Clinical clerkships have been gradually introduced in medical schools in Japan. Because all students do not rotate through the same departments, the satisfaction of medical students differs among the departments, although the underlying reasons for such differences are unclear. To investigate the factors associated with student satisfaction with clinical clerkships, we performed a questionnaire survey.1) Questionnaires were distributed to 99 fifth-year medical students at Kyoto University Medical School. The questionnaire consisted of Likert-type 5-level scales of satisfaction, clinical clerkship assignments, and the attitudes of clerkship supervisors and other attending staff. Eighty-nine students responded.2) The independent factors for students' satisfaction were the attitude of attending staff (beta coefficient, 0.34), the attitude of the clerkship supervisor (0.30), and the frequency of physical examinations (0.09).3) Twenty-two of the 34 students who expressed the lowest level of satisfaction (level 1) reported that "the attending staff rarely had contact with students."4) Factors not associated with satisfaction were: whether the rotation was in internal medicine or surgery; whether the rotation was in a community hospital or a university hospital, and the department.5) These results suggest that medical students are satisfied with a clerkship if they perform frequent physical examinations and if the attending staff have an enthusiastic attitude.

A 67-year-old man had been followed up in our cardiology clinic for ischemic foot, and routine echocardiography revealed an 8×9mm highly echogenic mass on the mitral posterior leaflet. Because of the high thromboembolic risk, open-heart surgery was scheduled for surgical treatment of the tumor. His preoperative coronary angiogram showed 3 vessel disease. Coronary artery bypass grafting and tumor removal were performed consequently. His postoperative course was uneventful and the lesion was pathologically diagnosed a papillary fibroelastoma. No recurrence has occurred one year after the operation. Surgical treatment of cardiac tumors is mandatory for preventing embolism regardless of the size and location. Most of the tumors on cardiac valves are papillary fibroelastomas and recurrence of this tumor has not been reported so far. When the tumor is attached to a mitral leafet, simple tumor resection, with or without mitral valve repair, is justified instead of performing mitral replacement with en bloc resection of tumors and the entire leaflets.

Extracts of 16 natural medicine powders (Galla chinensis, Malloti cortex, Cassiae semen, Sophorae radix, Myricae cortex, Crataegi fructus, Gambir, Mume fructus, Geranii herba, Phellodendri cortex, Coptidis rhizoma, Swertiae herba, and Cinnamomi cortex) were assayed for reactive oxygen concentrations using the per-oxyoxalate chemiluminescent detection system. High luminescence intensity was observed in Galla chinensis, Geranii herba, Malloti cortex, Myricae cortex, and Cinnamomi cortex. Additional experiments identified the reactive oxygen species as hydrogen peroxide. Galla chinensis generated 2.4 ? 10 ? 4 mol/L hydrogen peroxide from a 1 mg/mL solution. In bacterial growth tests, Galla chinensis extract had antibacterial activity against Escherichia coli, Staphylococcus aureus, Bacteroides thetaiotaomicron, Campylobacter sputorum biovar sputorum, Streptococcus salivarius thermophilus, Lactobacillus casei, and Bifidobacterium longum infantis. This antibacterial activity was de-creased by the addition of catalase. It revealed that hydrogen peroxide which Galla chinensis produced participated in antibacterial activity.

An in vitro infection system of Trypanosoma cruzi and HeLa cells was used to measure the anti-T. cruzi activities of various calcium antagonists classified into dihydropyridines, diphenylalkylamines, and benzothiazepines and of allopurinol and benznidazole as medium and highly effective reference compounds, respectively. Six dihydropyridines (10 μM each), i. e. nifedipine, nicardipine, nimodipine, nisoldipine, nitrendipine, and amlodipine, decreased the rates of infection of HeLa cells from 11.7% (control) to 5.8, 0.9, 1.2, 3.6, 5.9, and 1.7%, respectively. Nicardipine and amlodipine were highly toxic to HeLa cells, causing detachment of cells from coverslips. Nimodipine was thus the most effective inhibitor tested against T. cruzi infection in HeLa cells. Verapamil and gallopamil (diphenylalkylamines), diltiazem and midazolam (benzothiazepines), and allopurinol (positive control) were less effective than nimodipine. IC₅₀ values, the concentrations of compounds that elicited a 50% reduction in the infection rates of HeLa cells, were 2.5, 2.6, 1.3, 2.1, and 1.7 μM for nicardipine, nimodipine, amlodipine, verapamil, and benznidazole, respectively, while the values for nifedipine, diltiazem, and allopurinol were much higher. Nicardipine, amlodipine, and verapamil again showed significant cytotoxicities to HeLa cells. When Swiss 3T3 fibroblasts replaced HeLa cells, nimodipine markedly lowered the host-cell-infection rate, with an IC₅₀ value of 8.3 nM. Thus, nimodipine is expected to be a highly effective anti-T. cruzi lead compound, with low cytotoxicity to mammalian cells. Structural formulas of nimodipine and nicardipine in relation to their low and high cytotoxicities, respectively, against HeLa cells are discussed.

A 66-year-old man with an unknown medical history developed chest pain and a diagnosis of acute myocardial infarction (AMI) was given by his physician. Percutaneous coronary intervention was performed in the left anterior descending artery. Echocardiography revealed ventricular septal perforation (VSP) ; therefore, the patient was transferred to our hospital. After admission, his platelet count dropped rapidly during heparin administration, and left ventricular thrombosis and deep vein thrombosis were noted, raising a suspicion of heparin-induced thrombocytopenia (HIT). To establish cardiopulmonary bypass, argatroban alone was insufficient to prolong the Powered by Editorial Manager^® and ProduXion Manager^® from the Aries Systems Corporation activated clotting time (ACT) ; thus, nafamostat mesilate was also used for coronary artery bypass grafting and surgical repair of VSP. It took many hours to normalize the ACT, requiring re-exploration for excessive bleeding. On the 37th postoperative day, the patient was transferred to another hospital. We performed cardiac surgical procedures using argatroban in a patient who developed HIT during the course of VSP following AMI ; however, we had difficulty in controlling the ACT. Since, to the best of our knowledge, there are no previous studies reporting surgical case of VSP complicated by HIT, we present this case with a review of the relevant literature.

A 44-year-old male, with past history of mitral valve re-replacement, tricuspid annuloplasty and re-replacement of aorto-biiliac prosthetic graft 4 years previously, was admitted to Asahi General Hospital because of massive melena, sepsis and shock. Angiography revealed a false aneurysm at the site of the anastomosis between the graft and the right external iliac artery. He was diagnosed as having graft-enteric fistula, and the emergency operation, including partial resection of the graft, excision of the false aneurysm and extraanatomic bypass, was performed successfully. Pathogenesis, diagnosis and treatment of graft-enteric fistula are discussed.

A case of xenograft valve dysfunction presenting with musical cooing murmur is reported. The patient was a 47-year-old woman and had received mitral valve replacement with porcine xenograft (Carpentier-Edwards 31-M) 10 years before Preoperative echocardiogram showed vibration of a leaflet outside the stent of the bioprosthetic valve. Cardiac catheterization revealed stenosis as well as regurgitation of the bioprosthetic valve. The resected xenograft valve showed a tear which produced regurgitation and musical cooing murmur in one of three pliable leaflets and it also showed pannus formation which caused stenosis.

Tuberculous spondylitis, or so-called Pott's disease, seems to be overlooked because of a lack of severe inflammation in the insidious generating process and tends to cause non-specific symptoms, such as back pain, fever, weakness, and weight loss. Diagnostic delay is common and the results can be disastrous. Discriminating between Pott's disease and other diseases, such as malignancy and pyogenic infection, is difficult. However, the inflammatory process in Pott's disease tends to spare the disk space, while that of pyogenic infection typically affects the area. Herein, we present a patient with Pott's disease who showed the characteristic clinical and radiological findings.

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.

Local recurrence after endoscopic piecemeal mucosal resection (EPMR) for colorectal tumors is a crucial issue. However, such recurrence is usually detected within one year and cured with additional endoscopic treatment, which makes EPMR acceptable. Herein, we report a rare case of repeatedly recurrent colon cancer involving the appendiceal orifice after EPMR, which was not cured with additional endoscopic treatments. A 67-year-old man was referred to us for endoscopic treatment of a 25 mm cecal tumor spreading to the appendiceal orifice in May 2002. The tumor was resected with EPMR, showing well differentiated intramucosal adenocarcinoma with a positive lateral cut margin of tubular adenoma. Endoscopic surveillance was conducted and the first local recurrence was detected in August 2006. Although we resected it endoscopically, the second local recurrence was found in September 2007 and we removed it with endoscopic resection again. However, the third local recurrence was detected in March 2008. Although endoscopic resection was performed also for the third recurrence, curative resection was not achieved. In February 2009, laparoscopic assisted colectomy was performed and histopathological examination showed well differentiated adenocarcinoma with deep submucosal invasion. This case is important in considering indication for endoscopic resection in colorectal tumors involving the appendiceal orifice.
Adenocarcinoma/*diagnosis/pathology/surgery ; Aged ; Appendiceal Neoplasms/complications ; Colectomy ; Colonic Neoplasms/*diagnosis/pathology/surgery ; Colonoscopy ; Humans ; Intestinal Mucosa/pathology ; Male ; Neoplasm Recurrence, Local ; Recurrence