We experienced a case of extensively calcified mitral annulus and severe mitral regurgitation. A 75-year-old woman underwent successful debridement of an annular calcification with a CUSA^® and replacement of mitral valve with a MIRA^TM valve in a supra-annular position. Use of CUSA^® allowed safe removal of the calcification and prevented the tearing of the A-V groove vessels. In our technique, calcification is left to a certain extent to keep annular strength. Also the MIRA^TM valve has soft and rich sewing cuff, which enhances coaptation in highly calcified annuli and accommodates even fragile tissue. This makes it possible to implant valves even in severely diseased annulus conditions.

A 68-year-old man who had undergone previous coronary artery bypass grafting was admitted with cardiac failure because of aortic valve stenosis and severe mitral valve regurgitation. Preoperative cardiac catheterization showed a patent left internal thoracic artery (LITA) and a stenotic saphenous vein graft. We performed aortic valve replacement, mitral valve repair, and coronary artery bypass grafting with repeat sternotomy, moderate hypothermia (29.3°C), aortic cross-clamping, retrograde cardioplegia and proximal occlusion of the LITA graft using a soft bulldog clamp. The proximal LITA was occluded through a supraclavicular incision without intrathoracic dissection. Although cardiopulmonary bypass (CPB) time and aortic cross-clamp time were prolonged, the patient was taken off CPB without any problem. The postoperative course was uneventful. We believe that this technique is safe and effective for establishing myocardial protection without deep hypothermia and risk of LITA injury.

We encountered a very rare case of a patient with hereditary protein S deficiency who underwent successful coronary artery bypass grafting (CABG). A 38-year-old man was admitted for scheduled coronary artery bypass grafting. Preoperative investigation showed protein S deficiency. He underwent two-vessel CABG surgery with regular cardiopulmonary bypass. After hemostasis, intravenous heparin was started. The dose of warfarin was gradually increased until the INR reached about 2.5. Then heparin was stopped. His postoperative course was uneventful. There was no thromboembolic event. Both grafts were patent.

　At Showa University, which consists of the Schools of Medicine, Dentistry, Pharmacy, and Nursing and Rehabilitation Sciences, systematic interprofessional education for the purpose of training staff who can contribute to the medical team has been introduced with the cooperation of all 4 schools and through all undergraduate years. In the lower years, students study the basics of medical team care through a 4-school joint curriculum of experiential learning （such as early exposure） and problem-based learning inside and outside of the university. In the upper years, to acquire practical skills, students study the practice of medical team care through a joint curriculum of participatory learning in hospitals and the community. Through this curriculum, I expect that the medical staff to promote patient-centered team medical care in a variety of medical fields will grow in the future.

Objective To assess the effect of D-JNKI1, an inhibitor of c-Jun N-terminal kinase (JNK), on delayed neuronal death (DND) in a gerbil model of transient global cerebral ischemia, so as to further study the roles of JNK activation in mediating neuronal cell death in brain ischemia. Methods Fifty-five Mongolian gerbils were randomly divided into 11 groups. Animals (n=35) assigned into 7 groups (n=5 per group) were subjected to 5-min occlusion of bilateral common carotid arteries (BCCAO);among the 7 groups, different doses of D-JNKI1 (0.00012, 0.0012, 0.012, 0.12, 1.2 μmol/L in 2 μL PBS,n=5 each) were administered stereotaxically into right lateral ventricles 3 h after reperfusion; the control group (n=5) received 2 μL PBS; and another group (n=5) received 1.2 μmol/L of D-JNKI1 in 0.5 mL PBS intraperitoneally. Sham-operated animals (n=5) only received the exposure of bilateral common carotid arteries without occlusion. Three groups (n=5 in each) were pretreated with D-JNKI1 (0.00012,0.0012 μmol/L in 2 μL PBS) or only 2 μL PBS 30 min before 2-min BCCAO, and subjected to 5-min BCCAO 48 h after the first ischemic insult. All animals were sacrificed 4 d after 5-min BCCAO and prepared for frozen section and Nissl staining. Results The treatment with D-JNKI 3 h after 5-min ischemia was neuroprotective with a maximum effect at a dose of 0.0012 μmol/L. Pretreatment with D-JNKI augmented ischemic tolerance induced by 2-min ischemia. Conclusion D-JNKI1 has a potential neuroprotective effect on DND in CA1 of hippocampus in gerbils with global cerebral ischemia-reperfusion injury.

BACKGROUNDIn an earlier study, we identified a locus for Moyamoya disease (MMD) on 17q25.3.

METHODSLinkage analysis and fine mapping were conducted for two new families in additional to the previously studied 15 families. Three genes, CARD14, Raptor, and AATK, were selected based on key words, namely, "inflammation", "apoptosis", "proliferation", and "vascular system", for further sequencing. A segregation analysis of 34 pedigrees was performed, followed by a case-control study in Japanese (90 cases vs. 384 controls), Korean (41 cases vs. 223 controls), Chinese (23 cases and 100 controls), and Caucasian (25 cases and 164 controls) populations.

RESULTSLinkage analysis increased the LOD score from 8.07 to 9.67 on 17q25.3. Fine mapping narrowed the linkage signal to a 2.1-Mb region. Sequencing revealed that only one newly identified polymorphism, ss161110142, which was located at position -1480 from the transcription site of the Raptor gene, was common to all four unrelated sequenced familial affected individuals. ss161110142 was then shown to segregate in the 34 pedigrees studied, resulting in a two-point LOD score of 14.2 (P = 3.89 × 10(-8)). Its penetrance was estimated to be 74.0%. Among the Asian populations tested (Japanese, Korean, and Chinese), the rare allele was much more frequent in cases (26, 33, and 4%, respectively) than in controls (1, 1, and 0%, respectively) and was associated with an increased odds ratio of 52.2 (95% confidence interval 27.2-100.2) (P = 2.5 × 10(-49)). This allele was, however, not detected in the Caucasian samples. Its population attributable risk was estimated to be 49% in the Japanese population, 66% in the Korean population, and 9% in the Chinese population.

CONCLUSIONss161110142 may confer susceptibility to MMD among East Asian populations.

ELECTRONIC SUPPLEMENTARY MATERIALThe online version of this article (doi:10.1007/s12199-009-0116-7) contains supplementary material, which is available to authorized users.

OBJECTIVEPrevious studies on the association between physical activity (PA) and neighborhood environments (NE) focused on either objectively measuring the NE or the residents' perception of NE. Here, we investigate which actual or perceived NE is associated with residents' PA in Japan.

METHODSTwo regions with an objectively assessed high and low residential density, land use mix-diversity, and street connectivity, respectively, were identified in one city. The subjects were selected using a stratified random sampling method by sex and age in each region. The NE of the subjects was objectively measured using the Geographic Information System (GIS), and the subjects' perception of the NE was assessed using a questionnaire. The daily total number of walking steps was measured with an accelerometer, and walking and cycling time were assessed by a questionnaire.

RESULTSFor the female subjects, the mean cycling time, subjectively assessed as a means of transport, was significantly longer in the group with a high GIS score for the number of land use types, while the score for total number of walking steps was significantly higher among those who were aware of places to walk to, and cycling time for transport was longer for those who perceived an accessibility to post offices, banks/credit unions, gymnasiums/fitness facilities, and amusement facilities in their neighborhood. For the male subjects, the score for walking time for leisure was longer for those who perceived aesthetics and an accessibility to parks, and the score for total walking steps was significantly higher for those who perceived an accessibility to bookstores or rental video stores in their neighborhood.

CONCLUSIONSThe results to this study demonstrate that daily PA was high among female subjects living in a NE with land use mix-diversity, and who had an awareness of places to walk to and the accessibility to facilities for daily necessities in their neighborhood. For male subjects, daily PA was high among those who perceived the aesthetics of and accessibility to facilities for pleasure in their neighborhood. Further research is needed to determine the association between PA and NE on the basis of sex differences.

Objective: To evaluate the efficacy of high-flow nasal cannula oxygen (HFNC) for dyspnea in patients with advanced disease. Methods: A literature search was conducted using MEDLINE, Cochrane Library, EMBASE, and Ichu-shi Web. Inclusion criteria were: 1) randomized controlled trials evaluating the effect of HFNC on dyspnea; 2) aged 18 years or older with advanced disease with hypoxemia; 3) control group was conventional oxygen therapy or noninvasive positive pressure ventilation. Exclusion criteria were: 1) patients in intensive care unit, 2) weaning from ventilator. Results: Six studies (4 from database searches, and 2 from hand searches) were included. In the 2 studies evaluating short-term intervention, one showed HFNC was more efficacious, and the other conventional oxygen was more efficacious. In the 2 studies evaluating long-term interventions: one showed HFNC was more efficacious, and the other showed no significant difference. In the 2 studies evaluating the intervention during exercise, one showed HFNC was more efficacious, and the other showed no significant difference. Conclusion: HFNC may be effective for dyspnea in patients with advanced disease associated with hypoxemia.