The Endologix AFX is a bifurcated unibody endovascular aortic repair （EVAR） system used for the treatment of abdominal aortic aneurysms （AAA）. It consists of an inner metal endoskeleton with multiple metal struts covered by a polytetrafluoroethylene graft fabric, which is suitable for treating AAA with narrowed abdominal aortic bifurcations. However, the risk of type 3 endoleak （T3EL） has been alerted and it is recommended that a sufficient overlap length be considered when using a cuff device on the central side. We present the case of an 81-year-old man with a 45 mm AAA who underwent EVAR with an AFX2 main body device and AFX proximal cuff extension device, adhering to the recommended overlap length. However, postoperative aneurysm enlargement occurred gradually, and complete uncoupling of the main body and cuff was observed 4 years later. A retrospective review of 4 years of computed tomography （CT） scans revealed potential caudal migration of the main body device and cranial migration of the cuff device, potentially resulting in a type 3a endoleak （T3aEL）. An additional device was deployed to bridge both components, and the patient was discharged without complications. In cases where an AFX2 main body device and a cuff device are used on the central side, even with adequate overlap, careful follow-up is necessary because of the potential for sideways displacement or craniocaudal migration. The observation of device displacement using 3D reconstruction CT imaging is particularly useful.

Surgery for a shaggy aortic aneurysm requires a meticulous strategy to prevent embolic complications since the complications are associated with longer length of hospital stay and higher mortality. However, until now, there are no established treatment options to prevent embolic complications. We report a case of a 75-year-old man with a descending aortic aneurysm and a shaggy aorta who underwent thoracic endovascular aortic repair (TEVAR) with major branch artery protection. During the procedure, we placed balloon catheters in the left subclavian and left common iliac arteries, a filter device in the superior mesenteric artery, and a sheath at the ostium of the right common iliac artery. The patient did not develop embolic or other complications and was discharged on the eighth postoperative day. Our strategy of using the balloon occlusion technique and filter placement at the major vessels effectively prevented embolic complications during TEVAR for a shaggy aorta.

The venerable drug colchicine has garnered significant recent attention due to its endorsement by the United States Food and Drug Administration as an anti-inflammatory medication for cardiovascular diseases. However, the administration of this drug at its minimal available dose of 0.5 mg has been associated with certain adverse reactions.Once colchicine is administered, the drug disappears from blood in a short time and distributes in the leukocytes for a certain period of time that elicits anti-inflammatory effect.Consequently, an in-depth comprehension of the pharmacokinetics of lower dosages within leukocytes assumes important for its broader application in routine clinical contexts. In this study, we present a comprehensive analysis of the pharmacological disposition of colchicine in the plasma, polymorphonuclear leukocytes, and mononuclear leukocytes among healthy Japanese male subjects, following both single and multiple oral administrations of 0.5 mg and 0.25 mg doses of colchicine. Our investigation reveals that colchicine persists within leukocyte populations even when administered at reduced dosages. The findings herein hold promise for mitigating the adverse effects associated with its use in the treatment of inflammatory cardiovascular disorders.

Objective: Several evidence-based practice guidelines have been developed to better treat bipolar disorder. However, the articles cited in these guidelines were based on clinical or basic studies with specific conditional settings and were not sufficiently based on real-world clinical practice. In particular, there was little information on the doses of mood stabilizers. Methods: The MUlticenter treatment SUrvey on BIpolar disorder in Japanese psychiatric clinics (MUSUBI) is a study conducted to accumulate evidence on the real-world practical treatment of bipolar disorder. The questionnaire included patient characteristics such as comorbidities, mental status, treatment period, Global Assessment of Functioning (GAF) score, and details of pharmacological treatment. Results: Most patients received mood stabilizers such as lithium (n = 1,317), valproic acid (n = 808), carbamazepine (n = 136), and lamotrigine (n = 665). The dose of lithium was correlated with age, body weight, number of episodes, depression and GAF. The dose of valproic acid was correlated with body weight, number of episodes, presence of a rapid cycle and GAF. The dose of carbamazepine was correlated with age, mania, and the presence of a rapid cycle. The dose of lamotrigine was correlated with the number of episodes, depression, mania, psychotic features, and the presence of a rapid cycle. Doses of coadministered mood stabilizers were significantly correlated, except for the combination of valproic acid and lamotrigine. Conclusion The dose of mood stabilizers was selectively administered based on several factors, such as age, body composition, current mood status and functioning. Further prospective studies are required to confirm these findings.

Objectives : Many reports have investigated the work environment of physicians and reported the association between work environment, burnout, and the quality of medical care. We aimed to determine the key to improving the work environment by analyzing the results of a Japanese survey for young cardiovascular surgeons. Methods : A survey on work environment was performed among the young members of The Japanese Society for Cardiovascular Surgery (≤40 years of age) to measure their job satisfaction for 9 items : operation, perioperative work, number of hours working or sleeping, board affairs (application or renewal of board certification), motivation, salary, days off, quality of life, and mental status. Univariate and multivariate analyses using 16 factors for the work environment (age, number of years in practice, gender, subspecialty, board certification in surgery, board certification in cardiovascular surgery, primary practice hospital, workdays and nights on duty in a primary practice setting, workdays and nights on duty outside primary practice, total annual income, overtime work hours, overtime entitlement, gap in overtime work and entitlement, and presence of an intensive care unit [ICU] managed by ICU physicians) were performed to identify the risk factors for dissatisfaction. Results : The survey was completed by 327 of 1,304 (25.1% response rate) young members of the Japanese Society for Cardiovascular Surgery. The respondents had an average of 8.5±3.5 years in practice, and 292 (89.3%) respondents were male. Only 14.2% of the responding young surgeons reported no dissatisfaction in any items. In all items, the young surgeons were most satisfied with operation (34.6% of all responders). Age, years in practice, female gender, board certification in surgery, working at a university hospital, workdays in a primary practice setting, and workdays outside a primary practice setting were identified as significant factors for dissatisfaction, while a subspecialty in vascular surgery, total annual income, board certification in cardiovascular surgery, and the presence of an ICU managed by ICU physicians were identified as significant factors against dissatisfaction in the work environment. Conclusions : Our analyses of the survey results identified a number of risk factors for dissatisfaction in the work environment among young cardiovascular surgeons. Regarding the quality of medical care, respondents hoped for a reduced burden on surgeons and the establishment of a work-shift system in the cardiovascular department and an interdisciplinary team including an ICU physician. Multidimensional analyses including job satisfaction, rewards as training, and a quantitative evaluation of the quality of medical care will be necessary to clarify the corresponding relationship between consumers and providers of cardiovascular surgery in the work environment.

We analyzed inadvertent human errors during 3-day trial examinations for the National Examination for Physicians. Sixth-year medical students sat for 2 different examinations consisting of 500 multiple-choice questions and chose either 1 or 2 correct answers. After the first examination, the students verified their errors and were provided with educational guidance to prevent inadvertent errors.1) More than half of the students made inadvertent errors during the examination.2)The errors occurred when the students solved questions or marked the answer sheets.3) Most of errors were either the selection of the wrong number of answer options (i.e., a 2-choice selection was required, but only 1 choice was selected) or the selection of choices that differed from the intended choices when the answer sheets were marked.4) After the students were taught how to avoid errors, the mean number of errors per examination per student decreased significantly from 2.1 to 1.0.5) To our knowledge, this is the first report to show the educational effectiveness of a method to decrease the rate of inadvertent errors during examinations.

Ten patients, aged 3 to 43 years, with the tetralogy of Fallot underwent in situ pulmonary valve replacement (PVR) 13 times. The implanted valves were a St. Jude Medical prosthesis (3 times) and a bioprosthetic valve (10 times). In 5 patients PVR was performed at the time of radical repair and in the remaining 5 patients PVR was performed after radical repair. Three patients underwent re-PVR at 6 to 13 years after the first PVR. There was one operative death in re-PVR 14 years after the first PVR and one patient died from congestive heart failure 4 years after PVR. In the patients with the tetralogy of Fallot, the rate of PVR in those who had undergone open Brock's operation were significantly higher than that of the patients without open Brock's operation (p<0.05). Actuarial survival rates at 5 years and 10 years were 88.9% and 88.9%, respectively. Rates of freedom from reoperation at 5 years and 10 years were 88.9% and 59.3%, respectively. Although the early operative results are satisfactory, re-PVR is mandatory in the future. Thus the indications of PVR should be considered carefully.

A 64-year-old woman with dyspnea on exertion was referred to our hospital. CT revealed type B aortic dissection with 7cm of aneurysm including a thrombus in the false lumen at the distal aortic arch. Four intimal tears at the distal aortic arch were closed directly during hypothermic circulatory arrest, and the descending thoracic aorta was tailored without a prosthetic graft after fixation of the dissecting adventitia to the intima at the distal portion of the false lumen. The postoperative course was uneventful and this patient was discharged on the 22nd postoperative day. Three years after surgery, the postoperative CT revealed no evidence of dilatation of the descending thoracic aorta as far as the abdominal aorta although the dissection of thoracoabdominal aorta remained. This technique is effective as an surgical option for chronic type B aortic dissection to minimize operative stress and complications.

We present a rare case of acute type A dissection which developed compression of the true lumen after starting cardiopulmonary bypass (CPB) with femoral arterial return. In this case, the entry was located in the proximal descending thoracic aorta, and the dissection expanded up to the ascending aorta in a retrograde direction. After starting CPB, the false lumen suddenly enlarged and the true lumen was compressed. We observed those changes by intraoperative transesophageal echocardiography, so the perfusion was stopped immediately. A long arterial cannula (Wessex) was inserted from the left ventricular apex with the tip of the cannula remaining in the true lumen of the ascending aorta, and antegrade perfusion was restarted. After that we could maintain adequate extracorporeal perfusion and the replacement of the total aortic arch was completed uneventfully.