We analyzed the causes of death in 109 patients who began hemodialysis therapy between 1969 and 1986 at the Akita Kumiai General Hospital. Patients with acute renal failure were excluded from this survey.
The main causes of death were cardiac failure (25.7%), cerebro-vascular accidents (19.3%), infections (17.4%) and sudden deaths (10.1%).
The proportion of deaths due to cardiac failure was relatively high during the first year of dialysis, although very small among the patients who were dialyzed for more them 5 years, and it was greatest among older patients (especially those older than 60 years of age).
The deaths from cerebro-vascular accidents were due predominantly to cerebral hemorrhage. Death due to cerebro-vascular accidents accounted for the largest proportion (45%) of the deaths in patients treated by hemodialysis for more than 5 years. In comparison with the JSDT statistics throughout the country, the proportion was very high among our patients.
The proportion of deaths due to infections was relatively high during the first year of dialysis, although it was very small among the patients who survived more than 5 years. Of the 11 patients who began hemodialysis at the age of 50 years or greater and who died of infection, 6 died of tuberculosis.
Sudden deaths accounted for 30% of the deaths in those patients who were on maintenance hemodialysis for more than 5 years.
These findings emphasize the increasing importance of the prevention of cerebro-vascular accidents (especially cerebral hemorrhage) and sudden death in patients who survive more than 5 years of hemodialysis therapy.

Cardiac surgery using heparin was performed in a patient in whom AST and ALT had been increased due to continuous drip infusion of heparin sodium. Here, we report postoperative changes in AST and ALT in the patient. The patient was a 59-year-old man with a past medical history of left internal carotid artery constriction and right cerebral infarction. Because of his previous medical history, continuous drip infusion of heparin was initiated upon discontinuation of preoperative antithrombotic agents. AST and ALT increased, but returned to normal levels when heparin was discontinued. Heparin was used to avoid aggravation of the symptoms, and bypass of 3 branches was performed with pulsation. Postoperative respiration and circulatory dynamics were stable, and the courses of AST and ALT were similar to those after general surgery, without abnormally high levels. Although the cause of heparin-induced increases in AST and ALT is unknown, the absence of postoperative increases may have been due to transient use at a high dose and neutralization by protamine.

This report documents two rare cases we encountered in which paraplegia developed as a postoperative complication following elective operations for an unruptured abdominal aortic aneurysm (AAA). Case1: A 80-year-old man receiving dialysis therapy was found to have 75% occlusion of the left anterior descending branch by preoperative coronary arteriography but, as the cardiac function was satisfactory, replacement of the aneurysm with a tube graft was performed through a retroperitoneal approach for treatment of the AAA. Symptoms of paraplegia developed immediately following the operation and a diagnosis of anterior spinal artery syndrome was made based on the postoperative MRI findings. Case 2: A 62-year-old man underwent a coronary artery bypass operation (3 sites in 2 branches) using the bilateral internal thoracic artery with the breast beating prior to elective surgery for an unruptured AAA, and subsequently underwent an aneurysm replacement with a Y-graft through a midline incision. At the same time, the celiac artery and superior mesenteric artery cure found to be stenotic at their roots were also bypassed via vascular prostheses to the right arm of the Y-graft. Paraplegia was evident after emerging from anesthesia. In both cases, there were complicating coronary arterial lesions and significant atherosclerotic changes in the thoracic descending aorta. A CT scan demonstrated an artery coursing from the iliolumbar artery, a branch of the internal iliac artery, to the spinal cord in Case 2, indicating that intraoperative clamping of the internal iliac artery might have caused the paraplegia. In patients with marked arteriosclerosis of the thoracic descending aorta, there is the possibility of occlusion of spinal root arteries originating from that affected region. Blood supply to the spinal cord via a collateral vascular route is important in such cases.

We report surgically treated case of tricuspid valve endocarditis in a non-drug addict. A 35-year-old man with no history of cardiac disease was admitted to our institution for persistent fever. His blood culture was positive for methicillin-sensitive Staphylococcus aureus (MSSA). Echocardiography showed friable vegetations attached to the tricuspid valve with moderate tricuspid regurgitation. No other valves were affected. Chest computed tomography revealed multiple septic pulmonary emboli in both lungs. The infection was uncontrollable, so despite 6 weeks' of appropriate intravenous antibiotics therapy, he required surgery. Infected lesions had extended to parts of the septal leaflet and the posterior leaflet of the tricuspid valve. Valve repair with the resection-suture technique was performed. Half of the septal leaflet and a part of the posterior leaflet were excised with the vegetations, and the remaining septal leaflet was sutured to the posterior leaflet after annular plication without implanting an artificial ring. The postoperative course was uneventful, without further tricuspid regurgitation or stenosis. He was discharged after additional antibiotic administration for 4 weeks postoperatively, and he has remained free from endocarditis for over 1 year.

Echocardiography was performed in two gruops of patients with impaired renal function excluding those with diabetic renal failure. Group A was comprised of 19 patients who had recieved hemodialysis from 1 year to 5 years, and Group B, of 32 patients who had been undergoing hemodialysis for more than 10 years. Significant reductions in left ventricular diastolic dimensions and cardiac output were found in Group B. In these two groups, there were no statistically significant differences in left ventricular wall thickness and left ventricular ejection fraction. Left ventricular diastolic function was assessd by the ratio of the peak atrial velosity (A) to early diastolic velosity (E). 15 patients (83%) in Group A and 19 patients (76%) in Group B had left ventricular diastolic dysfunction. A high incidence of left ventricular diastolic dysfunction was revealed. Moreover, dilated and hypertrophic cardiomyopathy like patterns were observed in both groups. In Group B, significantly increased left ventricular wall thickness in patients with hypertension and reduced left ventricular systolic function in patients with dialysis hypotension were found.

We report a successful staged repair of anomalous origin of right pulmonary artery from the ascending aorta in a neonate. A two-day-old girl, who suffered from severe circulatory failure, was admitted. In spite of all medical treatment, acidosis and systemic hypotension developed. Right pulmonary artery banding was performed in an emergency procedure, resulting in immediate elevation of systemic blood pressure. Definitive operation was subsequently performed on the 48th day after birth. The right pulmonary artery, which was de-banded and divided from aorta, was anastomosed directly to the pulmonary trunk in a side-to-end manner. The postoperative course was uneventful and the pulmonary artery pressure was within the normal range.

Purpose: While the amylase concentration of the drainage fluid (dAmy) has been reported to be a predictor of postoperative pancreas-related complications (PPRC), the optimal timing for its measurement has not been fully investigated. Materials and Methods: The clinicopathological data of 387 patients who underwent elective gastrectomy for gastric cancer were reviewed. Laboratory data, including dAmy on postoperative days 1 (dAmy1) and 3 (dAmy3), and serum C-reactive protein (sCRP) concentrations on postoperative days 1 (sCRP1) and 3 (sCRP3) were compared between patients with PPRC and without PPRC. Results: Nineteen of the 387 patients (4.9%) developed PPRC. The optimal cutoff values of dAmy1, dAmy3, sCRP1, and sCRP3 were 1514 IU/L, 761 IU/L, 8.32 mg/dL, and 15.15 mg/dL, respectively. The area under the curve of dAmy1 was greater than that of dAmy3 (0.915 vs.0.826), and that of sCRP3 was greater than that of sCRP1 (0.820 vs. 0.659). In the multivariate analysis, dAmy1 (P<0.001) and sCRP3 (P=0.004) were significant predictors of PPRC, while dAmy3 (P=0.069) and sCRP1 (P=0.831) were not. Thirteen (41.9%) of 31 patients with both dAmy1 ≥1,545 IU/L and sCRP3 ≥15.15 mg/dL had PPRC ≥Clavien-Dindo II. In contrast, among 260 patients with both dAmy1 <1,545 IU/L and sCRP3 <15.15 mg/dL, none developed PPRC. Conclusions dAmy1 was more useful than dAmy3 in predicting PPRC. The combination of dAmy1 and sCRP3 may be a useful criterion for the removal of drains on postoperative day 3.

Academic dissertations on Kampo medicine have a certain peculiarity about them, when they are drawn up by the rules of western medical writing. Compared to western medicine, oriental medicine tends to employ more subjective terms, because of its many humanistic elements.Study objectives, methods, results and discussions however, need to be stated objectively in a way that makes a paper easy to understand for both referees and readers. Although it would be ideal to use designated terms when making objective statements, there are in fact many terms that have multiple meanings, which need to be clarified in a paper. And when presenting new evidence, one must declare how far any problems have been resolved, as clearly as possible.We have explained the recent changes to our regulations for contributors, regarding Kampo formulae naming conventions, abstract word counts, and contributions by mail. Here we discuss how our editing work proceeds, and our thoughts on how papers are re-reviewed or rejected.
Medicine, Kampo ; Medicine ; Academic Dissertations [Publication Type] ; counts ; Review [Publication Type]

BACKGROUND : Electronic medical records (EMRs) were first introduced in the 1960s, and in Japan they are starting to become popular. Recognizing the need to adapt to a new clinical setting with EMRs, we aimed to explore which interviewing skills were associated with patient satisfaction in this era of EMR use.
METHODS : A prospective observational study was conducted to evaluate interviewing skills among medical residents and to collate data on patients' satisfaction levels at an outpatient general medicine walk-in clinic at a teaching hospital in Japan. Five trained raters reviewed the video recordings of these interviews and assessed them based on a predetermined set of criteria for medical interview skills developed specifically for an outpatient EMR setting. The relationships between these assessment scores and patient satisfaction levels were analyzed.
RESULTS : Significant skills that were associated with higher scores of patient satisfaction included : employed appropriate eye contact (P=0.021) ; and, invited patients directly without using a microphone (P=0.008). In addition, the degree of keyboard typing during interviews was not associated with patient satisfaction.
CONCLUSIONS : In an outpatient setting with EMR, using good non-verbal communication skills to build trustful relationships with patients is more likely to influence patient satisfaction levels. Even when physicians are typing on a keyboard, if they keep appropriate eye contact during medical interviews, patient satisfaction can be improved.