on the intercept of 10-m hurdle walk performance development was significant (p<0.05) . The path coefficients of age to intercept and slope of 10-m hurdle walk development were also significant (p<0.05) . It was concluded that walking ability development through participation in exercise age and strength level was more effective for maintaining walking ability in older age.

Methods: We investigated 154 foramina at L5–S1 in 77 patients. All the patients had degenerative lumbar disorders and had undergone both conventional MRI and 3D-MRI during the same visit. Differences between the FSRs calculated from conventional and 3D-MRI reconstructions and any correlations with the plain radiography findings were assessed. Results: In foramina that had a FSR of <50% on conventional MRI, the difference between the FSR obtained using conventional MRI and 3D-MRI was 5.1%, with a correlation coefficient of 0.777. For foramina with a FSR ≥50% on conventional MRI, the difference was 20.2%, with a correlation coefficient of 0.54. FSR obtained using 3D-MRI was significantly greater in patients who required surgery than in those who were successfully treated with conservative methods (88% and 42%, respectively). Segments with spondylolisthesis or lateral wedging showed higher FSRs than those without these conditions on both types of MRI. Conclusions FSRs <50% obtained using conventional MRI were sufficiently reliable; however, the results were inaccurate for FSRs ≥50%. Patients with high FSRs on 3D-MRI were more likely to require surgical treatment. Therefore, 3D-MRI is recommended in patients with suspected stenosis detected using conventional MRI or plain radiographs.

Methods: We investigated 154 foramina at L5–S1 in 77 patients. All the patients had degenerative lumbar disorders and had undergone both conventional MRI and 3D-MRI during the same visit. Differences between the FSRs calculated from conventional and 3D-MRI reconstructions and any correlations with the plain radiography findings were assessed. Results: In foramina that had a FSR of <50% on conventional MRI, the difference between the FSR obtained using conventional MRI and 3D-MRI was 5.1%, with a correlation coefficient of 0.777. For foramina with a FSR ≥50% on conventional MRI, the difference was 20.2%, with a correlation coefficient of 0.54. FSR obtained using 3D-MRI was significantly greater in patients who required surgery than in those who were successfully treated with conservative methods (88% and 42%, respectively). Segments with spondylolisthesis or lateral wedging showed higher FSRs than those without these conditions on both types of MRI. Conclusions FSRs <50% obtained using conventional MRI were sufficiently reliable; however, the results were inaccurate for FSRs ≥50%. Patients with high FSRs on 3D-MRI were more likely to require surgical treatment. Therefore, 3D-MRI is recommended in patients with suspected stenosis detected using conventional MRI or plain radiographs.

A 69-year-old woman with a medical history of mitral valve replacement for infective endocarditis 14 years previously was recently admitted after being given a diagnosis with multiple cerebral infarction along with headache and speech disturbance. After emergency admission, both transthoracic and transesophageal echocardiographies revealed multiple, extensive vegetation on the mitral prosthetic valve. Based on these findings, we diagnosed prosthetic valve endocarditis with cerebral septic embolization ; and immediate mitral valve re-replacement surgery was performed. During the operation, a complication occurred when the left ventricular posterior wall ruptured during withdrawal from the cardiopulmonary bypass after mitral valve re-replacement. After a second cross-clamp and resection of the mitral prosthetic valve, we repaired the myocardial laceration and repeated the mitral valve re-replacement. We selected the following two methods from different approaches to repair the left ventricular rupture : (a) exclusion of the myocardial laceration using a bovine pericardial patch (intracardiac approach) ; and (b) direct suturing of the bleeding epicardium (extracardiac approach).Seven days after the surgery, computed tomography (CT) revealed a pseudoaneurysm in the left ventricular posterior wall. Several follow-up examinations using CT and echocardiography revealed gradual enlargement of the pseudoaneurysm. At 112 days after previous surgery, we successfully repaired the pseudoaneurysm through left lateral thoracotomy using the femorofemoral bypass with hypothermia. In the final surgery, we closed the orifice of the pseudoaneurysm using bovine pericardium. This case highlighted that left thoracotomy using a femorofemoral bypass with hypothermia could be a useful approach to address a left ventricular posterior wall pseudoaneurysm.

No abstract available.
Crohn Disease* ; Food, Formulated* ; Humans ; Infliximab*

An 87-year-old man underwent a transcatheter aortic valve implantation (TAVI) for severe aortic stenosis. Approximately 8 months later, he was readmitted to our institution because of a cerebral infarction. Viridans Streptococcus was identified from the blood culture, and transesophageal echocardiography revealed a mobile mass on the leaflet. Prosthetic valve endocarditis (PVE) was diagnosed and we initially administered intravenous antibiotic therapy for 4 weeks, after which the patient underwent surgical aortic valve replacement. Herein, we report on the surgical AVR in the patient using a pericardial valve after successful removal of the infected prosthetic valve, and discuss some issues related to this rare complication after TAVI.