We report a case of quadricuspid aortic valve concomitant with infective endocarditis. A 73-year-old woman was admitted to our hospital because of general fatigue, loss of body weight and high fever. Transthoracic echocardiography showed moderate aortic regurgitation and left ventricle-right atrium fistulae with vegetation. Infectious endocarditis was diagnosed. Since her fever and hemolytic anemia were not controlled by antibiotics, we operated and the aortic valve had four cusps and there were vegetations on the aortic valve and left ventricle outflow tract. Perforation of the membranous septum was observed. Complete debridement and aortic valve replacement with patch repair of a left ventricle-right atrium (LV-RA) fistula was performed. Although she needed a permanent pacemaker due to complete AV block, her postoperative course was uneventful.

A 48-year-old man was admitted with shortness of breath. He had been given a diagnosis of ankylosing spondylitis by an orthopedic surgeon 20 years previously. A grade III/VI to-and-fro murmur was audible at the left sternal border. Echocardiography revealed moderate to severe aortic regurgitation with annular dilatation. He had also suffered complained rigidity of the neck muscles and back pain for 20 years. He underwent aortic root replacement and his postoperative course was uneventful. Aortic valve regurgitation with ankylosing spondylitis in Japan has been seldom reported, compared with European or American. We discuss surgical problems and the management of these lesions are discussed.

A 62-year-old man presented with a chief complaint of swelling of the left lower extremity. Idiopathic retroperitoneal fibrosis had been diagnosed 6 years previously. Enhanced computed tomography demonstrated occlusion of the left common iliac vein, but without deep vein thrombosis, and a thick dense fibrous layer around the abdominal aorta and in front of the sacrum. After we administered steroid and anticoagulant therapy, remission of the swelling of the left lower extremity was obtained. Presently steroids are being gradually tapered, and he has remained free of recurrence of the swelling of his left lower extremity.

Objective: Acanthopanax senticosus Harms extract (ASE) is an ingredient of functional foods, such as health supplements, in Japan. We investigated the effects of ASE on CYP2C9 activity.
Methods and Results: CYP2C9-catalyzed diclofenac 4′-hydroxylase activities in human intestinal and liver microsomes (abbreviated as HIM and HLM, respectively) were significantly decreased by the addition of ASE in a concentration-dependent manner. Kinetic studies of diclofenac 4′-hydroxylase in HLM revealed that ASE addition significantly decreased V_max but had no effect on K_m. These results suggest that diclofenac 4′-hydroxylase activity is suppressed by ASE addition in a non-competitive manner. Then, we investigated the time courses of diclofenac 4′-hydroxylase activity in rat liver microsomes after ASE oral administration (50 to 400 mg/kg). Diclofenac 4′-hydroxylase activities were significantly lowered by the administration of 200 and 400 mg/kg ASE at 0.5 to 4 hr compared with control (0 hr). Furthermore, we investigated the effects of ASE oral administration on the pharmacokinetics of tolbutamide (substrate for CYP2C9) in rats. The area under the concentration-time curve of tolbutamide after ASE oral administration (400 mg/kg) was enhanced by approximately 1.6 times compared with that without ASE oral administration.
Conclusion: These findings indicated that ASE inhibits human intestinal and hepatic CYP2C9 activities.

We report a rare case of cystic adventitial disease of the popliteal artery causing intermittent claudication. About 2 months previously, a 21-year-old man had sudden intermittent claudication in the left leg. The left-sided ankle brachial pressure index (ABI) at rest was 0.66. Computed tomography revealed that the arterial occlusion was segmentally caused by cystic lesions. A cystic adventitial lesion of the popliteal artery, measuring 9 cm in diameter, was surgically removed and reconstruction was performed with a saphenous vein graft. Postoperatively the left ABI improved to 1.01, and his symptoms disappeared. The histopathological diagnosis was cystic adventitial disease and the cysts were in the adventitia. The postoperative course was uneventful and he has been without recurrence for 14 months.

Infective endocarditis in association with pyogenic vertebral osteomyelitis is rarely observed. We report an 80-year-old man with infective endocarditis and pyogenic vertebral osteomyelitis requiring reoperation due to aortic prosthetic valve dysfunction. He suffered from back pain as the initial symptom, and he was admitted to our hospital. On magnetic resonance imaging, vertebral osteomyelitis was revealed, and antibiotics were started. On blood sampling α-streptococcus was identified and infective endocarditis was diagnosed. He responded to the antibiotic treatment. Despite the improvement in his general condition and the inflammatory parameters of blood samples, the aortic prosthetic valve dysfunction progressed. On echocardiography, aortic regurgitation worsened to 4/4, and the ejection fraction decreased from 72 to 46%. As heart failure was apparent, we performed a redo aortic valve replacement. Tears were found in the leaflets of the removed prosthetic valve (Hancock II). The 21-mm Carpentier-Edwards PERIMOUNT valve (CEP Magna Ease TFX) was replaced. His post-operative course was uneventful, and intravenous administration of ampicillin was continued. Oral rifampicin was also continued. On the 69th post-operative day, he was discharged and was ambulatory. Although we have no evidence that the tissue valve deterioration had resulted from bacterial damage, we were able to confirm that the structural valve deterioration involved bacterial contact in this case. Patients with infective endocarditis and pyogenic vertebral osteomyelitis should be treated cautiously regardless of whether or not the inflammation is controlled.

OBJECTIVE: Our goal was to develop a system using virtual reality (VR) technology to test the haptic skills of medical students. Currently, surgical skills are learned on live patients in a clinical environment in which the student practices under the close supervision of an experienced surgeon. We are interested in using haptic feedback devices to enhance surgical skills, because simulated touch in a virtual world improves the performance of trainee surgeons. In this study, we evaluated the efficacy of a test that evaluates the surgical skill of medical students by using a VR simulator.
METHODS: We used a microsurgical simulator with a force-feedback system. Its effectiveness in helping 36 medical students to acquire the tactile skills used in microscopic surgery was evaluated experimentally. Operating time and the number of sites of hemorrhage were measured to evaluate surgical aptitude. We also evaluated system performance with respect to reality, immersiveness, and operability as secondary measures. Data were analyzed using descriptive methods.
RESULTS: The operating time and number of hemorrhagic sites were positively correlated. Subject students were clustered into three groups: dexterous, awkward, or clumsy. The relation between the number of hemorrhages in the retina and immersion and operability differed between the group of would-be surgeons and those of would-be internists and pediatricians. All the students commented that the simulator was a useful tool for medical education.
CONCLUSIONS: The VR simulator can be used not only to teach and evaluate subtle tactile and surgical skills relevant to the surgical profession, but also to test the aptitude of medical students. The training transfer from a haptic simulator to actual practice methodology should be quantifiable in the near future. This work has steered medical informatics research into a new type of medical education.

Objective: By using human liver microsomes (HLM), we analyzed the effects of 14 known components of A.senticosus Harms on the activities of CYP2C9 and CYP3A4.
Methods and Results: Sesamin and quercetin inhibited both enzyme activities, whereas quercitrin strongly inhibited CYP3A4 activity. The 50% inhibitory concentrations (IC₅₀s) of sesamin and quercetin on CYP2C9 activity were approximately 124- and 59-fold higher and the IC₅₀s of sesamin, quercetin, and quercitrin on CYP3A4 activity were approximately 427-, 135-, and 22-fold higher than that of A. senticosus Harms extract (ASE), respectively. All these components inhibited both CYP3A4 and CYP2C9 in a non-competitive manner. However, these components are present in small amounts in ASE.
Conclusion: Therefore, the food-drug interactions caused by A. senticosus Harms are presumed to be due to the additive or synergistic interaction of these components or the other existing components, including their metabolites.