A man in his 60s, who was diagnosed as having postoperative recurrent gastric cancer with lymph node and spinal metastases, was admitted to our palliative care unit (PCU). He was unable to receive further aggressive chemotherapy for cancer because of bilateral hydronephrosis and chronic renal failure. He had chronic urethral infection and hence required continuous antibiotic administration. Although his infection was well controlled with antibiotics, his oral intake gradually declined. Seventeen days after admission, he developed systemic hemorrhage, including hematuria and oral bleeding. Coagulation tests revealed that the patient had markedly prolonged prothrombin time (PT) and activated partial thromboplastin time (APTT) but no thrombocytopenia, fibrinogen consumption, or increased fibrin/fibrinogen degradation products (FDP) level. Serum level of protein induced by vitamin K absence or antagonist II (PIVKA-II) was markedly high, and vitamin K level was below the lower limit of the reference range. After he was administered intravenous vitamin K, his symptoms markedly improved. Many patients with advanced cancers tend to have malnutrition, anorexia, and chronic infection that require antibiotic administration. Prophylactic administration of vitamin K might be sometimes necessary for preventing catastrophic hemorrhage.

To investigate whether magnesium abnormalities are associated with the administration of magnesium-containing laxatives in a palliative care setting, we measured the serum magnesium levels in 48 patients with advanced cancer at our palliative care unit (PCU). The mean magnesium concentration in all patients was 2.09 mg/dl (confidence interval [CI], 1.38-3.62). Patients receiving magnesium-containing laxatives (n=38) showed significantly higher serum magnesium concentrations than patients without laxatives (n=10) (2.17 mg/dl vs 1.8 mg/dl, p=0.006). Although 10 patients had serum magnesium abnormalities (hypomagnesemia, 8 and hypermagnesemia, 2), we did not observe clinical manifestation associated with magnesium abnormalities. Interestingly, neither the duration nor the dose of laxatives correlated with serum magnesium concentration. Overall, patients at the PCU tend to have magnesium abnormalities and their symptoms may be analogous to those of advanced cancer patients; in particular, terminal patients with such symptoms might be considered to have magnesium abnormalities.

A 62-year-old woman with the tetralogy of Fallot (TOF) diagnosed at 24 years of age, was admitted with fever and dyspnea. She also had cyanosis and heart failure and was categorized as New York Heart Association (NYHA) functional class IV. Echocardiography showed TOF with a-grade III tricuspid valve regurgitation. Cardiac catheterization revealed major aorto-pulmonary collateral arteries (MAPCAs) for the left upper pulmonary circulation. After coil embolization of MAPCAs to reduce abnormal intracardiac return as well as postoperative left ventricular volume overload, the patient underwent total surgical correction (i.e., right ventricular outflow tract reconstruction using Medtronic FreeStyle Valve and transannular patch, ventricular septal defect closure, and tricuspid annuloplasty). Postoperatively, the patient had a satisfactory course during the 10-year follow-up period with a grade-I NYHA classification. In conclusion, intracardiac repair of TOF in case over 60 years of age can be performed safely by preoperative MAPCAs embolization and subsequent TOF repair with a strategy to abolish pulmonary and tricuspid valve regurgitation.

OBJECTIVESThere is a growing need to evaluate the performance status of the activities of daily living (ADL) of the elderly in the rapidly aging Japanese society. The purpose of this study was to verify the usefulness of our new scoring sheet for assessing present ADL status and to clarify whether or not the assessed ADL status can predict the future risk of adverse conditions related to falls.

METHODSThe validation study was performed using 116 non-handicapped community-dwelling Japanese elderly at least 60 years of age. Of those subjects, 44 were also analyzed for the relationship between baseline ADL status and subsequent risk of adverse conditions related to falls.

RESULTSThe daily living performance score sheet had good internal consistency, with a Cronbach's alpha of 0.82 and a sequential hierarchical structure that reflected the difficulty of the activities. The total score was significantly and positively associated with six of eight subscale scores on the Short-Form 36-Item Health Survey (P < 0.01). In the follow-up study, every one-point decrease in total score was significantly associated with a 39% elevated risk of a stumble or fall (P = 0.022) and also borderline significantly associated with higher risks of a fall, anxiety while walking indoors, and anxiety while walking outdoors (P < 0.10).

CONCLUSIONOur new scoring sheet can reliably and comprehensively assess present ADL status. The assessed ADL could predict the future risk of adverse conditions related to falls.

A 76-years-old woman was admitted with a left ventricular tumor that was accidentally found by a transthoracic echocardiogram. The tumor was located in the papillary muscle near the apex, had an irregular surface, and was well mobile. The urgent operation was planned because the tumor might have caused of embolism. A cardiopulmonary bypass was established with distal ascending aortic cannulation and bicaval venous cannulations. The resection of the tumor was performed by a transaortic approach. Pathological examination confirmed the tumor as primary papillary fibroelastoma. During the operation, a thoracoscope was used to assist the resection of the tumor. It was useful for a good visualization in the left ventricle. In this case report we describe a rare case of primary papillary fibroelastoma in the left ventricle and a technique of resection using a transaortic approach with an assistance of a thoracoscope.

The purpose of this study was to examine the effects of short-term immobilization on the maximum voluntary contraction (MVC) force. The first dorsal interosseus (FDI) of 10 healthy male adults was immobilized for 1 week using casting tape. Atrophy of the muscle was estimated from a cross sectional view of magnetic resonance images (MRI) . To clarify the factors of a peripheral neuromuscular system contributing to the change in the MVC force, twitch force at rest was measured. The contribution of central factors was estimated from a voluntary activation (VA) index, which was obtained by the twitch interpolation method.
The MRI showed no significant changes in the cross sectional area. The MVC force declined after immobilization (p<0.01), and recovered after 1 week from the termination of immobilization (p<0.01) . Both the twitch force at rest and the VA at MVC declined after immobilization (p<0.01), and recovered after 1 week (p<0.05) .
The results indicate that the temporary decline of the MVC force was not accompanied by atrophy of the muscle. Furthermore the decline of the MVC was caused both by the deterioration of peripheral and central functions in the neuromuscular system. Possible factors in the peripheral and central neuromuscular systems affected by the immobilization were discussed.

We examined three cases where Kampo medicine had effects on palindromic rheumatism. All the patients are men with arthralgia accompanied by redness, fever, and swelling. All cases are RF negative. Cases 2 and 3 are brothers. Case 1: A 58-year-old patient with recurrent arthralgia on shoulders, hands, and legs for 30 years. Eppi-ka-jutsu-to was administrated for arthralgia. When discomfort of the hypochondrium (Kyokyokuman) was noted, the administration of Sho-Saiko-to reduced the symptom.
Case 2: A 40-year-old patient with recurrent arthralgia on shoulders, hands and legs for nine years. Eppi-ka-jutsu-to was administrated for arthralgia. When discomfort of the hypochondrium (Kyokyokuman) and contraction of the abdominal muscles (Fukuhikokyu) was noted, the administration of Eppi-ka-jutsu-to-go-Shigyaku-san-ryo was replaced, which reduced the symptoms.
Case 3: A 46-year-old patient with recurrent arthralgia on knees and fingers, and pain in hip joints. Eppi-ka-jutsu-to was administrated for arthralgia. When discomfort of the hypochondrium (Kyokyokuman) and contraction of the abdominal muscles (Fukuhikokyu) were noted, the administration of Shigyaku-san reduced the symptoms.
All cases were typical palindromic rheumatism, and Eppi-ka-jutsu-to was effective to a certain degree. Kampo diagnosis of Saiko (Saiko-sho) was made and additional Saiko-drugs (Saiko-zai) reduced the frequency, the degree, and the length of the period of symptoms.

Female patients suffering from gallbladder stone disease were administered Sho-saiko-to (Xiao-Chai-Hu-Tang), Gorei-san (Wu-Ling-San) or Toki-shakuyaku-san (Dang-Gui-Shao-Yao-San) preoperatively, and were examined by cholangiomanometry during operation. Perfusion pressure was significantly elevated, when Sho-saiko-to or Gorei-san were administered, meaning that the pressure threshold of the sphincter of Oddi for volume load in the bile duct was lowered. This phenomenon tended to be more obvious in Gorei-san group, and will prevent duodenal fluid from transpapillary reflux. Parameters concerning the declining curve (T_1/2, T_1/4, T_1/5) showed a significantly rapid relaxation of the sphincter of Oddi only in Sho-saiko-to group, which will result in a prevention of stasis of bile. These modulating functions of Sho-saiko-to and Gorei-san for the sphincter of Oddi would be one of the main reasons why these formulas are used for hypochondriac fullness and distress or excessively accumulated intestinal fluid. Toki-shakuyaku-san showed no such effects on the sphincter of Oddi.

In the past 9 years, 37 patients with infective endocarditis underwent valve replacement. The aortic valve was involved in 17 patients, the mitral valve in 10, and both valves in 10, respectively. 35 patients had native valve and 2 had prosthetic valve endocarditis. Bacterial findings were Streptococcus in 20 patients (54%), Staphylococcus in 5 (13.5%), gram-negative in 3 (8%), and undetected in 10 (27%). 10 patients developed aortic annular abscess. After aggressive debridement of all apparently infected tissue of annular abscess, the defects left in the left ventricular outflow tract were repaired by interrupted mattress sutures with pledgets in 4 patients, by autologous pericardial patch in 4, and by valved conduit in 2 PVE patients, respectively. Retrograde cardioplegic infusion from the coronary sinus not only facilitated operative manipulation but also provided superior myocardial protection in such patients. Operative mortality was 11% (4/37). Reoperation was necessary in 2 patients; one for periprosthetic leak, and the other for newly developed severe left coronary ostial stenosis after the first operation, but both died eventually. Late mortality was 8% (3/37). Mean follow-up of 31 months was achieved in all 30 survivors, in whom there was no recurrence of infection and clinical improvement was excellent.

The regulatory effects of Gorei-san (Wu-Ling-San) on circulatory, metabolic and diuretic function were investigated analyzing the perioperative transition of serum sodium levels, peripheral platelet counts and urinary 6-keto-prostaglandin F₁α levels in fifty-eight female patients who underwent cholecystectomy because of cholelithiasis or gallbladder polyps.
The endothelial cells were considered to be activated by administration of Goreisan as shown by an increase of prostaglandin I₂ production, resulting in circulatory and metabolic stimulation and partly promotion of diuretic function by a dilatation of the renal vessels. The urinary 6-keto-prostaglandin F₁α, a metabolite of serum prostaglandin I₂ and also excreted by the interstitial cells in the renal medulla or by the epithelial cells of the renal collecting tubules, was considered to regulate diuretic function through suppressing the antidiuretic hormone.
The phenomena mentioned above were not recognized when Sho-saiko-to (Xiao-Chai-Hu-Tang) was administered instead of Gorei-san.