A 76-year-old woman, with a history of secundum atrial septal defect (ASD) patch closure 11 years earlier, presented with loss of appetite and dyspnea. She was treated for heart failure due to aortic regurgitation (AR), mitral regurgitation (MR), tricuspid regurgitation (TR), and atrial fibrillation (Af). Upon transfer to our department, she went into shock, leading to the introduction of V-A ECMO and IABP. Emergency surgeries, including aortic valve replacement (AVR), mitral valve replacement (MVR), tricuspid valve annuloplasty (TAP), and left atrial appendage closure, were performed. A second surgery for hemostasis was necessary, and V-A ECMO was removed on the second postoperative day. Transesophageal echocardiography revealed mitral bioprosthetic valve thrombosis. The patient was treated with heparin and warfarin, resulting in improved pressure gradients and removal of IABP by the seventh day. The sternum was closed on the seventeenth day, and she was transferred to the general ward on the thirty-ninth day. This case demonstrates the effective use of anticoagulant therapy for early valve thrombosis after mitral valve replacement under V-A ECMO.

Objective: In Sweden, primary healthcare centers play an important role in the performance of general practice, education, and clinical research. In Japan, general physicians or general practitioners are expected to be more active in the small-scale hospitals and clinics in rural areas. This study aimed to explore the differences in attitudes toward general practice and clinical research among medical students in Japan and Sweden to present solutions to help doctors stay in rural areas of Japan.Materials and Methods: This cross-sectional study was conducted at two medical schools in Japan and Sweden in 2018, using an anonymous and self-administered questionnaire survey that comprised 16 items including 9 items on clinical research.Results: Participants were 154 medical students (response rate: 69.4% for 222 students) in Japan and 56 (27.1% for 201 students) in Sweden. The proportion of medical students who wanted to become general physicians was greater in Japan than in Sweden (Japan:Sweden=36.4%:17.9%; P=0.012). Although fewer Japanese students wanted to conduct research in rural areas than Swedish students (43.5%:57.1%; P<0.001), the positive proportion of Japanese students working in clinical research and/or taking an academic degree in rural areas was greater than that of Swedish students (52.0%:23.2%; P=0.032).Conclusion: As Swedish medical students and young doctors learn considerably from primary healthcare centers, their attitudes toward clinical research are more developed than those of their Japanese counterparts. However, more Japanese medical students than Swedish students wish to become general practitioners, and they are likely to strive to conduct clinical research at small-scale hospitals/clinics in rural areas. Therefore, the improvement of the clinical research environment in small-scale hospitals and clinics in rural areas is needed at the earliest in Japan.

OBJECTIVESMercury allergy is a serious health problem. We investigated the relationship between positive patch test for mercury and sources of mercury exposure, indicated by concentrations in biological samples from healthy medical students.

METHODSPatch tests for mercury (Hg-PT) were performed on 580 students. For a group of 55 students with a positive Hg-PT result (Hg-PT(+)) and a reference group of 79 students with a negative Hg-PT result (Hg-PT)(-)), mercury concentrations in urine (Hg-u) and hair (Hg-h) were measured. In our search for environmental indicators of mercury exposure, the level of fish intake and mercurochrome usage were determined using a self-administered questionnaire. The oral cavity was investigated and the numbers of decayed teeth filled with amalgam (NA) were counted by dentists.

RESULTSFor the male Hg-PT(+) group, Hg-u and Hg-h were higher than those of a male reference Hg-PT(-) group; Hg-u values obtained in the early morning and after supper were significantly different. Multiple regression analysis with Hg-u as the objective variable among all students showed that increases in the level of fish intake, mercurochrome usage, and the NA independently increased Hg-u measured in the early morning for both gender groups. NA significantly affected Hg-u.

CONCLUSIONSWe showed that a higher NA was related to a higher Hg-u measured in the early morning. Therefore, exposure to amalgam may increase Hg-u. It was suggested that Hg-PT(+) might be related to a high Hg-u, and possibly to a high NA.

Hyaline ring granuloma (HRG) is a comparatively rare inflammatory condition occurring mainly in the oral region, and is characterized by hyaline rings (HRs) formed in the granulation tissue. This study describes a case of HRG occurring in the mandibular periosteum of an 18-year-old male. Histopathologic, histochemical and electron microscopic studies were performed on surgically excised materials. Histopathologically, ovoid bodies (OBs) surrounded by thin hyaline walls and HRs showing pale-stained eosinophilic thick hyaline walls were both detected. Histochemical study revealed that the OBs contained many granules chiefly composed of starch. Ultrastructurally, the HRs presented a stratiform structure due to the accumulation of cross-banded collagen fibrils with a basement membrane-like lining containing cellulose microfilaments. These results suggest that HRs are formed as follows: the exogenous vegetable materials are encapsulated by collagen, then the component is gradually degraded; the residual cellulose fraction adheres to the inner surface of the collagenous capsules, and the continuous deposition of collagen at the outer surface of the capsules increases its thickness. Finally, thick hyaline walls of HRs are formed. The possible pathogenesis of this curious lesion is discussed for stomatologists.

We reported nine cases of metastatic skin carcinoma experienced at the Department of Dermatology, Obihiro Kosei Hospital during the period from April 1991 to March 1993. Lung was the most common primary lesion (four out of nine cases), followed by uterus (two) and stomach, breast, and kidney (one each). The clinical features of the metastases were classified into nodular (five cases), inflammatory (one case) and sclerotic (three cases) types. Peculiar zoster-like inflammation was seen in metastatic gastric cancer. Pathologically, adenocarcinoma was more common than squamous cell carcinoma. The average interval between the diagnosis of the primary cancers and the development of the skin metastases was about 30±25 months. The average life span after the detection of the skin metastases was 6.8±5.6 months. Poor prognosis of skin metastasis was thus reconfirmed.

A 70-year-old man had annular erythema on the area extending from the right scapular region to the right axillary region, where he got tick bites on June 20, 1991. The erythema occurred soon after the bites and spread gradually to become as large as 20 square cm within 25 days. He also felt fatigue. An electrocardiogram revealed an atrioventiricular nodal block. We treated the patient with amoxycillin (750 mg daily) for 35 days. He has been now free from any symptoms over one year. Although repeated serological tests could not detect an antibody to Borrelia burgdorferi, typical erythema chronicum migrans and cardiac manifestation strongly suggested that the case could be diagnosed as Lyme disease.