We present a successful case of a patient with multiple metal allergy—cobalt, nickel, chromium, and zinc—who had a past history of systemic metal dermatitis. He was a 58-year-old man who complained of exertional chest discomfort. After admission, he had a fever and his blood culture was positive with methicillin-sensitive Staphylococcus aureus. Three days later, multiple micro cerebral infraction was detected in magnetic resonance imaging. After an improvement of inflammatory reaction, he was transferred to our facility for cardiac examination. Moderate mitral regurgitation due to valve perforation and multiple coronary vessel stenosis were detected. Mitral valve replacement and coronary artery bypass grafting were planned to perform. We chose surgical materials based on a preoperative epicutaneous (patch) test and his clinical course was uneventful without any allergic reaction. Metal contact allergy is an important issue in cardiovascular surgery. A collaboration with dermatologists is essential for the preparation of surgical materials.

BACKGROUND/AIMS: We applied a back light system (BLS) with a magnifying glass to improve the ability to assess the adequacy of specimen sampling using endosonography. We conducted this study to evaluate the efficacy of the BLS in sampling of specimens by endoscopic ultrasound-guided fine needle aspiration of solid pancreatic masses. METHODS: This was a prospective, randomized, crossover, single-center clinical trial. An endosonographer evaluated adequacy on gross visual inspection and identified whitish specimen sampling sites with and without the BLS according to a randomization sequence in the first and second passes with a 25-G needle. On cytological evaluation, the presence of well-defined pancreatic ductal epithelium was evaluated by a cytopathologist who was blinded to any clinical information. RESULTS: A total of 80 consecutive patients were eligible during the study period. Adequacy was observed for 52 specimens (65%) with the BLS and 54 (68%) without the BLS (p=0.88). In assessment of specimen adequacy on gross examination, only fair agreement was observed both with and without BLS (kappa score 0.40 and 0.29, respectively). CONCLUSIONS: The BLS did not influence the ability to identify specimen sampling sites or reliable assessment of specimen site adequacy using gross visual inspection.
Biopsy, Fine-Needle ; Cross-Over Studies ; Endoscopic Ultrasound-Guided Fine Needle Aspiration ; Endosonography ; Epithelium ; Glass ; Humans ; Needles ; Pancreatic Ducts ; Pancreatic Neoplasms ; Prospective Studies ; Random Allocation

SUMMARY OF EVENT: Bacterial, mycotic peritonitis and Candida fungemia developed in a patient with moderate ascites who had undergone endoscopic ultrasound-guided biliary drainage (EUS-BD). Antibiotics and antifungal agent were administered and ascites drainage was performed. Although the infection improved, the patient's general condition gradually deteriorated due to aggravation of the primary cancer and he died. TEACHING POINT: This is the first report to describe infectious peritonitis after EUS-BD. Ascites carries the potential risk of severe complications. As such, in patients with ascites, endoscopic retrograde cholangiopancreatography (ERCP) is typically preferred over EUS-BD or percutaneous drainage to prevent bile leakage. However, ERCP may not be possible in some patients with tumor invasion of the duodenum or with surgically altered anatomy. Thus, in patients with ascites who require EUS-BD, we recommend inserting the drainage tube percutaneously and draining the ascites before and after the intervention in order to prevent severe infection.
Anti-Bacterial Agents ; Ascites ; Bile ; Candida ; Cholangiopancreatography, Endoscopic Retrograde ; Drainage ; Duodenum ; Endosonography ; Fungemia ; Humans ; Peritonitis

A 67-year-old man with dilated cardiomyopathy was admitted to our hospital for treatment of cardiac failure. After using heparin because cerebral infarction developed during hospitalization, in acknowledgment of thrombocytopenia, we reach the diagnosis of HIT. We judged surgery to be necessary because heart failure had difficulty with catecholamine secession and the left ventricular dilation progressed rapidly, and performed left ventriculoplasty, mitral valve plasty. There were no complications such as the thrombosis during cardiopulmonary bypass, and the postoperative course was good without leading to re-thoracotomy due to bleeding. He passes without a heart failure symptom by the follow of one year 6 months after surgery at home.

STUDY DESIGN: Multicenter analysis of two groups of patients surgically treated for degenerative L4 unstable spondylolisthesis. PURPOSE: To compare the clinical and radiographic outcomes of posterolateral fusion (PLF) and posterior lumbar interbody fusion (PLIF) for degenerative L4 unstable spondylolisthesis. OVERVIEW OF LITERATURE: Surgery for lumbar degenerative spondylolisthesis is widely performed. However, few reports have compared the outcome of PLF to that of PLIF for degenerative L4 unstable spondylolisthesis. METHODS: Patients with L4 unstable spondylolisthesis with Meyerding grade II or more, slip of >10degrees or >4 mm upon maximum flexion and extension bending, and posterior opening of >5 degree upon flexion bending were studied. Patients were treated from January 2008 to January 2010. Patients who underwent PLF (n=12) and PLIF (n=19) were followed-up for >2 years. Radiographic findings and clinical outcomes evaluated by the Japanese Orthopaedic Association (JOA) score were compared between the two groups. Radiographic evaluation included slip angle, translation, slip angle and translation during maximum flexion and extension bending, intervertebral disc height, lumbar lordotic angle, and fusion rate. RESULTS: JOA scores of the PLF group before surgery and at final follow-up were 12.3+/-4.8 and 24.1+/-3.7, respectively; those of the PLIF group were 14.7+/-4.8 and 24.2+/-7.8, respectively, with no significant difference between the two groups. Correction of slip estimated from postoperative slip angle, translation, and maintenance of intervertebral disc height in the PLIF group was significantly (p<0.05) better than those in the PLF group. However, there was no significant difference in lumbar lordotic angle, slip angle and translation angle upon maximum flexion, or extension bending. Fusion rates of the PLIF and PLF groups had no significant difference. CONCLUSIONS: The L4-L5 level posterior instrumented fusion for unstable spondylolisthesis using both PLF and PLIF could ameliorate clinical symptoms when local stability is achieved.
Asian Continental Ancestry Group ; Follow-Up Studies ; Humans ; Intervertebral Disc ; Spondylolisthesis*

1) We have implemented a portfolio as a learning and assessment tool into clinical clerkship rotation focusing on primary care medicine.
2) We received favorable responses both from students and teachers.
3) It is further required to promote the understanding of portfolio among teachers and students to enhance its utilization.

Objectives: Human T cell leukemia virus type-I (HTLV-I) is a causative agent of human T-cell leukemia and HTLV-I associated myelopathy (HAM/TSP). HTLV-I carriers are often infected vertically, especially via mother's milk. Since 1985, clinical measures have been adopted at a hospital in Okinawa to prevent vertical infections.
Methods: We examined HTLV-I antibodies in all of the women (total 11, 506) who gave birth after 24 gestational weeks at a hospital on the Okinawa main island from January 1985 to December 1999.
Results: The positive rate among all pregnant women was always higher than that among primipara alone. Both figures decreased over the period studied, but the primiparity rate (36-39%) did not change significantly. The percentage of HTLV-I positive primipara pregnant women among the HTLV-I positive total was close to the primiparity rate from 1985 to 1988, but it was considerably lower than the overall primiparity rate thereafter (22-26%).
Conclusions: Preventive measures against HTLV-I infection did not contribute to the decrease in HTLV-I positive mothers before 1999 because these measures were adopted from 1985, and so there must be other reasons for the decrease in HTLV-I positive rate. Further studies on social factors and by year of birth are needed to identify factors influencing HTLV-carrier ratios among pregnant women.

We studied cardiac function and outcome long after aortic valve replacement using a 19mm bileaflet valve. The subjects consisted of 10 of 12 patients living 10 or more years after the operation and 7 of 8 living 5-9 years after the operation. We measured the left ventricular ejection fraction (LVEF), %fraction shortening (%FS), left ventricular diastolic dimension (LVDd), systolic dimension (LVDs), PWT, IVST, and LV-aortic pressure gradient (PG) of in 6 patients each in 10 more years after the operation (Group I) and 5-9 years after the operation (Group II) who underwent ultrasonography, and calculated the left ventricular mass index (LVMI). No statistically significant differences were seen in either parameter in either group. Prognosis was 1 cardiac 2 cancer deaths each in 10 or more years after the operation group. The cumulative survival rate was in 85.7% post operative 5-9 years and 72.7% in 10 years. Although cardiac function was maintained in both groups, more observation is needed from now on because the pressure difference or LVMI may increase.

Risk factors for stroke after coronary artery bypass grafting (CABG) were assessed. We retrospectively investigated 681 consecutive patients who underwent isolated, first-time CABG at our institute between 1987 and 1998. Ninety-eight patients (14%) had a history of preoperative stroke. They tended to be older and with a higher incidence of peripheral vascular disease (PVD) than those without preoperative stroke. In spite of several techniques for prevention of postoperative stroke, such as the aortic non-touch technique, 14 patients (2.0%) suffered postoperative stroke. Postoperative stroke was diagnosed soon after surgery in 7 patients (50%), and the causes of stroke in these patients seemed to be intraoperative manipulation of the ascending aorta in 5, and hypoperfusion during cardiopulmonary bypass in two. Stroke in the remaining 7 patients occurred after normal awakening from anesthesia, and the cause was unknown. We then compared the patients with postoperative stroke (n=14) to those without postoperative stroke (n=667). Statistical analysis demonstrated no significant difference between the two groups in variables such as history of preoperative stroke, duration of cardiopulmonary bypass, and prevalence of PVD. Four (29%) of the patients with postoperative stroke died, due mainly to aspiration pneumonia. The morbidity and mortality of the patients who suffered postoperative stroke were very high.

Patients with an aortic aneurysm have a high incidence of coronary artery disease. Percutaneous transluminal coronary angioplasty (PTCA) has not established as a safe, effective procedure in patients with an aortic aneurysm. From November 1987 to November 1993, 5 patients underwent PTCA prior to aortic aneurysm repair. Three patients had abdominal aortic aneurysm and 2 had thoracic aortic aneurysm. There were 4 men and 1 woman whose mean age was 68 years (range 63 to 76). In 4 patients primary success of PTCA was achieved. The remaining 1 patient failed PTCA and underwent emergency coronary bypass surgery. Early mortality was 0%. All five were followed up after aneurysm repair for a mean of 28 months (range 12-66 months). There was no myocardial infarction or death. These results indicate that PTCA prior to aneurysm repair is a relatively safe and effective procedure, particularly in elderly patients with an aortic aneurysm.