We report a case of syphilitic aortitis (SA) associated with severe right coronary ostial stenosis, aortic regurgitation (AR), and annuloaortic ectasia (AAE). A 48-year-old man presented to a regional hospital with easy fatigability and nocturnal dyspnea. Echocardiography revealed Seller's grade 3 AR. A computed tomography scan showed AAE, dilatation of the ascending aorta, and calcification of both coronary ostia. Coronary angiography demonstrated that the left coronary artery was intact ; however, the right coronary artery was obscure. Active syphilis was detected on routine blood tests on admission. Therefore, the patient was started on a course of ampicillin/sulbactam (ABPC/SBT). Subsequently, he underwent the Bentall procedure and coronary artery bypass grafting with the right internal thoracic artery. The intraoperative findings showed degeneration of the aorta and severe right coronary ostial stenosis. The pathological findings of the aortic wall and aortic valve were consistent with SA. The postoperative course was uneventful. The patient continued receiving ABPC/SBT for 3 weeks postoperatively, and was then switched to oral amoxicillin.

A 64-year-old man with congenital factor V deficiency and hereditary spherocytosis was attending our hospital for type II diabetes and stage 4 diabetic nephropathy. Coronary angiography performed to assess chest pain revealed severe triple-vessel disease, including total occlusion of the right coronary artery. The patient required surgical coronary revascularization. In the preoperative examination, the activated partial thromboplastin time (APTT) and prothrombin time-international normalized ratio (PT-INR) were high (89.5 s and 1.95) and factor V activity was low (6% ; normal range, 70-135%). Hemodialysis was performed on the day of the operation, and 6 units of fresh frozen plasma (FFP) were administered, which reduced immediately the preoperative PT-INR to 1.33. We performed off-pump coronary artery bypass grafting (OPCAB) and perioperatively administered 6 units of FFP with 4 units of red blood cells (RBC) transfusion. The postoperative course of the patient was uneventful, and he was discharged on postoperative day 22. Here we report the case of a patient with a very rare disease of congenital factor V deficiency and hereditary spherocytosis complicated with stage 4 diabetic nephropathy who required OPCAB.

Percutaneous endoscopic gastrostomy (PEG) is a common procedure for placing a feeding tube in the stomach to provide fluids and nutrition to patients who have difficulty in swallowing or in taking enough noutrishment through the mouth. Thought the procedure is simple and easy, PEG is not without its risks. The reported complication ratio is not low-, -between 5.7% and 33.3%. This is probably because the patients are lacking in reserves of physical faculties.The present study was conducted to work out measures to reduc the incidence of PEG complications by reviewing the complications cases treated in our hospital.From March 1997 to December 2005, we performed PEG on 110 patients, of which 11 patients (9.6%) had complications. In some cases, we inadvertently perforated the colon. From our experience, we have learned that it is not safe to perform PEG with the aid of radiography alone on cases in which the intervention of the transverse colon between stomach and abdominal wall was suspected by CT scan, and concluded PEG should be done using gastrography of the transverse colon, to guide the placement of a feeding tube in the stomach. In view of the systemic condition of the patients, we thought it necessary to take safety measures by all possible means.
Percutaneous endoscopic gastrostomy ; Complications Specific to Antepartum or Postpartum ; Stomach ; Management ; Prevention

Teaching ambulatory-care medicine is essential for primary-care education. However, few studies of ambulatory-care training have been done in the past decade. We performed a nationwide survey to examine whether and how ambulatory medicine is taught to medical students and residents. We sent questionnaires to all medical schools (n=80) and accredited teaching hospitals (n=389) in February 2001. The response rates were 83.3% and 79.2%, respectively. Fifty-one (78.5%) of the 65 medical schools provided ambulatory-care education, although the programs varied considerably from school to school. Only 104 teaching hospitals (26.7%) had an ambulatory-care training program.

Although postgraduate training in an ambulatory care setting is recognized as beneficial in Japan, such training has not been widely implemented. In April 2001 we surveyed all 389 accredited teaching hospitals in Japan about their ambulatory care training. We asked 1) whether they provide a postgraduate training program in ambulatory care, particularly for problems commonly encountered in primary care settings, 2) if such a program was provided, how it was organized, and 3) if such a program was not provided, what the reasons were. One hundred eighty physicians responsible for the residency programs of 120 hospitals replied (response rate, 87%). Most residents at these hospitals see patients in outpatient clinics regularly during their training. Many faculty members supervise their residents at the outpatient clinic and also see their own patients. Sixty-eight percent of the respondents did not set teaching objectives for ambulatory care training. Frequently mentioned barriers to providing ambulatory care training were limited space and tight outpatient schedules. To promote postgraduate ambulatory care training in accredited teaching hospitals, adequate resource allocation and a national policy are needed.

The aim of this study is to report and analyze the results of a questionnaire concerning the present programs for the junior residents in the postgraduate clinical course in Japan.
A questionnaire was sent to the administrators or the persons in charge of the programs of 347 institutions including 80 university hospitals and 267 clinical training hospitalsas designated by the Ministry of Health and Welfare.
Answers to a questionnaire were returned by 271 institutions (78.1%). The results were analyzed and summarized as follows.
(1) About 95% of both university and clinical training hospitals have their own programs at present.
(2) In the substantial formula of programs, university hospitals have had straight or rotation form while the clinical hospitals have selected rotation or super rotate (comprehensive) form.
(3) The programs of university hospitals have started in majority before 1992 while those of clinical hospitals have began after 1993.
(4) The programs of university hospitals have contained the clinical training at the other departments or institutions in a significantly higher ratio compared to those of clinical hospitals.
(5) The check system for the evaluation of the programs has well functioned in half of both hospitals.
(6) For the assessment of the programs used, about half of the staffs of both university and clinical hospitals feel unsatisfactorily in their active programs.
(7) Concerning the intention to renewal or modification of their programs used, there were rather passive agreements in both university and clinical hospitals.

The aim of this study is to report the results of the workshop which was designed to define several indispensable conditions for the implementation of the compulsory clinical training. These conditions discussed include the guarantee of position and improvement of labor conditions for trainees, standard for the authorization of institutions receiving trainees, training curricula and teaching staff of institutions, and the certificate of qualification for the trainees after the compulsory training. The products of the workshop showed plans and guidelines to these conditions as seen in this paper.

Prostaglandin E₁ (PGE₁) was used continuously in adults from immediately after induction of anesthesia, during extracorporeal circulation, to the acute phase after open heart surgery. Using blood flow in the toe determined by laser Doppler flowmeter and the temperature difference between periphery and core as indices, the effects of afterload reduction and improvement of peripheral circulation were investigated. Subjects were 17 adults who underwent open heart surgery. PGE₁ was used in 7 patients and not used in 10. In the group using PGE₁, continuous injection of 0.015μg/kg/min of PGE₁ was started immediately after induction of anesthesia and was maintained during extracorporeal circulation until the acute phase after surgery. During extracorporeal circulation, perfusion pressure was kept at 50∼60mmHg and PGE₁ injection was controlled within the range of 0.015∼0.030μg/kg/min. At completion of extracorporeal circulation, the dose was fixed at 0.015μg/kg/min again. The degree of improvement of peripheral circulation was evaluated on the basis of hemodynamics, blood flow in the toe determined by laser Doppler flowmeter and the temperature difference between periphery and core, at induction of anesthesia (before using PGE₁) on completion of extracorporeal circulation, and in the acute phase after surgery. The value of blood flow in the toe determined by laser Doppler flowmeter was significantly higher in the PGE₁ group than in the non-PGE₁ group, from completion of extracorporeal circulation to the acute phase after surgery. Moreover, peripheral temperature was significantly higher in the PGE₁ group than in the non-PGE₁ group at completion of the extracorporeal circulation as well as immediately after surgery, and the temperature difference between periphery and core was significantly smaller. Continuous injection of PGE₁ enabled smooth control of perfusion pressure during extracorporeal circulation. Although there was no significant difference in peripheral vascular and total pulmonary resistance, the coefficients tended to be lower in the PGE₁ group. The use of PGE₁ during open heart surgery seems to be an effective method to improve peripheral circulation.

The positional relation between the point Jingei and the bifurcation of the common carotid artery was investigated with dissection of the neck after inserting a needle into the bilateral Jingei, using nineteen Japanese cadavers. We determined first the position of the point Futotsu as a point in the sternocleidomastoid lying about 10cm lateral to the laryngeal prominence along the neck wrinkle, and defined the location of Jingei in the cadavers as the mid-point between the laryngeal prominence and Futotsu mentioned above. The common carotid artery shows a dilatation, termed the carotid sinus, at its point of division into the external and internal carotid arteries. The needle did not prick the carotid sinus in all of the thirty-eight cases of insertion; it pricked the common carotid artery at a lower level than the carotid sinus in four of these cases, and in the other cases the needle did not prick the vessel, but rather a portion of the neck medial to the vessel at the lower level, similarly as in the former cases. The points of division of the common carotid arteries of the cadavers dissected were all located at a considerably higher level than the laryngeal prominence; the average level was 32.8mm higher than the prominence on the left, with maximum and minimum values of 52 and 11mm, respectively, and 29.9mm upper on the right (maximum and minimum values: 45 and 8mm). Furthermore, it was suggested that the insertion of a needle at the level of the hyoid bone has a higher possibility of reaching the carotid sinus than that at the level of the laryngeal prominence in acupuncture of the sinus.