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A 73-year-old male was admitted to our hospital due to fever and right lower limb pain. Contrast-enhanced computed tomography (CT) revealed occlusion from the right common femoral artery to the right superficial femoral artery and from the left common iliac artery to the left internal and external iliac arteries, leading to a diagnosis of bilateral acute arterial occlusion of the lower extremity. Emergency thrombectomy was performed to improve arterial blood flow. However, the patient continued to experience persistent fever and blood culture results were positive, prompting further investigation for the source of infection. Echocardiography revealed vegetations on the mitral valve and infective endocarditis with embolic complications was diagnosed. Because of the presence of residual vegetation, urgent mitral valve replacement was performed. The patient experienced no recurrence of infection postoperatively and was discharged home on continued oral antibiotic therapy.

Chylothorax is an intrathoracic leakage of chyle due to thoracic duct damage. Malignant lymphoma is the most common nontraumatic cause of chylothorax. In March 2019, a 74-year-old woman presented to our department with bilateral pleural effusion and mesenteric/retroperitoneal masses. She was diagnosed with diffuse large B-cell lymphoma upon performing a biopsy. In May 2019, she was hospitalized for dyspnea due to pleural effusion, and thoracentesis revealed abundant chyle. Although the tumor shrunk after chemotherapy, chylothorax improvement was poor; thus, she could not be discharged. For the management of refractory chylothorax, lymphangiography, thoracic duct embolization, and pleurodesis were performed, and the chylothorax improved immediately. However, in May 2020, right chylothorax recurred without a relapse of malignant lymphoma, which did not improve with conservative treatment. Lymphangiography was performed again; however, treatment via the lymphatic vessels was difficult. Thus, pleurodesis was performed four times, after which the chylothorax regressed. Chylothorax is often refractory. When chemotherapy for malignant lymphoma does not improve chylothorax, multidisciplinary treatment is effective.

Objectives　The Japan Health Insurance Association (JHIA) conducts training in each branch facility to improve the ability of public health nurses (PHNs). The headquarters of the PHNs of JHIA and the researchers conducted a training program for leaders of PHNs at each JHIA branch. The goal of the program was to create a training plan using role-play to acquire facilitation skills. This study aimed to examine the effects of training.Methods　The study was designed in accordance with the Instructional Designs. The training goals were as follows: (1) understanding the role of facilitation and the facilitator in the debriefing session after the role-play, (2) understanding facilitation techniques, (3) being confident in performing as facilitators in the debriefing session; and (4) conducting the debriefing sessions using facilitation skills. The evaluation of the training was based on the Kirkpatrick model from the viewpoint of confidence in using facilitation, knowledge of facilitation, and conduct of training and utilization of facilitation technology. Questionnaire evaluations were conducted three times before the training, immediately after the training, and three months after the training. In August 2016, 4.5 hours of training were conducted in one day.Results　There were 79 participants in the training group. The mean points of knowledge and confidence were 2.6-3.6 before training, 6.3-7.9 after training, and 6.0-6.9 at 3 months after training. The participants rated their interest in three questions of the training as high as 8.1-8.6. In addition, 64.6% of participants held a role-play session at each branch within three months of the initial training. In the role-play session planned by the participants, the practitioners implemented the explanation of the purpose and the rules at each branch 96.1% and 98.0%, respectively. Participants who had attended facilitation training prior to our program scored higher points of knowledge and confidence before and after three months. Three months after the training, 79 participants responded to the question of the role of the facilitator in role-playing. The descriptions were categorized into "opinions on the basics and planning of role-play training" and "opinions on the roles in retrospectives."Conclusion　The participants evaluated the training contents and the materials used as appropriate, and their knowledge and confidence in facilitation improved after the training. To maintain and improve facilitation skills, the educational system needs to implement training using role-playing at each branch consistently.

To maintain a trusting relationship between clinical and hospital laboratory staff, highly reliable reporting based on precise quality control of the test results is required. Testing work is divided into 3 steps: pre-testing, testing, and post-testing. Quality control (QC) of laboratory testing has been performed to improve the precision and accuracy of measurements after sample collection, mainly in the testing step. However, various factors influencing the measurement results are present in the process from requests for testing to the reporting of the test results, and it is necessary to make efforts to minimize these factors. The characteristics of POCT devices and reagents are their simple operation method, compact size, and use at sites other than laboratories, and most users are physicians and nurses. Sample measurement rooms have opened at sites other than medical institutions, and testing using POCT-compatible devices and reagents has been rapidly spreading. It is very important to clarify factors leading to false high and low values in the pre-testing step. The results of investigating reasons for predicted events were presented, and the necessity of quality management in the pre-testing step was clarified. If the pre-testing step is not properly performed, accuracy cannot be assured even though quality management of the testing and post-testing steps is optimal.

Purpose: To evaluate the effectiveness of selective laser trabeculoplasty (SLT) on steroid-induced glaucoma., Methods: The study included 46 eyes of 41 subjects who were followed up for at least 12 months after SLT. The included 10 eyes with steroid-induced glaucoma, 16 eyes with primary open angle glaucoma (POAG), 10 eyes with pseudoexfoliation glaucoma (PEX.G) and 10 eyes with mixed glaucoma (Mixed. G). The range of the SLT laser was 360 degrees. Intraocular pressure (IOP) before and after SLT, and cumulative survival rate after SLT were determined., Results: Significant decreases in IOP were observed after SLT in the steroid-induced glaucoma group, the POAG group and the PEX.G group. At 12 months after SLT, preoperation IOP decreased by 35.9% (29.9 +/- 7.5 mmHg to 17.9 +/- 2.2 mmHg) in the steroid-induced glaucoma group, 13.2% (20.0 +/- 3.0 mmHg to 17.3 +/- 3.1 mmHg) in the POAG group, 10.7% (21.1 +/- 4.0 mmHg to 18.1 +/- 4.1 mmHg) in the PEX.G group and 6.9% (21.3 +/- 1.9 mmHg to 19.9 +/- 3.4 mmHg) in the Mixed.G group. Cumulative survival rates were 80%, 56.3%, 50.0%, 40.0% in the steroid-induced glaucoma, POAG, PEX.G, and Mixed. G groups, respectively, at 12 months after SLT (Logrank test, p = 0.467)., Conclusion: These data suggest that SLT increased IOP reduction rates for steroid-induced glaucoma more than for any other group.

The Great East Japan Earthquake caused a tragic tsunami and resulted in serious damage to north region of Japan on March 11, 2011. The Japanese Society of Laboratory Medicine, JSLM launched an ad hoc Committee to support Laboratory Medicine affairs in the affected area. We expected that laboratory testing demands would increase during the weeks following the disaster. We decided to support the use of Point-of-Care Testing. Many POCT devices use battery-powered analyzers. This is definite advantage for their use in areas with limited access to power and water supplies. We contacted many companies about the possibility of providing POCT devices, IVD reagents and/or any laboratory supplies including disposable materials. Finally, forty companies agreed to support this project and we received list of reagents materials for more than one hundred IVD tests. We entered this information on our web site and continued to update it as additional support was received. Once a request of support was received, communication were made to confirm the amount of material, the method of shipping/receipt and if any specific training that would be required for its use at the testing site. Also, we dispatched volunteer Medical Technologists for eight weeks to assist in the laboratory work. Some of the crucial points in recruiting volunteer laboratory professions are expenses and accommodations. We prepared not only accommodations but also transportation methods and covered all expenses including insurance and meals. Our relief activities have shown that Laboratory Medicine and Medical Technologists are useful in disaster-affected area.

Devices for self monitoring of blood glucose (SMBG) are used by diabetic patients themselves. Evaluation of the environmental temperature during use by patients showed the importance of the temperature environment. When measurement is performed at a temperature outside the measurement temperature range, a function to display errors or does not display measurement values is indispensable. Measures to reduce puncture pain in SMBG include use of a thin needle, shallow puncturing, and the selection of the palm or forearm instead of the fingertip as a puncture site. Using these measures to reduce puncture pain, the blood volume required for measurement is often difficult to collect. Therefore, the puncture site is massaged or squeezed. However, these actions were reported to have serious influences on measurement values. Changes in the blood glucose and Ht levels and the hemolysis phenomenon were confirmed as the influences of the massaging or squeezing method. The correct blood collection method free of such influences is blood sampling from the fingertip using the pushing out method.

Infection of thoracic synthetic grafts is a serious problem, potentially leading to septicemia. Total removal of infected grafts might be too invasive for patients in poor general condition or who have long synthetic grafts. Effective and safe chemotherapy regimens are needed to control infection. A 75-year-old man with infected synthetic grafts of the ascending aorta, aortic arch, descending aorta, and thoracoabdominal aorta caused by methicillin-resistant Staphylococcus aureus was admitted to our hospital because of septicemia. He had previously received vancomycin for about 1 year at an outpatient clinic. The blood culture after admission was positive for vancomycin-intermediate Staphylococcus aureus. Linezolid was effective against septicemia, but caused side effects, such as blurred vision, severe diarrhea, and thrombocytopenia. Intermittent oral treatment with linezolid (1,200 mg/day) was then given for 7 days every 2 weeks. This treatment decreased the incidence of the side effects and had a beneficial effect on the infection.

A 65-year-old woman was admitted to our hospital with a diagnosis of cerebral infarction. She had incomplete paralysis of the right upper extremity. The echocardiogram showed a soft, mobile mass on the atrial side of the mitral posterior leaflet. Surgical treatment was performed 3 weeks after the episode of cerebral infarction. The mass originated from the P1 portion of the posterior leaflet. It was soft and fragile and was carefully resected along with the endocardium of the leaflet, from which it arose. The leaflet was reconstructed with direct 6-0 proline sutures. There was no mitral insufficiency. The histological diagnosis was a papillary fibroelastoma of the mitral valve. The postoperative course was uneventful, with no neurologic complications.

A 65-year-old woman was admitted to the hospital because of anterior chest pain. Computed tomography and transthoracic 2-D echocardiogram demonstrated aortic valvular stenosis with calcification of whole aortic root. Cardiac catheterization study showed a transaortic pressure gradient of 73 mmHg and coronary angiography showed 75% stenosis at the right coronary ostia. Aortic valve replacement and coronary artery bypass grafting were planned. At operation, sinotubular junction and bilateral coronary ostia severely calcified with stenosis, prompted us to translocate the aortic valve with the composite graft, a 19 mm Bicarbon prosthesis and 25 mm woven Dacron graft. The postoperative course was uneventful. On cardiac catheterization done 27 days after operation, satisfactory valve motion and patent coronary bypass grafts were confirmed.

After open-heart surgery, we sometime experience a patient whose respiratory function worsens extremely, though a heart function is improved. We experienced four such cases and treated with high-dose methylprednisolone. Then, we recognized that the respiratory function was improved at all cases. However, one case deteriorated again regarding the respiratory function, as a start of the treatment was delayed. There is a possibility that host resistance to infection is decreased by administration of corticosteroids. Therefore, we hesitate to treat with corticosteroids. Concerning respiratory failure after open heart surgery, however, we think that a respiratory function of a patient is improved if high-dose methylprednisolone pulse therapy is started in early stage.

Intermittent retrograde cold blood cardioplegia was compared with retrograde crystalloid cardioplegia. Twenty-two adult patients underwent open heart surgery divided into two groups. Group BCP (n = 10) was protected with 15 degrees C blood containing potassium 15 mEq/l; Group CCP (n = 12) was protected with 4 degrees C St. Thomas' Hospital cardioplegic solution. Lactate, pyruvate, and CK-MB levels in coronary sinus blood were measured at 5 and 15 minutes after aortic unclamping and 5 minutes after weaning from cardiopulmonary bypass (CPB) in both groups. CPB time, cross-cross clamp time, incidence of postoperative low output syndrome and spontaneous return to sinus rhythm after aortic unclamping were not different between two groups. Cardiac index and pulmonary capillary wedge pressure measured immediately after weaning from CPB, were not different in both groups. Lactate level was significantly low in group BCP. Lactate uptaking ratio of myocardium was significantly high in group BCP. CK-MB levels were not different between two groups. Cold blood cardioplegia was seemed to provide better aerobic myocardial metabolism during aortic cross clamp. However, CK-MB levels and hemodynamic studies were not different.

Xanthine oxidase has been demonstrated to be an important factor in postischemic reperfusion injury. Allopurinol is the inhibitor of xanthine oxidase. In this study, we evaluated usefulness of allopurinol for prevention of myocardial reperfusion injury in open heart surgery. Twenty adult patients were divided into two groups; Ap-group (n = 10) were administered allopurinol for seven days just before operation and control-group (n = 10) were administered nothing. The dose of allopurinol was ranged 100-300 mg/day. The dose was determined according to renal function of patients. Coronary sinus blood hypoxanthine, xanthine, uric acid, lactate, pyruvate, CK, and CK-MB levels were measured at before CPB, 5 and 15 min. after aortic declamping, 5 min. after CPB. Hypoxanthine and xanthine levels in Ap-group were significantly higher than those in control-group at 5 and 15 min. after aortic declamping, 5 min. after CPB. Uric acid levels in Ap-group were significantly lower than those in control-group at 5 and 15 min. after aortic declamping, 5 min. after CPB. Lactate, pyruvate, CK, and CK-MB levels were not different between Ap-group and control group. We considered that allopurinol suppressed the reaction rate of xanthine oxidase. Therefore, the levels of intermediates, hypoxanthine and xanthine, were high and, the level of final product, uric acid was low in Ap-group. However, allopurinol had no efficacy for the level of lactate, pyruvate, CK, and CK-MB, in this study.

The preoperative diagnosis of less than ss depth gallbladder cancer is difficult. Its preoperative diagnosis rate was low (27.5%), and even lower with the presence of concomitant gallstone. In the latter case, the diagnosis rate was particularly low when the stones diameter was greater than 1 cm. Gallstones are frequently associated with macromorphologically invasive type of gallbladder cancer and this may be the reason for the lower diagnostic rate. We compared preoperative diagnosis rate of ultrasonography (US), computed tomography (CT) and drip infusion cholecystography (DIC) for each invasion depth. In US, the preoperative diagnosis rate for m depth invasion was 6/16 (37.5%), pm depth was 1/13 (7.7%), and ss depth was 14/41 (34.1%). In CT, its rate for m depth was 3/11 (27.3%), pm depth was 1/10 (10.0%), and ss depth was 11/37 (29.7%). In DIC, its rate for m depth was 3/11 (27.3%), pm depth was 1/10 (10.0%), and ss was depth 1/23 (4.3%). None of the currently used imaging techniques were very accurate in diagnosing gallbladder cancer. Thus, during preoperative work up, if one discovers a gallbladder full of stones, stones of greater than 1 cm in diameter, thickened gallbladder wall, or a non visualized gallbladder with DIC, gallbladder cancer must be highly suspected.

A 59-year-old male was found to have two aneurysms in the mitral valve, mitral regurgitation, and aortic regurgitation by the echocardiographic examination. The patient had a previous history of infectious endocarditis by streptococcus at the age of 24. Under the diagnosis of mitral aneurysms developed after infectious endocarditis, surgery was undertaken. A 5 x 8 mm sized perforation in the right coronary cusp and two aneurysms in the anterior mitral leaflet, 22 mm and 17 mm in size, were found intraoperatively. Both the mitral and aortic valves were replaced. Patients with a history of infectious endocarditis have to be followed up for a long period of time. Transesophageal echocardiogram is useful in those patients. Considering high prevalence of aortic valvular diseases in those with a mitral aneurysm after infectious endocarditis, aortic valves should be carefully evaluated.

As the technique of open heart surgery has improved, CMC has been abandoned in favor of OMC and MVR. We evaluated and compared the results of CMC, OMC and MVR. METHOD. Between 1965 and 1978, 141 patients with mitral stenosis (MS) underwent CMC, and late follow-up obtained in 117 (83%) of them (CMC group). Between 1980 and 1989, 72 patients and 37 patients underwent OMC (OMC group) and MVR (MVR group), respectively. Cumulative follow-up periods were 1982, 632 and 200 patient-years in the CMC, OMC and MVR groups, respectively. RESULTS. (1) Survival rate; In the CMC group there were 2 operative deaths due to severe mitral regurgitation (MR). There were 17 late deaths, due to reoperations in 4 patients, cerebral infarction in 4 patients, congestive heart failure in 3 patients, myocardial infarction in 2 patients and unknown causes in 4 patients. The survival rate was 95%, 91% and 86% at 5, 10 and 15 years, respectively, in the CMC group. In the OMC and MVR groups there was no death. (2) The event free rate was 89%, 79% and 58% at 5, 10 and 15 years, respectively, in the CMC group, 97% and 97% at 5 and 10 years in the OMC group, and 95% and 90% at 4 and 5 years in the MVR group. (3) Reoperations; In the CMC group of 40 patients (34%) required reoperations in an average of 10.4 years after the initial operation, due to re-MS in 22 patients, MR in 10 patients and MRS in the 8 patients. Reoperative findings consisted of clefts in the mitral leaflets in 7 patients. There were pulmonary hypertension in 15 patients and tricuspid regurgitation in 22 patients. Fourteen patients underwent tricuspid anuloplasty and one patient underwent a tricuspid valve replacement. In the OMC group one patient required a reoperation due to MR; in the MVR group one patient required a reoperation due to a thrombosed valve. CONCLUSION. In the CMC group the survival rate and the event free rate were lower, and the rate of reoperation was higher than in the other two groups.

A 24-year-old female with unstable angina due to aortitis syndrome was reported. The coronary-arteriogram in hospital showed 75 percent stenosis of the left coronary ostium. Following two months' steroid therapy for active inflammation, aortocoronary bypass graft was implanted. After the operation. This patient became free from angina attack. Steroid therapy was continued postoperatively as well. The coronary-arteriogram taken seven months after the operation, revealed the patency of the graft.