Objective: With the recent aging trend in the Japanese population, dysphagia appears to be increasing. However, few epidemiologic surveys have been conducted to determine the prevalence of dysphagia in local inhabitants. Ohkuma et al. prepared a highly reliable questionnaire using a simple test and safe examination method. We investigated the presence/absence of symptoms of dysphagia in local inhabitants, evaluated their association with subjective symptoms, and examined whether the inhabitants were following a particular diet, which is the most important factor in management of dysphagia.
Methods: A cross-sectional study involving 743 inhabitants (age: over 20) of an isolated island was performed. Each subject was asked basic questions (awareness about the presence/absence of dysphagia and dietary habits), and the data was analyzed by chi-square test. Based on their responses, dysphagia incidence was determined and rated on a 3-category scale (severe, mild, and no dysphagia).
Results: Responses were recollected from 368 subjects (response rate, 49.5%). The percentage of subjects aware of dysphagia in the severe, mild, and no dysphagia groups was 13.8%, 3.2%, and 0%, respectively and the percentage of subjects who changed their dietary habits was 17.2%, 2.6%, and 0%. These percentages were significantly higher in the severe group than in the mild and no dysphagia groups, though the value was less than 20% in the 3 groups.
Conclusion: Most subjects in the present study were unaware of dysphagia, suggesting that patients with dysphagia tend to be unaware of the key symptoms of dysphagia.

Infective endocarditis with apical abscess is very rare. A 49-year-old man was admitted in a diabetic coma. The next day, he suddenly developed chest pain and headache. Echocardiogram revealed mitral valve vegetations and mitral regurgitation, and brain CT showed multiple cerebral hemorrhage that was thought to be due to cerebral embolism. Surgery was performed on the 10th hospital day for progressive heart failure. During surgery, an abscess was noted at the apex, but the abscess cavity was not connected to the cardiac cavity. The mitral valve was replaced, and the abscess cavity was resected. The defect of the ventricle was repaired with an 8×5cm Goretex sheet. Cultures of blood, vegetation, and the abscess were negative. It was thought that the abscess formation in the apex was caused by infectious coronary embolism, since cerebral embolism and chest pain happened simultaneously, and the abscess cavity was isolated and not in communication with the cardiac cavity.

The patient was a 61-year-old male, who underwent thoracoabdominal aortic aneurysm repair with Gelseal Triaxial prosthetic graft 2 years previously. False-aneurysm due to prosthetic graft dilatation was diagnosed. The direct closure of the ostium of the disruption of the anastomosis was successfully performed by an emergency operation. The postoperative course was uneventful. This case suggests that prosthetic graft dilatation may cause false-aneurysm at the site of end-to-side anastomosis.

Between December of 1989 and May of 1993, 7 of 338 patients (2.1%) who underwent median sternotomy for cardiac operations developed mediastinitis. All of these infections caused by Staphylococcus species. Six of seven patients with mediastinitis were successfully treated with debridement, irrigation and omental transposition into the mediastinum. Between December of 1989 and May of 1992, sterile bone wax was used as a hemostatic agent in 233 of these patients. Between June of 1992 and May of 1993 an argon beam coagulator was used in place of bone wax in 105 patients. The incidence of mediastinitis significantly differed in relation to whether patients received bone wax or not (7 of 233 patients who did (3.0%) versus none in 105 patients who did not (0%) p<0.01). We conclude from this study that bone wax may be a promoting agent in postoperative mediastinitis, so the routine use of bone wax should be reconsidered.

Bypass grafting from the ascending thoracic aorta to the common iliac artery was performed to manage proximal hypertension in a patient with atypical coarctation of the thoracic aorta. The patient's history was significant for an acute aortic thrombosis at the level of the diaphragm for which she underwent an axillo-bifemoral bypass grafting as an emergency operation. Although she was doing well following the initial bypass grafting, the second bypass grafting was required to treat proximal hypertension refractory to medical management. The axillo-femoral bypass graft had a smaller diameter and a longer subcutaneous distance, and the blood supply to the abdominal viscera may have been insufficient. The proximal hypertension was well controlled following ascending thoracic aorta to common iliac bypass, because the diameter (16mm) of the graft is larger than that of the axillo-bifemoral bypass graft (8mm).

A 65-year-old woman underwent abdominal aortic replacement using a woven Dacron tube graft for abdominal aortic aneurysm on April 2nd, 1996. She had pyrexia on the 6th postoperative day and abdominal enhanced CT scan showed periprosthetic bubble formations. She underwent relaparotomy 14 days after the initial procedure due to large retroperitoneal abcess bacterial culture of which revealed methicillin resistant staphylococcus aureus. She underwent debridement and local irrigation by an electrolyzed strong acid solution. Her pyrexia diminished immediately after relaparotomy and bacterial culture of the drain of the left retroperitoneal space became negative 82 days later. She was discharged and has had no active inflammatory signs for 3 years. She is doing well at present.

Dacron prostheses are the most widely used grafts in replacement procedures for abdominal aortic aneurysms, but they are not perfect grafts. We encountered a rare case of late graft complication. A 66-year-old man was admitted to our hospital with a pulsatile mass in an abdominal operation scar. He had received placement of a Y-shaped Cooley double velour knitted Dacron graft 18 years previously. Computed tomography and angiography demonstrated graft dilatation and an aneurysm. After resection of the graft aneurysms, the operative findings showed a non-anastomotic aneurysm formation due to longitudinal division near the graft guideline. In this case, this graft failure may have been due to the deterioration of the filter of the Dacron prosthesis itself. Therefore it is important to perform careful long-term follow-up in patients with implanted Dacron arterial prostheses.

Abdominal aortic aneurysms (AAA) are frequently associated with clinically significant coexistent ischemic heart disease (IHD). Cardiac events are the most common cause of death after AAA repair. Preoperative coronary evaluation and revascularization have been recommended to reduce postoperative cardiac complications following AAA repair. In this study, we retrospectively reviewed all patients who underwent AAA repair and compared operative results in patients with and without IHD. Of 388 patients who underwent elective AAA repair, 382 (98.5%) had aortography and coronary angiography for preoperative evaluation. Significant coronary artery disease was seen in 124 patients (32.5%). As a result of the evaluation, 46 patients (12.0%) were considered candidates for medical therapy, 18 for percutaneous coronary intervention (PCI), and 60 for coronary artery bypass grafting (CABG). In 24 patients (6.3%) who needed CABG and had large sized AAAs (>60mm), simultaneous CABG and AAA repair were performed. In the remaining 36 patients (9.4%) who needed CABG and had medium sized AAAs (40mm<, <60mm), staged operation was performed. We performed retrospective review comparing postoperative cardiac events and operative mortality among these treatment groups. There were 5 operative deaths (5/388, 1.3%) in patients following AAA repair. There were 2 operative deaths (2/124, 1.6%) in patients with significant IHD and 3 deaths (3/258, 1.2%) without IHD. In patients with IHD, 1 patient who received medical therapy died of acute renal failure and another one who received PCI died of acute myocardial infarction. There were no operative deaths or cardiac-related events in patients who received CABG before or concomitant AAA repair. There was only 1 cardiac-related event in all patient groups following AAA repair. Coronary arteries were preoperatively evaluated in almost all patients with AAA. If IHD was significant, the treatment for the IHD preceded AAA repair. Our strategy succeeded in reducing operative mortality and cardiac-related events in patients with both AAA and IHD. If a patient with a large sized AAA (>60mm) needs CABG, one-stage operation is recommended.

Septic pulmonary embolization (SPE) is an uncommon pulmonary disorder. The diagnosis of SPE is frequently delayed because of its nonspecific chest roentgenological features. A 76-year-old woman who underwent pacemaker implantation one year previously received antibiotic therapy under a diagnosis of infectious colitis. She suffered septic shock and disseminated intravascular coagulation (DIC) and was admitted to our hospital. Methicillin-resistant Staphylococcus aureus (MRSA) was cultured from her blood and echocardiography demonstrated 13×16 mm vegetation originating from the tricuspid valve. Multiple peripheral nodules with cavitation were found on chest computed tomography and she was given a diagnosis of SPE. She rapidly presented acute respiratory failure and mechanical ventilation was inevitable for 23 days before surgery. She underwent removal of the entire pacing system, resection and repair of the tricuspid valve and epicardial pacemaker lead implantation. Tracheostomy and long-term mechanical ventilation (16 days) was required after surgery, however, she was discharged from our hospital without any complication.

Forearm bone mineral content for adult white elite synchronized swimmers is lower than that of normative data (Roby et al. 1988). However, bone mineral density (BMD) in local body regions and the body as a whole are unclear in adolescent synchronized swimmers. The purpose of this study was to examine BMD of adolescent synchronized swimmers. This study also examined the relationship between BMD for young athletes and biological (e. g. morphological and functional aspects) and habitual (e. g. physical activity and nutritional state in daily living) variables. Subjects were nine females selected nationwide out of a large number of synchronized swimmers of fourth to sixth grade in elementary school, who participated in an audition with the committee of synchronized swimming in the Japan Swimming Federation. Chronological and bone age were 13.4±1.0 years and 12.7±0.9 years (n=8), respectively. BMD was evaluated in local regions and the body as a whole by dual X-ray absorbtiometry (DXA). Walking was measured by pedometer, and physical activity and nutritional status were analyzed by activity diary and food weighing method, respectively. As a result, mean BMD in athletes tended to be lower than in normal Japanese girls for lower limbs and lumbar vertebra (L2-L4), while it was almost the same between the two groups for whole body, upper limbs, thoracic vertebrae and pelvis. The correlations between BMD for whole body and bone age, the number of years since menarche, body mass, lean body mass and physical activity in leisure time of daily life were significant. An analysis using a general linear model indicated that bone age and active leisure activity together explained 94.6% of the variance of the BMD. These findings indicate that BMD of adolescent synchronized swimmers tended to be unique in local regions. Furthermore, BMD in athletes was affected by the biological maturation level and physical activity in leisure time of daily life.