The task of a physician is a type of a learned profession. A learned profession such as this should meet the following five requirements: 1) it is a profession charged with a sense of mission; 2) it should be furnished with a good general culture; 3) physicians must undergo a training for a long term and must have a public license; 4) physicians must continue to learn throughout their lives; and 5) medicine is not a trade but a type of public service.
The continuing medical education system, which was established by the Japan Medical Associaition and officially launched on April 1, 1987, for all members of the association, involves two major characteristics: the freedom and the independence of each physician are respected, and each participant submit reports voluntarily to the president of the medical association to which he or she belongs.
Continuing medical education is needed because of 1) the acceleration of medical development, 2) the exponential increase in medical information, 3) the progress in clinical examination, 4) the development and introduction of new methods of therapeutic procedures, and 5) the extension of the range of health care.
The role of medical universities and colleges in continuing medical education for doctors is very important. Specifically, they should be open for education for practitioners in various areas of medicine.
Hospital doctors as well should try to participate in the continuing medical education system established by the Japan Medical Association. However, after considering the ideals of continuing medical education for hospital doctors, which will be different from those for practitioners, a concrete system should be established for them.
The slogan, “Not four years, but forty years”, is an effective phrase which will encourage us while we continue our lifetime education.

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Because of the increased elderly population and a progress of surgery, operative indications have been extended beyond the barrier of chronological age in the field of cardiac surgery using cardiopulmonary bypass. Those patients who aged over 65 years had been reported as the elderly until late in 1970s. In 1980s the number of reports on cardiac surgery in patients aged over 70 or 80 years have been increasing in medical journals. This is a review to delineate current trend of cardiac surgery in the elderly.
Reports of coronary artery bypass operations in septuagenarians and octogenarians have been increasing in the past decade. The incidence of the operated elderly patients among the total population are in the range from 3.2% to 12.6%, and it has been increasing yearly. A report showed an increasing rate of approximately doubling every five years. The rate of operative mortality in the elderly ranged from 0 to 12.7% and was less than 6.9% in three fourth of the reports. In the majority of the reports the mortality rate was about three times in the elderly over the younger. Causes of operative death were commonly attributed not to chronological aging but the severity of the cardiac lesions and or concomitant disorders of the other organs. Considering about low mortality and morbidity by the long-term follow-up after the operations, most of the authors recommended the bypass operations for the elderly.
In the valve replacement surgery less favourable results were stated because of higher mortality rate especially in the early postoperative period, which was influenced significantly by numbers and severity of valve lesions with concomitant ischemic heart disease. Most authors, however, stated a beneficial effect of valve surgery especially for single aortic valve replacement. Because of acceptable mortality and favorable physical status late after the operation, valve surgery in the elderly was recommended by most authors as a treatment modality.
Preoperative assessment of the elderly patients independent from chronological age is most important and essential to determine proper criteria for operative indications. The criteria should be objective and hence reliable to assess the severity of the heart lesions and the concomitant disorders of the other organs. It was confirmed that invasive cardiopulmonary examinations provided efficient informations for the criteia.

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Bicer Val valve is a new type of tilting disc valve, and the outstanding feature is that a maximum opening angle is very large (82°).
Evaluation of Bicer Val valve in mitral valve replacement (MVR) was done in comparison with that of Björk-Shiley valve in MVR.
As for the gradient across the valve, and effective mitral valve area, Bicer Val valve obtained a good result as well as Björk-Shiley valve in hemodynamics.
But, Bicer Val valve had a poor response to tachycardia, especially over a rate of 130/min of ventricular pacing. On the contrary, Björk-Shiley valve remained stable in tachycardia.
There were almost no problems about hemolysis, although LDH level was slightly high, in cases of both valves.
The blood flow pattern by pulse doppler method of valve position demonstrated almost normal flow pattern, same as Björk-Shiley valve.
Postoperative cardiac function recovered sufficiently.
Thus, evaluation of Bicer Val valve within 1 month after the operation demonstrated a good result in hemodynamics without hemolysis, but there remained unknown factors including the durability of the valve itself, possibility of thromboembolism and so on.

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Sixty-eight patients underwent either closed or open commissurotomy for mitral stenosis from Feb. 1963 to Nov. 1986. Sixty patients were followed up for 10 months to 22 years (average 10.4 years) after surgery. In the late period reoperation was performed in 10 patients. The reoperation rate was 1.9% per patient-year. Cumulative survival rate was 79% at 10 years, 76% at 15 years, 66% at 20 years and 46% at 22 years after surgery. Cumulative event-free rate was 65% at 10 years, 56% at 15 years, 35% at 20 years and 23% at 22 years after surgery.

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From 1967 to May 1987, 484 cases of heart surgery including 32 neonates were performed in Kagawa Shoni Byoin National Sanatorium. From 1977, surgery for neonate and infant heart disease was started. Recently, mortality of heart surgery in neonates has declined. This paper presented 32 cases of neonatal heart surgery and analyzed the mortality rate by dividing this decade into 3 stages. In the first period from 1977 to 1980, 11 cases of neonatal heart surgery were performed, but all patients expired due to severe heart failure. In the second period from 1981 to 1984, 10 cases of neonatal heart surgery were performed with 4 survival cases. In the third period from 1985 to 1987, 11 cases of neonatal heart surgery were performed with 7 survival cases.
The thirty-three cases, including 10 cases of PA, TA, PS, 8 cases of TAPVR, 10 cases of IAA, CoA comp and 4 cases of TGA, were referred to this hospital at an average age of 11 day old. There was no relationship between the stage mortality and age on admission.
Before surgery, respiratory care including intratracheal intubation was performed in 9/11 in the first period, in 6/9 in the second period, in 9/11 in the third period, without any relation between mortality and respiratory distress. The most important reason for high mortality in the first period was vagueness about pathophysiological studies concerning treatment and inadequate surgery at that time. In the second period, cine angiography and echo cardiogrm were introduced for diagnosis and more accurate diagnosis of the diseases was established.
Method of rescue for severe cardiac disease was to maintain the ductus blood flow by prostagrandin E1 and shunt surgery in PA, TA, PS, and early total corrective surgery for TAPVR in good condition using prostagrandin E1 was performed to maintain PDA for a release of pulmonary congestion. Also, early correction of the aortic arch for IAA, CoA comp in good condition using prostagrandin E1 was done to maintain perfusion of the ductus into the lower half of body before deteriolation of metabolism.
In TGA, it was important to postpone operation by using BAS or conservative surgery for widening of interatrial communication, because of no improvement in the survival rate in the third period.

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The patient was a 46-year-old man with sick sinus syndrome. He had been implanted with an AAI pacemaker 3 years prior to the first attack of chest pain. His chest pain developed at midnight and disappeared following sublingual administration of nitroglycerin. An electrocardiogram during the attack showed ST segment elevation in the inferior leads (II, III, _aV_F) which returned to baseline after nitroglycerin administration.
Coronary angiogram demonstrated no organic stenosis. Ergonovine provocation test induced an occlusion of a right coronary artery (segment 1). This was accompanied by chest pain and return of ST segment elevation similar to that seen in his spontaneous attack.
The QRS pattern remains unchanged in the electrocardiogram of patients with AAI pacing. This is one of the advantages of AAI pacing, However there have been few case reports of variant angina in AAI pacing. In the present case diagnosis of variant angina was easily made since AAI pacing did not affect the ST segment of the electrocardiogram. From this viewpoint AAI pacing is recommended for patients with sick sinus syndrome.

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Several exposure media were compared in order to simultaneously survey air-borne molds on gravity plates at different institutions located at various geographical portions of Japan. The investigation was carried out during 1, 2 or 3 years of the period of 1978 through 1980 in 6 stations of the country. Media compared were potato dextrose agar with chloramphenicol (PDA). PDA adding glucose or NaCl, modified Mehrlich's medium, malt extract agar with chloramphenicol (MEA), Waksman agar with chloramphenicol (WA) and Czapek-Dox agar. PDA was used together with 1 or 2 additional types of the media which were frequently used in each institution. PDA, MEA and WA were favorable in the spectrum of fungal growth, but they were somewhat different in detecting low-incidence organisms from each other. PDA seemed least restrictive in its selected mycoflora and its supported growth.

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Airborne fungi on gravity plates were surveyed simultaneously at 8 institutions during the period of 1978 through 1980. They were located throughout Japan from Sapporo of the northern district to Nagasaki of the southern district. Afterwards, those were investigated only at Sagamihara, in Tokyo metropolitan area, during the period from 1983 to 1986. There were several common dominants including Cladosporium, Alternaria, Penicillium and Epicoccum throughout the country. Other dominants, which were more or less consistently found with some fluctuations from year to year and with a geographical dependence, included the following strains: Aureobasidium, Arthinium, Aspergillus, Botrytis, Cephalosporium, Fusarium, Nigrospora, Periconia, Pithomyces, Poecilomyces, Phoma and Trichoderma.

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A computer program written in a simplified data processing language, dbase II, for education of diabetics, was rewritten into MUMPS. By using MUMPS, help and error messages were easily inserted. This soft ware was clinically applied.

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In order to develop a new method of treatment in patients with chronic renal failure. A new hemopurification method was designed and studied using absorbents in the surgically prepared colon of mongrel dogs in which renal failure was experimentally induced.
From the results, the possibility of clinical application was evaluated.
The absorbents used are activated charcoal [alumina (5:2)] 100g; sodium polystyrene sulfonate 20g; and 60% sorbitol 350ml.
Several parameters of Ht, TP, BUN, creatinine, uric acid, Na, K, Cl, Ca, and P were measured before and 3 hours after insertion of absorbents and compared the above results. Whether the effects of 1) removal of body fluid, 2) removal of uremic toxin and 3) maintenance of stability of electrolyte were recognized or not, was evaluated.
The effectiveness of the hemopurification method was recognized from the following observations: 1) there was a significant increase in Ht (p<0.01) and TP (p<0.1), 2) there was a significant decrease in creatinine (p<0.01) and uric acid (p<0.05) but not BUN, 3) there was a significant decrease in K (p<0.01) and P (p<0.05), but a significant increase in Ca (p<0.05). Removal of BUN and a solution of additional unsolved problems were considered to be possible by other modalities of treatment.
In conclusion, the new hemopurification method which the author designed, proved experimentally excellent, and it is concluded that it would be possible to use this method clinically.

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Two patients with metastatic bone cancer admitted to our orthopedic ward were presented. Examinations revealed renal cell cancer as the primary lesion, and radical nephrectomy was performed. Re-evaluating the clinical data retrospectively, it was found that both cases had microscopic hematuria on their admission. Moreover, the primary lesions had been visualized as the defect of RI uptake on the bone scintigrams.

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Two cases of localized cutaneous sporotrichosis are reported. Recently, in Tokyo, the decline of the incidence of this deep fungus infection has been pointed out by the dermatologists. The first case in this report was a very rare one because the ulcerating lesion was localized on the lower back of the 66-year-old man, which was an unusual site for cutaneous sporotrichosis, and because he had suffered from the disease for as long as 6 years. Although histopathological examination failed to reveal the fungus elements, mycological studies including culture and sporotrichin skin test confirmed the diagnosis. The clinical feature of the second case, which was a localized lesion composed of small flat firm papules on the radial side of the left forearm of the 36-year-old housewife, suggested that she was suffering from a kind of granulomatous lesions such as atypical mycobacteiral infection. Histopathologically the spores of sporothrix schenckii were observed in the cytoplasm of the abundant giant cells in the epithelioid cell granulomas with PAS stain. Mycological studies also confirmed the diagnosis. The authors consider that autoinoculation might be the cause of the unusual clinical feature. As for the therapy, potassium iodide was dramatically effective in both cases.

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Two cases of chronic respiratory failure are presented. One was the case of respiratory acidosis noted upon acute exacerbation of chronic pulmonary emphysema, and the other was the case of chronic bronchitis showing CO₂ narcosis. In the former case, after improvement of the acidosis by drip infusion of sodium bicarbonate, plasma HCO₃^- elevated by sodium bicarbonate was reduced with oral administration of acetazolamide and the patient's condition became stable. In the latter case, administration of acetazolamide reduced plasma HCO₃^- concentration and simultaneously improved the general condition, hypoxia and hypercapnia. Inhalation of O₂ at a low concentration was applied to both cases.
In cases of hypercapnia noted in chronic obstructive lung diseases, administration of acetazolamide is useful to reduce the plasma HCO₃^- level to expect improvement of respiration.

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A 26-year-old female with headache and skin eruption was admitted to our hospital. She had plenty of erythema over the whole body involving palms and soles, lymphade-nopathies of the neck, and mild hepatomegaly. Because of the sero-positive reaction of syphilis eruption was easily diagnosed as “roseola”. Results of liver function tests revealed so-called “bile-stasis” type dysfunction. Her symptoms and liver dysfunction were completely improved by the antibiotics. Recently there have been few reports of syphilitic hepatitis in Japan.

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