Thromboembolic events after cardiac surgery, including ischemic strokes, can be devastating complications, however only a few studies manifest the platelet activation and coagulation state after off-pump coronary artery bypass (OPCAB). Platelet-derived microparticles (PMP) are observed as released vesicles from platelets following platelet activation, and are believed to play a role in some clinical diseases because of their procoagulant activity. The aim of the present study was to evaluate the hypercoagulant state after OPCAB using PMP and other indices. Data were obtained from 15 patients (aged 69±7 years; only men) undergoing elective OPCAB surgery. One hundred milligrams of aspirin were used as postoperative antiplatelet drugs. Preoperative risk factors, operation time, postoperative hospital stay, transfusion and blood samples of CBC, PMP, βTG, PF 4, platelet aggregation, FDP, D-dimer and TAT of pre- and postoperative days (POD) 3 and 7 were studied. There was no difference between the PMP level with or without risk factor. The PMP levels of POD 3 and 7 were significantly higher compared to the preoperative levels (pre-op, POD 3, 7:9.1±5.1, 15.2±10.3, 28.4±24.5/10⁴plt respectively, p<0.05). The levels of FDP, D-dimer and TAT rose significantly on POD 3 and 7 and significantly correlated with the PMP levels. Beta TG, PF 4 and platelet aggregation did not change after OPCAB surgery, and no correlation was found with the PMP levels. Elevated levels of PMP, TAT, FDP and D-dimer persisted until POD 7 and suggested not only platelet activation, but also activation of the coagulation and fibrinolytic system. The findings suggest that 100mg of aspirin may not be adequate for the inhibition of platelet activation after OPCAB surgery.

Total replacement of the aortic root in patients with anomalous origin of the coronary arteries has not been reported. We report a 63-year-old male with anomalous origin of the right coronary artery from the left sinus of Valsalva in whom aortic root replacement was performed to correct a 60mm aortic root aneurysm and a grade 4/4 aortic regurgitation. In this operation with a composite graft (a 24mm Gelseal graft with a 23mm St. Jude Medical prosthesis), modified reconstruction of the coronary arteries was necessary not only because both coronary ostia were in close proximity but also because the proximal portion of the right coronary artery was intramural. We used a modification of Piehler's technique in which both coronary ostia were simultaneously anastomosed to a beveled 10mm Gelseal graft. In this anastomosis, a small piece of the autologous pericardium was interposed between the graft and the aortic wall surrounding the ostium of the right coronary artery to protect the intramural artery from injury. This modification in reconstructing the coronary arteries was technically easy and effective in the special setting of the anomalous origin of the coronary arteries.

The pitching motion requires neck, trunk and hip rotations. The purpose of this study was to investigate the relationship between pitching injuries and dominant versus non-dominant differences of the ranges of these motions. The subjects were 66 high school baseball pitchers who received medical checkup during baseball classes in Kyoto prefecture. During medical checkup, physical therapists measured the ranges of neck/trunk rotations, and internal rotation of the bilateral hips. Then orthopaedic doctors did special tests such as shoulder internal impingement test, subacromial impingement test, elbow valgus stress test and elbow hyper extension test. Fourteen pitchers (21.2%) who were positive in one or more special tests were judged to require second screening (injured group). In normal group, average neck/trunk rotations toward the non-dominant side were significantly wider than rotations toward the dominant side. Average hip internal rotation was significantly wider on the non-dominant side than on the dominant side. In injured group, a larger number of pitchers had wider neck and trunk rotation ranges toward the dominant side than toward the non-dominant side, and had wide hip internal rotation range on the dominant side compared to the non-dominant side. Comparing the ranges of the neck/trunk rotations and hip internal rotation between dominant and non-dominant sides might be useful for the prediction of pitching injuries of the shoulder and the elbow.

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a relapsing-remitting disorder for which steroid administration is a key to control the progression. CLIPPERS can exhibit radiological features similar to malignant lymphoma, whose diagnosis is confounded by prior steroid administration. We report a case of CLIPPERS accompanied by abnormal elevation of beta-2 microglobulin in the cerebrospinal fluid (CSF). A 62-year-old man started to experience numbness in all fingers of his left hand one year ago, which gradually extended to his body trunk and legs on both sides. Magnetic resonance imaging demonstrated numerous small enhancing spots scattered in his brain and spinal cord. CSF levels of beta-2 microglobulin were elevated; although this often indicates central nervous system involvement in leukemia and lymphoma, the lesions were diagnosed as CLIPPERS based on the pathological findings from a biopsy specimen. We emphasize the importance of biopsy to differentiate between CLIPPERS and malignant lymphoma because the temporary radiological response to steroid might be the same in both diseases but the treatment strategies regarding the use of steroid are quite different.
Biopsy ; Brain ; Central Nervous System ; Cerebrospinal Fluid ; Diagnosis ; Fingers ; Hand ; Humans ; Hypesthesia ; Inflammation* ; Leg ; Leukemia ; Lymphoma ; Magnetic Resonance Imaging ; Middle Aged ; Spinal Cord ; Steroids*

Problem-based learning (PBL) tutorials were introduced at our university in April 2001. Because a complete PBLbased curriculum could not be adopted, a transitional curriculum incorporating 3-hour PBL tutorial sessions into the traditional curriculum was introduced. More than 80% of students agreed that PBL is an effective way of learning problem solving at the bedside. Twenty percent to 40% of teachers felt that students who took PBL were more motivated for bedside learning and self-directed learning and had better at presentation than were students who did not take PBL. Because of 80% of the curriculum comprised didactic lectures, most students considered PBL tutorials a type of lecture. For this reason, motivating students to learn additional material originating from PBL tutorials was difficult. Although the combination of a traditional curriculum and PBL tutorials may appear to be a new curriculum, this type of PBL has limited value as a method for studying problem solving.

1)We reproduced a problem–based learning (PBL) tutorial at our school and developed our own PBL tutorial, which we call "Fujita–style PBL." This is a clinical problem-solving type of PBL, in which both a monitoring room and small–group learning rooms are used.
2)To maintain the present number of PBL lessons despite the limited number of tutors, one tutor supervises several groups simultaneously. Coordinators observe the progress of PBL from a monitoring room and support the tutors.
3)Students learn the given scenario and identify their learning issues. After they study the learning issues by themselves, the students return to tutorials to explain their learning issues. Thereafter, each group's findings are presented to the groups supervised by one tutor.

Pitching motion is made up by three-dimensional whole body movement. Pelvic and trunk rotation movement is important for the prevention of throwing injuries. Throwing is not a simple rotation movement. Evaluation should reflect muscle strength, coordination, and pitching motion characteristics. We have devised throwing rotational assessment (TRA) similar to throwing as the new evaluation of total rotation angle required for throwing. The purpose of this study was to introduce the new method and to examine the characteristics of players with throwing disorders. The subjects were 76 high school baseball pitchers who participated in the medical check. Pain-induced tests were elbow hyperextension test and intra-articular shoulder impingement test. Pitchers who felt pain in either test were classified as disorder group. TRA evaluation was performed as follows. In the positions similar to the foot contact phase, rotation angles of the pelvis and trunk were measured. In the position similar to follow through phase, the distance between the middle finger and the second toe was measured. All tests were performed in the throwing and opposite direction. Twenty five pitchers were classified as disorder group. All TRA tests in healthy group were significantly higher in the throwing direction than in the opposite direction, but there was no significant difference in the disorder group. Disorder group had significantly lower average rotation angles of the pelvis and trunk in the throwing direction and rotation angle of trunk in the opposite direction than the healthy group. Restrictions on TRA reflecting the complex whole body rotation movement may be related to the throwing disorder. This evaluation is a simple method. It would be useful early detection of throwing disorder and systematic evaluation in medical check, as well as self-check in the sports field.

Purpose: General surgeons at regional hospitals should have the primary trauma care skills necessary to treat critically ill trauma patients to withstand transfer. This study was conducted to identify a consensus on primary trauma care skills for general surgeons. Methods: An initial list of acute care surgical skills was compiled, and revised by six trauma experts (acute care surgeons); 33 skills were nominated for inclusion in the Delphi consensus survey. Participants (councilors of the Japanese Society for Acute Care Surgery) were presented with the list of 33 trauma care skills and were asked (using web-based software) to rate how strongly they agreed or disagreed (using a 5-point Likert scale) with the necessity of each skill for a general surgeon. The reliability of consensus was predefined as Cronbach’s α ≥ 0.8, and trauma care skills were considered as primarily required when rated 4 (agree) or 5 (strongly agree) by ≥ 80% participants. Results: There were 117 trauma care specialists contacted to participate in the Delphi consensus survey panel. In the 1st round, 85 specialists participated (response rate: 72.6%). In the 2nd round, 66 specialists participated (response rate: 77.6%). Consensus was achieved after two rounds, reliability using Cronbach’s α was 0.94, and 34 items were identified as primary trauma care skills needed by general surgeons. Conclusion A consensus-based list of trauma care skills required by general surgeons was developed. This list can facilitate the development of a new trauma training course which has been optimized for general surgeons.

Abdominal draw-in is a functional transversus abdominal muscle exercise to acquire the contraction. However, it is difficult for even healthy subjects to selectively contract the deep transversus abdominal and internal oblique muscles without over-contraction of the superficial rectus abdominis and the external oblique muscles. This study examined whether the transversus abdominal muscle is selectively contracted by our taping method. The subjects were 20 healthy males. Using ultrasound, we compared the thickness of external oblique, internal oblique, and transversus abdominal muscle among no taping, kinesio taping and abdominal muscle activation taping in the standing position. The thickness of transversus abdominal muscle significantly increased in the activation taping more than the other methods. This study showed that abdominal musculature activation taping made it possible to contract the transversus abdominal muscle selectively.