Few studies have examined medical students' perceptions of community medicine and specialty choice through comparison between students of quotas related to community medicine and regular admission. We conducted a questionnaire survey on students' desire for future work places, types of health facility/hospital, medical specialization, and community medicine involving year 1 to year 5 students in Gifu University School of Medicine (n=335, selective admission: regular admission=81:254) . This study demonstrated that the selected students for community medicine (years 1 to 5) preferred to work at a core/small-sized hospital in a rural area and tended to choose the specialties that were characterized by primary care, such as pediatrics. Moreover, they had positive perceptions of community medicine. Further follow-up study needs to be undertaken in order to explore how students are actually engaging in community medicine after graduation.

Patients on chronic hemodialysis, undergoing coronary artery bypass grafting (CABG) have high perioperative mortality and morbidity. In order to reduce the perioperative risks, we performed intraoperative hemodiafiltration (HDF) during off-pump CABG (OPCAB). A 62 year-old-man, who had been on dialysis for 2 years, was admitted with a sensation of chest compression. A coronary angiography revealed 75% stenosis with severe calcification in the left anterior descending artery and 90% stenosis in the second diagonal branch. During the operation, veno-venous HDF was started, using a double lumen catheter that was introduced into the femoral vein at the same time that a skin incision was made. During the exposure of the diagonal branch by rotating the heart, the blood flow of HDF was decreased and dehydration was halted to avoid hemodynamic deterioration. The patient was extubated 1.5h after the operation and did not require continuous hemodiafiltration (CHDF) in the intensive care unit (ICU). Routine hemodialysis was restarted on the 3rd postoperative day. The postoperative course was uneventful, and the patient was discharged to home on the 11th postoperative day. HDF during OPCAB for this chronic dialysis patient was observed to be effective and yielded an excellent postoperative recovery without CHDF in the ICU.

Pulmonary blastoma is rare and its prognosis very poor. A 6-year-old boy was referred to our hospital with chest pain. Computed tomography demonstrated that the left pleural cavity was filled with a tumor. Cardiac echocardiography demonstrated that the tumor had invaded through the pulmonary vein into the left atrium and that the tumor extended into the left ventricle. Part of the tumor was adhered to the anterior leaflet of the mitral valve. To increase operative radicality, an autotransplantation technique was performed concomitantly with resection of the original lesion. Through a median sternotomy, a moderate hypothermic cardiopulmonary bypass was established to obtain cardiac arrest. First, longitudinal incision of right-sided of the left atrium was made. The tumor invaded into the left atrium through the left superior pulmonary orifice. The ascending aorta, the main pulmonary artery, and both caval veins were transected. The left atrium was incised along the pulmonary venous orifices. The heart was completely removed from the mediastinum and transferred to another table. Resection of the intracardiac metastatic lesion and mitral valve replacement was accomplished. During this time, thoracic surgeons performed a left pneunectomy. The left atrial wall around the left pulmonary venous orifices was resected in combination with the left lung. After the deficit of the left atrial wall was repaired with a Gore-Tex patch, the heart was replaced and we reconstructed the great arteries and caval veins. The autotransplantation technique is a useful procedure for combined lesions of the heart and lung.

Our strategy for treatment of thoracic aortic aneurysms with severely stenotic or occluded cerebral vessels is as follows. 1) The status of cerebral vessels and brain is assessed in detail by a team of neurologists and neurosurgeons, 2) cerebral surgical treatment is performed prior to aortic arch surgery, and 3) reconstruction of the total arch is performed using the arch-first technique through a median sternotomy. We successfully performed artificial graft replacement of the total aortic arch in two patients with old cerebral infarcts and severely stenotic cerebral vessels. In both cases, the operation was performed through median sternotomy under circulatory arrest by feeding the blood to the ascending aorta and draining it from the right atrium. Cerebral protection during reconstruction of the aortic arch was provided by profound hypothermia and retrograde cerebral perfusion (RCP). Prior to the incision of the aneurysm, cerebral branches were dissected to avoid escape of debris into cerebral vessels. The graft replacement was completed in 4 steps: 1) anastomosis of each of the 3 arch vessels, 2) distal anastomosis of another graft for the elephant trunk procedure, 3) anastomosis of the arch graft and the graft for the elephant trunk, and 4) proximal anastomosis. Just after cerebral branches were anastomosed to the 3 branches of the graft, the blood was supplied to the brain through the side branch of the graft instead of RCP. No signs of neurological deficit occurred postoperatively. The above protocol provided protection of high-risk patients with old cerebral infarcts from possible postoperative brain damage.

We developed a new double-lumen balloon catheter for retrograde cerebral perfusion (RCP) via jugular vein cannulation. Between November 1996 and September 2000, 34 of 73 patients treated with surgical procedures for thoracic aortic aneurysms underwent RCP using the new catheter during circulatory arrest under deep hypothermia. Nine patients underwent a median sternotomy, and 25 underwent a left thoracotomy. In all cases, the new catheter installation under fluoroscopy was easy, and it took about 15min. The mean RCP time, pressure, and flow rate were 26.8min, 20.0mmHg, and 202.6ml/min, respectively. Our procedure using the new catheter was safe and easy in RCP during circulatory arrest in aortic arch replacement regardless of surgical approaches such as a left thoracotomy or median sternotomy.

An 11-year-old boy, who underwent a Rastelli operation using a 14mm artificial graft and left pulmonary artery (PA) plasty with an autologous pericardium patch 7 years previously, had severe recurrent left pulmonary stenosis. Reoperation was performed including right ventricular outflow tract reconstruction and left PA plasty. The PA at the most stenotic site was only 2mm in diameter; it was enlarged to 10mm by good exposure and an incision on the pulmonary intima. A bovine pericardium patch with a handmade ePTFE valve was sutured onto the autologous tissue not onto the pulmonary intima to avoid restenosis and in expectation of the growth of the pulmonary orifice. On postoperative 3-D CT, the left pulmonary artery was patent and 9mm in diameter. Pulmonary scintigraphy showed an improvement in the left pulmonary perfusion. This sutureless technique was useful in this case of severe pulmonary stenosis.

Aortitis syndrome is a disease of non-specific inflammation of the arterial wall which produces necrosis and fibrosis of the intima. Indications, timing, and the choice of operative procedures should be determined carefully because of its complex pathology. We encountered a patient with combined aortic valve incompetence and left main coronary artery stenosis due to aortitis syndrome. The patient received adequate steroid therapy and the inflammatory reaction was well controlled before surgery. The patient underwent concomitant aortic valve replacement using an intravalvular implantation technique and coronary artery bypass grafting. The hospital course of the patient was uneventful. Neither paravalvular leakage nor inflammatory recurrence was observed during 18 months of follow-up.

Rheumatoid arthritis and interstitial pneumonitis were diagnosed in a 72-year-old man and thoracic computed tomography revealed an aortic arch aneurysm 50mm in diameter. Steroid therapy gave symptomatic relief and improved laboratory findings, but hyperglycemia and hypertension developed. Two months later the thoracic aneurysm ruptured, and computed tomography revealed expansion of the aneurysm to 60mm in diameter and surrounding hematoma. Emergency total arch replacement was performed successfully with deep hypothermic cardiopulmonary bypass and selective cerebral perfusion. The steroid therapy was considered to be responsible for the rapid expansion and rupture of the thoracic aneurysm. When prescribing steroids for a patient who has a concomitant atherosclerotic cardiovascular disease, we should not only control the steroidal side effects strictly, but also carefully watch the course of the atherosclerotic lesion.

An 60-year-old man who initially presented with ventricular tachycardia was suspected of cardiac tumor because of localised hypertrophy of the right ventricle. Although the localized region detected by an echocardiography suggested malignancy, percutaneous transcatheter myocardial biopsy failed to obtain a histological diagnosis. Six months later, a permanent pace maker was implanted due to complete AV block. Two years after the first admission, echocardiogram and computed tomography demonstrated a cardiac tumor in the right ventricle. To obtain a histological diagnosis, open biopsy was performed under median sternotomy and showed malignant lymphoma. Antemortem diagnosis of cardiac malignancy is usually very difficult. Median sternotomy is an established procedure for cardiovascular surgeons. Open biopsy can be an acceptable technique to obtain histological diagnosis of the neoplastic region in terms of safety and simplicity, and has good sampling accuracy compared with other diagnostic modalities. We recommend early stage surgical exploration when cardiac malignancy is a diagnostic possibility.

Fifty consecutive patients who underwent elective repair for abdominal aortic aneurysms were preoperatively evaluated on blood coagulation tests and retrospectively classified into three groups. Class I had a normal profile on the tests. Class II had either high FDP (≥20ng/ml), TAT (≥20ng/ml), or positive results on the FM test. Class III had either thrombocytopenia (≤120/μl) or bleeding symptoms with Class II conditions. Operative mortality was 0% (0/26) in Class I, 13% (2/15) in Class II, and 22% (2/9) in Class III patients. This classification is considered to be simple and useful to assess specific coagulopathy for aortic aneurysms.