A 51-year-old female inserted a needle through the chest wall in a suicide attempt. Chest roentgenogram showed the needle located in the cardiac shadow and chest CT showed the needle penetrating into the ventricular wall. We removed the needle through median sternotomy. The needle had penetrated the right ventricular myocardium 2mm from the LAD. The tip of the needle reached the diaphragm and the surface of the diaphragm had been injured by the needle. The needle was removed without any difficulty and she was discharged 14 days after the operation.

To clarify what are contributing factors associated with the place to die (home or hospital) in a rural area, we investigated several background factors of 107 patients who died at home or in hospital after receiving home care service during the period of four years from July 1995 to June 2000. The subjects were divided into two group those who died at home (39 cases, 36%) and those who died in our hospital (68 cases, 64%). The ratio of deaths at home increased every year, and reached a half of those who died after receiving home care service. The average age in those who died at home were 87.1±9.5 years, that was higher than that of those who died in our hospital (82.2±9.8 years). There was no difference betwe two groups about sex, basic diseases and the time required to get to the hospital by car. Death at home was more preferred by patients, whereas death in the hospital was preferred by patients' families. The level of activities of daily living (ADL) in those who died at home was lower compared with that in those who died in the hospital. Those who died at home significantly had lesser complaints (pain, dyspnea and so on) and had more care-givers in the family, than those who died in the hospital. These results revealed that the major factors in death at home are: 1) low level of ADL, 2) preference to death at home expressed by patients, 3) presence of additional care-givers, and 4) no complaint of symptoms from patients.

Background: Bathing is an important behavior for keeping the body clean and is one of the habits of daily life. Among other things, bathing is regarded as a means of relieving fatigue, refreshing oneself, benefiting health, and improving sleep. As such it can be considered a health-maintaining activity. Apart from a previous study by the authors, there has been very little research on the relationship between home bathing habits and health. Objective: The aim of this study was, therefore, to clarify how physical and mental health relate to daily bathing in the home, particularly the habit of full bath immersion. Method: The participants were 198 employees of a quasi-drug manufacturing company and their family members who could and cooperated in the present study. The study was conducted as a self-report survey from October 1-30, 2010, with questionnaires being distributed to and collected from subjects before and after this period. Participants were asked about their sex, age, frequency of bathing per week, frequency of use of bath additives per week, temperature of bath water, bathing duration, and water level when in the bath, health, and sleep quality. Health was assessed using the Profile of Mood States (POMS) inventory, and self-rated health and quality of sleep were assessed using a Visual Analog Scale (VAS). Results: Among bathing habits, the group with a high bath frequency had significantly low scores for tension-anxiety and depression-dejection mood scales, and significantly high self-rated health. In the present study, self-rated health and quality of sleep were significantly better in the group who frequently used bath additives. In the full bath group, Fatigue score was significantly low and self-rated health and quality of sleep scores were significantly high. Discussion and Conclusion: Taking a full bath frequently and frequent use of bath additives are bathing habits that increase physical and psychological health in the middle-aged.

Patient: A 74-year-old man. Previous history: Total arch replacement for thoracic aortic aneurysm at 72 years old. History of current condition: The patient presented at a local otolaryngology clinic complaining of hoarseness of the voice. Left vocal cord paralysis was present, and as he had previously undergone thoracic vascular graft replacement, he was referred to our department. Further investigation with computed tomography (CT) revealed air in the mediastinum, and he was admitted for treatment of mediastinitis. Post-admission course: Upper gastrointestinal endoscopy revealed esophageal ulceration. After antibiotic treatment, thoracic subtotal esophagectomy via right thoracotomy, esophagostomy, and gastrostomy were performed on admission day 39. Vascular graft infection was also suspected, and antibiotic treatment was therefore continued. As some improvement in inflammatory response was evident, antibiotic treatment was discontinued and the patient's condition was monitored, but fever developed on day 107, and CT again revealed air in the mediastinum. Bronchoscopy revealed a broncho-mediastinal fistula in the left main bronchus. On day 110, repeated total arch replacement using a vascular graft, omentoplasty, and left main bronchus repair were performed via left thoracotomy. Esophageal reconstruction was left for later surgery, but follow-up CT on day 160 again revealed air in the mediastinum. Bronchoscopy was performed the same day and revealed a broncho-mediastinal fistula in the left main bronchus, located on distally from the previous fistula. This fistula was surgically closed on day 173. The subsequent course was favorable, and antethoracic esophageal reconstruction by jejunal elevation was performed on day 233. The patient was able to start eating on day 244, and was discharged in an improved condition on day 250.

Valsalva sinus aneurysm (VSA) is a rare disease, especially that of Konno classification Type IV. When VSA ruptures, the patient has uncontrollable congestive heart failure because of massive left-right shunt. We encountered two cases with ruptured VSA of the right atrium. Case 1 : A 71-years-old man with a ruptured noncoronary VAS complained of dyspnea on effort. He underwent surgical treatment consisting of aneurysm resection and patch closure with Hemashield after medical treatment for congestive heart failure. He progressed well after operation and was discharged on the 14th postoperative day in stable condition. Case 2 : A 41-year-old man had heard systolic murmur. We diagnosed VSA rupture with echocardiography. He was symptomless but his left ventricle diastolic diameter was dilatated and Qp/Qs was 2.0 by blood gas sampling. He underwent elective surgical treatment consisting of aneurysm resection and patch closure with Hemashield. He was discharged on the 14th postoperative day in stable condition.