Right pulmonary artery-left atrial communication is a rare congenital heart disease that is usually diagnosed before adulthood, and its main symptoms are cyanosis and dyspnea on exertion. We report a 51-year-old man with a large aneurysm of the right pulmonary artery and left atrial communication, which was diagnosed after a brain abscess. We are concerned that simple ligation alone may cause embolism, so we report on the use of an autologous pericardial patch to close the opening to the left atrium.

Chronic contained rupture of an abdominal aortic aneurysm （AAA） is a rare condition that can present with atypical symptoms, making diagnosis challenging. We report a case of chronic contained rupture of an AAA with vertebral destruction presenting as right lower extremity pain. A 78-year-old man with a history of mitral valve replacement and pyogenic spondylitis （L2-L3） presented with a two-month history of low back pain and a four-day history of right lower extremity pain and numbness. Computed tomography revealed a 61 mm diameter ruptured AAA with an irregular margin. Magnetic resonance imaging demonstrated vertebral destruction at L4-L5. The patient underwent open surgical repair with a rifampicin-soaked graft and debridement. Intraoperatively, a large defect was found at the posterior aspect of the aneurysm, exposing the destroyed vertebral bodies. Postoperatively, the patient required spinal immobilization for persistent neurological symptoms, which improved and the patient was discharged on postoperative day 55.

Introduction: The purpose of this study was to clarify factors related to recognition of the possibility of end-of-life care at home (hereafter referred to as end-of-life care) among middle-aged and elderly people living in heavy snowfall and depopulated areas.Methods: Residents aged 40~69 years in town B, prefecture A were surveyed by mail using a self-administered, unmarked questionnaire. Analysis methods were: (1) a reliability analysis of survey items, (2) basic statistics, (3) tests for differences in composition ratios, (4) tests of differences between the two groups for each item, and (5) binomial logistic regression analysis. Recognition of the possibility of end-of-life care was used as the objective variable, and sex, age, and 18 indicators significant in (3) and (4) were used as explanatory variables.Results: There were 63 in the positive group for end-of-life care, 239 in the negative group, and 120 in the unknown group (Response rate: 44.1%). Factors related to perception of the possibility of end-of-life care were positively related to "existence of a community hospital, " "positive image of end-of-life care, " and "trust in people in the community. "Conclusion: In depopulated areas, it is necessary to consider specific measures to promote the three factors that raise awareness of the possibility of end-of-life care.

We report the successful treatment of a rare case of chronic expanding hematoma and visceral pericardium thickening constrictive pericarditis with no history of trauma or surgery. A 70-year-old woman, who had no history of trauma or surgery was admitted for exertional dyspnea. An echocardiographic study demonstrated a mass located anterior to the right ventricle that severely compressed the right ventricle toward the ventricular septum. Enhanced chest computed tomography demonstrated pericardial calcification and a 125-mm heterogeneous mass in the middle mediastinum. A mosaic pattern was seen on T1, T2-weighted magnetic resonance imaging. Surgical resection of the mass and removal of the visceral pericardium were planned to treat heart failure and to confirm the diagnosis of the mass. The mass was old degenerated coagula. Histopathological examination confirmed the diagnosis of chronic expanding hematoma. The postoperative course was uneventful. There has been no sign of recurrence 19 months after the operation.

A 62-year-old man with Marfan syndrome had a modified Bentall procedure and total arch replacement for annuloaortic ectasia, aortic insufficiency and thoracic aortic aneurysm fifteen years ago at another hospital. A follow-up CT revealed bilateral coronary artery aneurysms and an aortic root pseudoaneurysm, and thus he was referred to our hospital. The previous prosthetic valve was removed, followed by the re-Bentall procedure. Coronary artery aneurysms were resected and consequently coronary arteries were reconstructed directly. Although the shortcoming of the Bentall procedure was pseudoaneurysm, the outcomes of the modified Bentall procedure have shown some improvements. However, as there is still a high risk of postoperative complication in connective tissue diseases, long-term follow-up is required.

BACKGROUND: We aimed to examine the association of exposure to environmental tobacco smoke with dental caries among preschool children. Exposure to environmental tobacco smoke was assessed in terms of urinary cotinine concentrations and pack-years of exposure to smoking by parents and other family members at home. METHODS: This cross-sectional study included 405 preschool children aged 3-6 years from two preschools in Japan in 2006. Information on the smoking habits of family members living with the child was obtained from parent-administered questionnaires. Dental examination was conducted to assess dental caries, that is, decayed and/or filled teeth. Urinary cotinine levels were measured using first-void morning urine samples. RESULTS: Overall, 31.1% of the children had dental caries, and 29.5% had decayed teeth. Exposure to current maternal and paternal smoking was positively associated with the presence of dental caries after controlling for covariates. More than three pack-years of exposure to maternal smoking and more than five pack-years of exposure to smoking by all family members were significantly associated with the presence of dental caries as compared with no exposure (odds ratio [OR] = 5.55, 95% confidence interval [CI] = 2.17-14.22, P for trend < 0.001 and OR = 2.00, 95% CI = 1.12-3.58, P for trend = 0.004, respectively). These exposure variables were similarly associated with the presence of decayed teeth (OR = 2.92, 95% CI = 1.23-6.96, P for trend = 0.01 and OR = 1.75, 95% CI = 0.96-3.20, P for trend = 0.03, respectively). As compared with lowest tertile of the urinary cotinine level, the highest tertile of the urinary cotinine level was significantly associated with the presence of dental caries as well as decayed teeth; the ORs for the highest vs. lowest tertile of urinary cotinine levels were 3.10 (95% CI = 1.71-5.63, P for trend = 0.012) and 2.02 (95% CI = 1.10-3.70, P for trend = 0.10), respectively. CONCLUSIONS These data suggest that exposure to tobacco smoke may have a dose-dependent influence on the development of caries.
Child ; Child, Preschool ; Cotinine ; urine ; Cross-Sectional Studies ; Dental Caries ; epidemiology ; etiology ; Female ; Humans ; Japan ; epidemiology ; Logistic Models ; Male ; Maternal Exposure ; adverse effects ; Parents ; Paternal Exposure ; adverse effects ; Risk Factors ; Surveys and Questionnaires ; Tobacco Smoke Pollution ; adverse effects ; Tobacco Smoking ; adverse effects ; epidemiology

Purpose: The purpose of this study was to clarify the state of eating -related distress and struggle in the daily lives of cancer outpatients in cancer center hospital. Methods: Cancer outpatients who consented to participate in the study filled out self-administered questionnaires regarding eating distress and the means of coping with them. The data were qualitatively analyzed via content analysis method. Results: Data from 176 patients who responded that they experienced eating difficulties were analyzed. A total of 222 codes were extracted for eating-related distress, and these were classified into five categories, which included eating-related symptoms accompanying the disease and its treatment, difficulties related to food preparation, and concerns about eating outside food. A total of 224 codes were extracted for eating-related struggle made by the patients, and these were classified into eight categories, which included adjusting eating methods to make food easier to eat, controlling one’s feelings when unable to eat certain foods, and adjustments related to food preparation. Conclusions: The study results suggested that cancer outpatients require care not only at early stages after treatment for eating-related symptoms but also related to food preparation and concerns when eating outside food.

　The objective of our study was to examine delays between onset of symptoms and treatment for malignant spinal cord compression （MSCC） and to investigate outcomes of neurological function. We performed a retrospective study of clinical records for 25 patients who had been diagnosed with MSCC at a regional center hospital. Thirteen patients had a history of malignancy at the onset of MSCC and 12 patients had no history. For most patients, pain was the first symptom of MSCC. Pain preceded neurologic symptoms by approximately 2 months. The median delays from onset of symptoms of MSCC to treatment were 49 days for all patients, 79 days for those without a history of malignancy and 41.5 days for those with a history of malignancy. It took 39 days from onset to consultation at the hospital, 7 days from consultation to diagnosis and 11 days from diagnosis to treatment. Neurological status was not exacerbated in 8 of 9 patients who had no other neurologic dysfunction at the time of treatment, while only 4 of 10 patients who had deterioration of motor or sensory function at the time of treatment showed improvement in neurological status. In conclusion, there were many delays in all processes from onset to treatment for MSCC and these delays resulted in poor outcome of neurological function.

A 77-year-old man underwent aortic valve replacement with a Carpentier-Edwards Pericardial Magna (19 mm) for aortic stenosis. He presented with a low grade fever and congestive heart failure 6 months after the initial valve replacement. Staphylococcus aureus was detected in blood culture, and peri-valvular leakage was revealed by echocardiography. Prosthetic valve endocarditis was diagnosed and underwent re-aortic valve replacement with Medtronic Mosaic 21 mm bioprothesis. Six months after the re-do operation, perivalvular leakage was newly observed between the right and non-coronary cusps, which was opposite to endocarditis affected cusps. The peri-valvular leakage was considered to have resulted from the fragile valve annulus because he did not have fever, and repeated blood culture showed no bacterial growth. We performed a third surgery and repaired the leakage by adding sutures through the right atrium and the interventricular septum to avoid directly suturing the fragile annulus. The post-operative course was uncomplicated, and no sign of endocarditis nor perivalvular leakage was observed during 9-months of observation. It is considered that the aortic valve fixation sutures through the right atrium and inter-ventricular septum are useful alternatives for fragile aortic annulus after prosthetic valve endocarditis.

Infectious endocarditis (IE) concomitant with patent ductus arteriosus (PDA) is now considered rare because the early treatment of PDA in infancy has become standard. We report a case of PDA with IE diagnosed by computed tomography (CT). A 51-year-old man complained of arthralgia and numbness of the left extremities. He had fever of 39°C and left hemiplegia, and was referred to our hospital. A chest X-ray film showed infiltration in both lungs. CT revealed a mass lesion in the main pulmonary artery and a tubular connection between the main pulmonary artery and the aortic arch. Multiple small infarctions were also found in the brain, lungs, kidneys and spleen. Ultrasonic cardiography revealed a bi-leaflet aortic valve, and vegetations on the aortic and mitral valves. Staphylococcus aureus was detected by culture of an intravenous catheter tip. These findings suggested IE concomitant with PDA, and we started intravenous administration of antibiotics. However, congestive heart failure occurred due to severe aortic and mitral regurgitation 2 days after hospital admission, and therefore, we performed emergency surgery. The main pulmonary artery was incised after cardiopulmonary bypass was initiated. A 20-mm length of vegetation was found on the orifice of the PDA. The vegetation was removed and the PDA directly closed. Aortic and mitral valve replacement was then performed. The post-operative course was uneventful and his neurological symptoms did not exacerbate. No sign of IE recurrence was observed 2 years after the surgery. CT clearly showed PDA and vegetation in the main pulmonary artery, although ultrasonic cardiography did not. CT was useful to make a diagnosis of PDA with IE in the present case.