Association between Asian dust exposure and respiratory function in children with bronchial asthma in Nagasaki Prefecture, Japan

BACKGROUND@#Studies on the adverse effects of Asian dust (AD) on respiratory function in children are scarce. The objective of this study was to examine the association between AD and respiratory function by measuring peak expiratory flow rates (PEFRs) in asthmatic children.@*METHODS@#The study was carried out from March to May from 2014 through 2016. One hundred ten children with bronchial asthma were recruited from four hospitals in the Goto Islands and south Nagasaki area in Nagasaki prefecture. The parents were asked to record their children's PEFRs every morning/evening and clinical symptoms in an asthma diary. AD was assessed from light detection and ranging data, and a linear mixed-effects model was used to estimate the effects of AD on daily PEFR. Time-stratified case-crossover analyses were performed to examine the association between AD and asthma attacks defined by reduction levels in PEFR.@*RESULTS@#AD was detected on 11 days in the Goto Islands, and on 23 days in the south Nagasaki area. After adjusting for age, sex, temperature, and daily oxidants, we found a consistent association between AD and a 1.1% to 1.7% decrease in PEFR in the mornings and a 0.7% to 1.3% decrease in the evenings at a lag of 0 to 5 days. AD was not associated with the number of asthma attacks, respiratory symptoms, or other symptoms at any lag days examined.@*CONCLUSIONS@#Exposure to AD was associated with reduced PEFR, although the effects were not large enough to induce clinically apparent symptoms, in clinically well-controlled asthmatic children.

Autologous Pericardial Patch Closure for a Giant Right Coronary Artery Aneurysm with a Coronary Arteriovenous Fistula / 日本心臓血管外科学会雑誌

A 53-year old female was noted to have an enlarged heart on a medical checkup. A multislice computed tomography study demonstrated a giant coronary artery aneurysm measuring 10 cm in diameter and a coronary arteriovenous fistula, both located below the left atrium. Resection of the aneurysm and ligation of the feeding arteries and arteriovenous fistula were performed under cardiopulmonary bypass. As the native coronary sinus was occluded, we reconstructed the vessels draining from the aneurysm into the right atrium with an autologous pericardial patch to preserve the coronary venous blood flow. To our knowledge this is the first report of an autologous pericardial patch being successfully used to reconstruct the coronary venous flow during surgical treatment of a giant coronary artery aneurysm with a coronary arteriovenous fistula.

A Case of Mitral Mechanical Valve Thrombosis after Switching to Edoxaban / 日本心臓血管外科学会雑誌

A 65-year-old man who had been taking warfarin for a mitral mechanical valve, was transported to our hospital for acute heart failure 3 months after switching to edoxaban. The fluoroscopy revealed restriction of the mechanical valve opening, and the catheterization showed an increased pressure gradient of the mechanical valve. The patient was diagnosed with valve thrombosis, and emergency redo mitral valve replacement was performed. The patient recovered well without complication. In cases with mechanical heart valves, sufficient explanation and education about warfarin administration is mandatory for patients' home doctors as well as patients and their families.

Gallbladder Infarction Complication after Total Arch Replacement / 日本心臓血管外科学会雑誌

A 73-year-old man was referred to our hospital for treatment of a sacral aneurysm of the distal aortic arch with a maximum dimension of 66 mm. He underwent total arch replacement (TAR) with cardiopulmonary bypass (CPB), moderate hypothermia, circulatory arrest (CA) of the lower body and antegrade selective cerebral perfusion (SCP) via a median sternotomy. Through the aneurysm, the descending aorta was divided and distal anastomosis was performed using the stepwise technique. After the inserted tube graft was extracted, a four-branched arch graft was anastomosed. The arch vessels and the proximal aorta were then anastomosed to the four-branched graft. The operation time was 515 min, CPB time was 305 min, aorta cross clamp (ACC) time was 213 min, SCP time was 143 min, and CA of the lower body was 97 min. On postoperative day (POD) 5, right-upper abdominal pain suddenly developed, with low grade fever. Acute cholecystitis was suspected and antibiotic therapy was started. On POD 6, his abdominal pain shifted to the lower-right region. His blood examination results were unchanged. Acute peritonitis was suggested by abdominal-enhanced computed tomography (CT), and emergency open cholecystectomy was then performed. There was no evidence of gall stones, and a bacterial culture of the ascites was negative. The pathological diagnosis was thromboendarteritis of the gallbladder artery, accompanied with thrombophlebitis and thrombosis, causing massive infarction at the neck of the gallbladder wall. His postoperative course was uneventful and he discharged in an ambulatory state on POD 16. In TAR, the risk of gastrointestinal ischemia is considerable because of prolonged circulatory arrest of the lower body and debris embolism. It is necessary to recognize possible gallbladder infarction, although it is rare, as a differential diagnosis of acute abdomen after TAR.

A Case of Mitral Valve Plasty without Autologous Pericardium for Active Infective Endocarditis / 日本心臓血管外科学会雑誌

In recent treatment of mitral regurgitation due to active infective endocarditis, significant attempts have been made to repair as much of the mitral valve as possible. In cases where the leaflet is damaged extensively because of infection, valve repair generally becomes difficult unless the defect is reinforced by glutaric aldehyde-preserved autologous pericardium. We report a case in which mitral valve plasty for mitral regurgitation was performed under these circumstances. A 27-year-old man was admitted to our hospital because of headache and persistent fever. Transthoracic echocardiography revealed a 13-mm friable vegetation attached to the anterior leaflet of the mitral valve with severe mitral regurgitation. Urgent surgery was performed based on a diagnosis of active infective endocartitis. After cardiopulmonary bypass was performed and the aorta was cross-clamped, a left atriotomy was carried out on the interatrial groove. Much vegetation was attached to the damaged mitral leaflet from A3 to P3, and prolapse of the commissural leaflet was observed. The vegetation and damaged leaflet were then removed. Removal of the superficial vegetations enabled preservation of more than half of the A3. The valve was repaired by the resection-suture technique without using the autologous pericardium, as glutaric aldehyde solution was not available. Mitral annuloplasty using a 28-mm physio ring was performed thereafter. The postoperative course was uneventful and without any residual regurgitation. Nine months after surgery, no recurrence of infection or mitral regurgitation was not observed.

Preparing Students for Overseas Clinical Rotations / 医学教育

Medical students in Japan often want to do clinical rotations abroad. Preparation for these important clinical experiences is essential to maximize the learning opportunities. Language ability is only one small part of assuring success.1) It is important to consider the hospital where the rotation will take place, the specific rotation, the living arrangements and commuting to the hospital. Preparation before the rotation should include practice in performing and writing a complete patient history and physical examination.2) It is very helpful to have a cell phone while abroad, as well as a credit card. Students must bring a white coat, and it is recommended that they also bring a Japanese textbook in the field they will study.3) While on a clinical rotation, students must be active participants in patient care and in discussions. They must be aggressive about answering questions during ward rounds. Students must be aware of many cultural differences to have good relationships with patients and colleagues.

A Case Study of Acute Aortic Dissection, Which Occurred in a Mother and Daughter with Marfan Syndrome on the Same Day / 日本心臓血管外科学会雑誌

Case 1 was a 48-year-old mother who was under observation for Marfan syndrome and thoracic aortic dilation. She was brought to the hospital with chest pain, and a CT scan revealed acute aortic dissection (Stanford A). Aortic incompetence was also observed, and an emergency Bentall procedure was performed. Case 2, her daughter, was a 26 years old and 39 weeks pregnant. She did not meet the diagnostic criteria for Marfan syndrome. She experienced severe back pain on the same day that her mother was admitted for aortic dissection. Because the patient did not agree to the use of a contrast agent due to concern about its effect on the fetus, emergency cesarean section was performed. Subsequently, a CT scan performed on the patient showed acute aortic dissection (Stanford B). Accordingly, antihypertensive therapy was commenced. In both cases, the patients were discharged after they recovered. Although case 2 did not meet criteria for Marfan syndrome, because of the hereditary disposition, we strongly suspect this was a Marfan syndrome pregnancy. This type of case is included in the case literature on cesarean and vigilant perinatal care is thought to be necessary.

Medical education at Harvard Medical School. Experience of the new pathway program / 医学教育

The personal experiences as a student of the “New Pathway Program” at Harvard Medical School and one of its 17 affiliated institutions, New England Deaconess Hospital (March, 1988 and March and April, 1989), are reported. In a problem-based curriculum, students' learning occurs mainly around investigative and clinical problems. In the Department of Cardiology, the consultation service, intern conference, medical grand round, CCU, noon talk and cardiology conference are described. In the Department of General Surgery, under the “Blue Team”, team round, tumor conference, surgical grand rounds, surgical operation, morbidity mortality conference, chief conference, night duty and chief resident conference are described. In summary, the clinical clerkship of the students and teaching by the residents are much more intensive than those in Japanese medical schools.