[in Japanese]

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[in Japanese]

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The aim of the present study was to clarify the current circumstances related to the use of coil embolization for cerebral aneurysms in neurosurgical facilities where there are no full-time neuroendovascular specialists. A total of 146 patients（44 men and 102 women；mean age of 63.4 years）with cerebral aneurysms treated surgically during a 10-year period from April 2002 to March 2012 at Kanmon Medical Center were identified, and their medical records were reviewed. One hundred and thirty-three clippings（105 ruptured aneurysms and 28 unruptured aneurysms）and 25 coilings（16 ruptured aneurysms and 9 unruptured aneurysms）were performed in 125 and 25 patients, respectively. The main reasons for performing coiling were that the aneurysm was located in the posterior cerebral circulation, and severe subarachnoid hemorrhage was present. Two coilings were performed at the subacute stage for non-medical reasons, and postoperative cerebellar infarction and intraoperative hemorrhage occurred in 3 and 3 patients, respectively. However, these events had no adverse influence on outcome. Even in neurosurgical facilities lacking full-time neuroendovascular specialists, coiling is performed appropriately mainly in patients with aneurysms that are unsuitable for clipping. However, 1 patient with a ruptured de novo aneurysm after coiling requiring emergency coiling was present. Therefore, the training of neuroendovascular specialists is a pressing problem at Kanmon Medical Center.

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The importance of career education is increasing in medical education. A career education curriculum of making career path was conducted in virtual cases, and the usefulness of the curriculum was examined. The curriculum was conducted in second grade students of the Yamaguchi University School of Medicine. The students were asked to make a career path for one case selected from among three virtual cases. The contents of their careers were analyzed in terms of occupation, specialty, workplace, marriage and children. In addition to major occupations including clinicians in hospitals, clinics and faculties and researchers in universities, various careers including public health practitioner, politician and businessman were selected. Although surgery and internal medicine were the dominant specialties, the proportion of the specialties was different among cases. In the case who came from Yamaguchi prefecture, most of students selected working at Yamaguchi prefecture, but most in the cases from other prefectures selected working outside of Yamaguchi prefecture. In the female virtual case, life events of marriage and children were described more frequently. Making a career path was a good opportunity for medical students to consider their own career and improve their knowledge and attitude to their medical career. Also, analyses of the career path elucidated consciousness of students about their career. This curriculum might be useful and applicable for career education at medical schools.

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Here we report on a 67-year-old woman with a splenorenal shunt. Her serum ammonia level was elevated during the treatment for hallucination, defect of memory and loss of motivation by vascular dementia. Enhanced computed tomography and angiography showed the presence of a splenorenal shunt. We considered that it was caused by hyperammonemia due to a splenorenal shunt. Firstly we chose in internal use of lactulos and branched chain amino acid to treat. However, it was not ineffective. On this account, we surgically ligated the splenorenal shunt during an open laparotomy. The preoperative high level of serum ammonia decreased to the normal range after the operation. Her loss of motivation was improved, but her hallucination and defect of memory were not improved. A Creutzfeldt-Jakob disease was suspected as her diagnosis by head MRI re-examination. Ligation a splenorenal shunt may be possible to give us good clinical course for hyperammonemia.

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A 74-year-old female patient with a history of severe diabetes was admitted for amputation of right foot for the diabetic gangrene. We selected ultrasound-guided sciatic and femoral nerve block as the anesthetic management and avoided general anesthesia due to the obesity（body mass index 35.6），which might have accompanied with the difficult airway management and the respiratory complications as atelectasis and hypoxia during the operation. Sciatic nerve block was selected for this case in terms of the anesthetized area which the surgical procedure might have directly invaded. Additionally, femoral nerve block was performed as a treatment against tourniquet pain and additive amputation which were not definitely planned before the operation. During the operation, we used propofol on purpose to slight sedation following the patient’s request with monitoring of capnogram and inspection. There was no significant change of the vital signs and no complaints of the patient during the operation. As the aging population of our country increases, cardiovascular disease and therapy of anticoagulation/platelet would be more common in the patients in operating rooms. The chances, therefore, to introduce solely the technique of nerve blockade would be more frequent in anesthetic management instead of general anesthesia.

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