In this case report we describe an 80-yearold man with sick sinus syndrome (SSS) who developed syncope attacks. The diagnosis of SSS was based on electrocardiographic evidence of markedly prolonged sinus arrests associated with syncope attacks while in hospital. The patient was given cilostazol, an antithrombotic agent that selectively inhibits cyclic nucleotide phosphodiesterase type 3, at a dose of 100 mg twice daily. The syncope attacks ceased, and an electrocardiogram obtained 1 week after the start of cilostazol administration showed no evidence of sinus arrest. The outcome of this case suggests that cilostazol may be useful in patients with syncope attacks due to SSS, although the long-term chronotropic effects of cilostazol need to be evaluated.

An 80-year old woman presented with macroscopic hematuria on June 4(th), 2008. She had been suffering from general malaise and appetite loss since about 10 days previously. She had received anticoagulant therapy with warfarin due to chronic atrial fibrillation and PT-INR was well controlled between 1.6-2.2. When she presented, PT-INR was 12.88, and urinary tract infection (UTI) and hypoalbuminemia (2.2 g/dl) were observed. Therefore, warfarin therapy was discontinued, and antibiotics and vitamin K were administered. Normalization of PT-INR resulted in the disappearance of hematuria and UTI improved as a result of antibiotics administration. As the appetite loss improved, for serum albumin level increased. The previous dose of warfarin achieved PT-INR around 1.8. Her drug compliance had been good, and she took no drug nor food which could interact with warfarin. We also found no liver dysfunction, acute renal failure, malignancy, nor hyper- or hypo-thyroidism. Hypoalbuminemia caused by appetite loss due to UTI seems very likely to increase concentration of circulating free warfarin resulting in extreme prolongation of PT-INR. Our findings in the present case may suggest that we should pay more attention on changes of drug pharmacokinetics in elderly patients because of their poor adaptation to their circumstances such as infection or dehydration.

Key words：obturator hernia, male, hemodialysis 〈Abstract〉 This medical case involves a 75-year-old male who had been on hemodialysis since April, 2007 due to chronic renal failure stemming from chronic nephritis. He began experiencing abdominal distension early in July, 2012 and came to the hospital the next day for hemodialysis. Prominent distention of the intestinal tract was detected by plain X-ray of the abdomen and a diagnosis of left obturator hernia was made by plain CT of the abdomen. Hernioplasty was carried out the same day through emergency surgery, and the patient made good post-operative progress. An obturator hernia is a rare disorder that makes up only 0.073％ of all hernias and 0.4％ of all ileus. In addition, the disorder appears most commonly in older, thin women, with men affected in only 5％ of cases. In some instances, the clinical manifestation is mild, and although it is difficult to suspect obturator hernia, early diagnosis and early treatment are important since the disorder has a high fatality rate.

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