Reoperation for Rupture of the Porcine Aortic Wall of a Stentless Bioprosthesis / 日本心臓血管外科学会雑誌

A 63-year-old woman presented with pseudoaneurysm formation due to rupture of the porcine aortic wall of the stentless bioprosthesis. She had undergone aortic root replacement using the full root technique with the 25-mm Prima Plus bioprosthesis for annuloaortic ectasia. Congestive heart failure, appearing 65 months after the first surgery, progressed rapidly. Multidetector computed tomography (CT) showed a pseudoaneurysm of the aortic root, and echocardiography revealed severe mitral regurgitation. At reoperation, a large pseudoaneurysm with a 20-mm horizontal tear was seen in the non-coronary sinus of the Prima Plus valve. A repeat aortic root replacement and mitral valve replacement with two mechanical valves were performed. The patient had an uneventful recovery. Histologic examination of the explanted porcine aortic root showed host mononuclear cells and macrophages between the well-stained and poorly stained areas, suggesting that the torn tissue had undergone host-mediated degeneration to some extent. Porcine aortic roots have excellent hemodynamic features, but ruptures in the aortic sinuses of the porcine aortic root have been reported in some cases. Careful follow up with CT or echocardiography is therefore needed after aortic root replacement with stentless bioprostheses.

Analysis of narratives by volunteers who are bereaved families of cancer patients: clarification of meanings of volunteer activities in palliative care unit

<b>Purpose</b>: The purpose of this article is to clarify the meanings of palliative care unit volunteers who are bereaved families of cancer patients (hereafter referred to as "the volunteers"). <b>Methods</b>: Authors analyzed narrative by the seven volunteers using SCAT (Steps for Coding and Theorization). <b>Results</b>: Meanings of their volunteering consists of following four themes which consists of nineteen categories, ‘affectation to the place of the patient's death’, ‘motivations’, ‘role to achieve’, ‘actual activities’, Motivations of the volunteers are overlapped with the results by classical motivation theories plus "satisfaction with palliative care", "optimal last moment including death attending harmonized with the family's thanatological view". Supporting to an aspect of palliative care that is place of life rather than that of medical treatment is core of volunteer activities. <b>Conclusion</b>: It is suggested to necessary for medical professionals to intervene with understanding of the volunteers ambivalent feelings so that they can work safely. Suitable moment to start volunteering for them is further problem to solve.

A Case of Coronary Artery Bypass Grafting for Anomalous Aortic Origin of a Coronary Artery / 日本心臓血管外科学会雑誌

Anomalous aortic origin of a coronary artery (AAOCA) can cause sudden death, especially in young athletes. AAOCA does not have any clinical cardiovascular manifestations and sudden death is often the first manifestation ; hence, it is difficult to diagnose AAOCA before a major episode occurs. We report the case of a 58-year old woman with a right coronary artery arising from the left sinus and passing between the aorta and the pulmonary artery. Although the results of the exercise treadmill test and various other tests were normal, this patient underwent coronary artery bypass, surgery using the right internal thoracic artery to preventing sudden death. Two years after the operation, she is asymptomatic and has normal results on the exercise treadmill test.

Aortic Valve Replacement in Octogenarians: Are Concomitant Coronary Artery Bypass Grafting Operations Predictive Factors? / 日本心臓血管外科学会雑誌

Because of increasing life expectancy and the high incidence of aortic stenosis (AS) in high-age groups, aortic valve replacement (AVR) for severe AS has become more frequent in recent years. The purpose of this study is to analyze operative outcome in octogenarians and evaluate the effect of concomitant coronary artery bypass grafting (CABG) for coronary artery disease. Between 2003 and 2010, 77 patients (18 men) aged over 80 years (80∼88 years ; mean age, 82.7 years) underwent AVR (bioprosthesis in 75 cases). Of these patients, 43.4% were categorized in New York Heart Association (NYHA) class III∼IV and 41% had a history of congestive heart failure. In addition, 26 patients (33.8%) underwent associated CABG operations (1-4 grafts ; mean, 1.8 grafts) with AVR. Operative mortality was 5.2% (4 patients). The operation time, cardiopulmonary bypass time, and aortic clamp time were significantly longer and amount of blood transfusion needed was greater in the concomitant CABG group than in the AVR-alone group. However, there were no differences between the groups with regard to intensive care unit (ICU) stay, postoperative hospital stay, operative mortality, and long-term survival. The outcome of AVR in octogenarians was good even in concomitant CABG patients. Aggressive surgical treatment of both aortic valve disease and concomitant coronary artery disease is warranted for most patients, despite advanced age.

Aortic Valve Replacement in Octogenarians : Are Concomitant Coronary Artery Bypass Grafting Operations Predictive Factors ? / 日本心臓血管外科学会雑誌

Because of increasing life expectancy and the high incidence of aortic stenosis (AS) in high-age groups, aortic valve replacement (AVR) for severe AS has become more frequent in recent years. The purpose of this study is to analyze operative outcome in octogenarians and evaluate the effect of concomitant coronary artery bypass grafting (CABG) for coronary artery disease. Between 2003 and 2010, 77 patients (18 men) aged over 80 years (80∼88 years ; mean age, 82.7 years) underwent AVR (bioprosthesis in 75 cases). Of these patients, 43.4% were categorized in New York Heart Association (NYHA) class III∼IV and 41% had a history of congestive heart failure. In addition, 26 patients (33.8%) underwent associated CABG operations (1-4 grafts ; mean, 1.8 grafts) with AVR. Operative mortality was 5.2% (4 patients). The operation time, cardiopulmonary bypass time, and aortic clamp time were significantly longer and amount of blood transfusion needed was greater in the concomitant CABG group than in the AVR-alone group. However, there were no differences between the groups with regard to intensive care unit (ICU) stay, postoperative hospital stay, operative mortality, and long-term survival. The outcome of AVR in octogenarians was good even in concomitant CABG patients. Aggressive surgical treatment of both aortic valve disease and concomitant coronary artery disease is warranted for most patients, despite advanced age.

Enforcement and analysis of the Objective Structured Teaching Evaluation / 医学教育

In Japan, awareness has increased in recent years of the importance of evaluating clinical educators. In Europe and North America, the Objective Structured Teaching Evaluation (OSTE), which employs standardized students, multiple stations, video recording, and scoring by multiple observers, is used to evaluate clinical educators. We report on the implementation of an OSTE in Japan.1) Ten clinician-educator physicians participated in the OSTE, which comprised 5 stations and included standardized residents. The stations were video-recorded, and the educators were assessed by 7 different evaluators.2) The educators were evaluated with a checklist and a 5-point scale. We assessed the reliability and validity of the checklist and analyzed the background characteristics of the clinician educators.3) The factors most closely associated with high ratings on the checklist and the 5-point scale were: having a history of attendance at a seminar for clinician-educators, having greater than 5 years experience as an educator, and not being an internist. There was no interobserver variability among the evaluators.4) The generalizability of the checklist was 0.81, and its reliability index was 0.83. The correlation coefficient between the total scale score and the checklist score was 0.8. 5) Although biases by participants were identified, our project suggests that the OSTE could be used in Japan to objectively evaluate the teaching skills of clinician-educators. Further research on the OSTE in Japan is warranted.

Masters Program in Medical Education / 医学教育

1) University of Toronto offers two kinds of Masters Degree programs for medical education. Masters degree is regarded as a fundamental qualification for "lifelong leadership".2) Masters degree is a degree which is expected for professionals of medical education in the US and Canada. But in Japan, such understanding has not been shared because of different teaching hospital system and medical school system.3) Significance of Masters programs for medical education is to make a medical doctors who is a professional another professional who is medical education professional. The research field is not within medicine but a complex of medicine and education. Therefore it is necessary to learn at Masters program specifically. Curriculum contents of medical education may consist of contents of medicine, contents of education, and proper contents of medical education.

A New Trend toward Interprofessional Education in Canada / 医学教育

1) The concept of interprofessionality, i. e., cohesive and cooperative practice between professionals, is necessary in North America because health professionals specializing in various fields work together on medical services.<BR>2) To introduce the concept of interprofessionality, interprofessional education, in which many kinds of health profes-sionals or students learn together, is extremely important. The Canadian government has been promoting and generously subsidizing interprofessional education as a way of improving public health and emphasizing patient-cen-tered medicine.<BR>3) In 2006, the University of Toronto established a new certificate course for future educational leaders who promote in-terprofessional education. We participated in this course and recommend that a course of this type be introduced toJapan.