From November 1998 to January 1999, multi-vessel coronary artery bypass grafting (CABG) was performed in four patients under a beating heart without cardiopulmonary bypass (CPB). The patients included one male and three females aged from 58 to 83 years. Their preoperative major risk factors were poor renal function in one patient, left heart failure requiring intraaortic balloon pumping support, and continuous hemodialysis in one, and advanced age (age>80yr) in 2. Double bypass graftings were attempted with left internal thoracic artery and saphenous vein grafts via a median sternotomy. Distal anastomoses were performed with interruption of the coronary flow using snare sutures, a mechanical stabilizer and a carbon dioxide blower. The postoperative courses of the patients were uneventful except for one patient who died of left heart failure 38 days after surgery. Off pump CABG is useful for patients who have risk factors associated with the use of CPB, such as renal failure, cerebrovascular disease, poor left ventricular function, and advanced age.

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We have reported the availability of a new portable hypothermic perfusion apparatus which was originally designed by us. After excision, perfusion of the donor heart was performed with this apparatus. We made a round trip by car with a heart perfused by this apparatus from Maebashi to Tokyo, and then the donor heart was orthotopically transplanted. The total ischemic period of the donor heart was seven hours and 35 minutes. There were no problems during the period of preservation and transportation using this apparatus. Hemodynamics following orthotopic transplantation were stable and satisfactory for circulatory maintenance of the recipient animal, thus strongly indicating clinical application of this new apparatus.

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The purpose of this paper is to study the content and effectiveness of home instruction given to bed-bound elderly patients, improvement of their health status and to identify the role of home instruction given by municipal public health nurses. 60 cases of home visits made by public health nurses in K-town, Gunma Prefecture during 1995 and 1997 were investigated through interview of the nurses. Ten families of the patients who passed away were also inteviewed to find opinions and responses of families to the instruction given.
Such effects as expansion of living space, expectation of death and support during the terminal stage and support of families through adjustment and reconciliation of interpersonal relationships within the family were confirmed. It is also found necessary to provide local professional support to help elderly people live in their own home and familiar enviroment till their death. The significance of home nursing for families and neighbors and the role of home instruction provided by municipal public health nurses to support home nursing and care were identified.

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Advances in antibiotics and the development of preventive medicine have led to a significant decrease in the number of tuberculosis patients.
In the field of head and neck surgery, therefore, tuberculosis is rarely encountered. We report a case of tuberculous sialoadenitis of the submandibular gland. A 48-year-old female presented with a left submandibular swelling. On palpation, the swelling was hard but slightly mobile. A diagnosis was made as an abscess of the left submandibular gland and was treated at first with broad spectrum antibiotics. Because of no improvement of the swelling, however, a malignant tumor was suspected. Since computed tomography revealed a submandibular gland tumor, we resected the lesion. Pathological examination resulted in a diagnosis of tuberculous sialoadenitis of the submandibular gland. Treatment by antituber-oculotics was started, after which the patient's corse was uneventful.

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A rare case of occult lung carcinoma in situ of left B³ was reported. A 71-year-old man was referred to our hospital because of positive sputum cytology. Despite detailed bronchoscopic examination, the localization of malignant cells could not be identified. At the annual follow-up during three years, squamous cell carcinoma of the lung was detected by sputum cytology and transbronchial brushing cytology of the left B³. A careful and consecutive follow-up is indispensable in the management of patients with positive sputum cytology and no evidence of cancer.

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A 28-year-old woman with right adrenal tumor had paroxysmal hypertension since 8 months ago. General laboratory data including urinalysis, hematology, liver function, renal function and electrolytes were normal. Urinary excretion of adrenaline, metanephrine and vanillylmandelic acid levels were elevated. In contrast, plasma adrenocorticotropic hormone, cortisol, aldosterone, parathyroid hormone, calcitonin and gastrin levels and urinary noradrenaline and normetanephrine levels were within the normal range. Normal growth hormone (GH) response to oral glucose ingestion test and thyrotropin releasing hormone-luteinizing hormone releasing hormone test was shown, however, augmentation of growth hormone (GH) response to GH releasing hormone (GHRH) was recognized. After removal of the tumor, which was compatible to pheochromocytoma histologically, her blood pressure, urinary excretion of catecholamine levels and augmentation of GH response to GHRH were normalized. It is concluded that augmentation of GH response to GHRH was due to pheochromocytoma.

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A left ventricular assist device (LVAD) was effective in two patients with intractable heart failure following open-heart surgery. A 47-year-old female was diagnosed as having effort angina with 75% stenosis of the left main trunk, and a 58-year-old female was diagnosed as having persistent unstable angina with twice percutaneous transluminal coronary angioplasties and a stent insertion. In both cases, intra-aortic balloon pumping and pharmacologic support were ineffective at the time of weaning from cardio-pulmonary bypass. Cardiac function improved gradually after the use of LVAD, and both patients were weaned from the device at 6 and 8 days, respectively after the introduction of LVAD without significant complications. Circulatory support using an LVAD is a powerful aid in the treatment of patients with refractory heart failure following open-heart surgery.

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The wandering behavior of 4 senile dementia patients was observed to study response strategies. Agenda behavior, searching behavior, non-oriented behavior identified by Koizumi et al were again observed with the similar background conditions as discussed before. It was indicated that the following response strategies would be effective according to the type of wandering behavior.
(1) Agenda behavior pattern : wandering is a necessary activity for the patients and therefore they are allowed to wander with the staff monitoring their safety.
(2) Searching behavior pattern : the purpose of wandering is to search and inquire. The staff will first explain that the patients do not have to go to work, or see their family at this time. If anxiety and delusion increase, the situation must be designed where the senile dementia patient can fulfill the role they are searching for. If the patients express a strong desire to return home, their families must be informed of it.
(3) Non-objective oriented behavior pattern : dementia is suspected to be well advanced. It is difficult to control the patients' behavior through group activities or words. It is essential to provide a safe and quiet environment for patients exhibiting this pattern type.

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We report a patient experiencing acute pain in the hip resulting in a limp. Computed tomography and magnetic resonance imaging of the pelvis clearly demonstrated calcification within the iliac tendinous origin of the rectus femoris, although this was obscure in plain radiographs. Laboratory findings revealed a systemic inflammatory reaction. She obtained dramatic relief from pain, which parallel improvement in laboratory data, one day after oral non-steroidal anti-inflammatory drug treatment. Inflammatory responses to hydroxyapatite crystals may play an important role in the pathogenesis of the symptoms induced by calcific tendinitis in the rectus femoris, most of which are self-limiting.

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