To establish a framework for clinical education as a continuum from undergraduate clinical clerkships to postgraduate residency programs is an enormous challenge for Japanese medical education. The purpose of this article is to compare learning objectives achieved by clinical clerkship students to those achieved by postgraduate residents.1) Eighty-seven clerkship students and 67 residents at our hospital were assessed with the Web-based Evaluation System of Postgraduate Clinical Training with 253 learning objectives established by the Ministry of Health, Labour and Welfare.2) Clerkship students achieved most attitudinal objectives and performed well on the medical interview, basic physical examinations, and physician's order sheet.3) Clerkship students could observe major symptoms and diseases.4) These findings indicate the need to establish a common template for learning objectives used in both clerkships and residency programs.

Objective: To quickly collect and provide information on package insert revisions, packaging changes, discontinuation of drug manufacturing and distribution, and other information without fail.
Methods: Information was collected with the use of a drug information service site (SAFE DI) managed by an organization formed by 15 pharmaceutical wholesalers (SAFE Co., Ltd.).  The information obtained was processed into a house journal and provided to the department of pharmacy and other hospital personnel via an employees-only website (hospital LAN).
Results: Before the introduction of the SAFE DI, incomplete or delayed information collection sometimes forced personnel to urgently cope with packaging changes or discontinuation of drug manufacturing and distribution and assume a heavy workload.  Introduction of the system allowed quick collection and dissemination of such information without fail.
Conclusion: The recently introduced SAFE DI contributes to qualitative improvement in collection and dissemination of information.  Introduction of such a system may also be useful in other hospitals.

Since 1998 the Synthetic Personality Inventory (SPI), a well-established aptitude test, has been used to select residents at St. Luke's International Hospital. The aims of our study were to analyze the association of the SPI with several characteristics of residents, e. g., intellectual capability, results of examinations in medicine, and evaluation during 2 years of residency, and to clarify the significance of the SPI for selecting residents. General mental ability measured with the SPI was strongly correlated with the intellectual capability of residents but was not correlated with results of examinations in medicine. High scores for general mental ability, for activity, and for tendency of extroversion were correlated with high evaluations of residents for 2 years, whereas a cooperative personality, reasoning ability, and practicality were related to an improvement in grades from the first to second years. These results demonstrate that the results of the SPI are correlated with several characteristics of residents.

Primary biliary cholangitis (PBC) causes chronic and persistent cholestasis in the liver, eventually resulting in cirrhosis and hepatic failure without appropriate treatment. PBC mainly develops in middle-aged women, but it is also common in young women and men. PBC is considered a model of autoimmune disease because of the presence of diseasespecific autoantibodies, that is, antimitochondrial antibodies (AMAs), intense infiltration of mononuclear cells into the bile ducts, and a high prevalence of autoimmune diseases such as comorbidities. Histologically, PBC is characterized by degeneration and necrosis of intrahepatic biliary epithelial cells surrounded by a dense infiltration of mononuclear cells, coined as chronic non-suppurative destructive cholangitis, which leads to destructive changes and the disappearance of small- or medium-sized bile ducts. Since 1990, early diagnosis with the detection of AMAs and introduction of ursodeoxycholic acid as first-line treatment has greatly altered the clinical course of PBC, and liver transplantation-free survival of patients with PBC is now comparable to that of the general population.

Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease, characterized by the elevation of aminotransferases, presence of anti-nuclear antibody or anti-smooth muscle antibody, elevated immunoglobulin G (IgG), and interface hepatitis/plasma-lymphocytic inflammation based on histology. Recent epidemiological studies have indicated an increasing trend in the prevalence of AIH worldwide, especially in male patients; this trend may suggest the alteration of environmental triggers of disease onset over time. As no disease-specific biomarker or histological finding is currently available, AIH requires a clinical diagnosis, and a validated diagnostic scoring system with acceptable specificity and sensitivity has been proposed. Regarding treatment, corticosteroids and azathioprine are recommended, and in those who exhibit an incomplete response or those who are intolerant to these drugs, second-line therapy, such as mycophenolate mofetil, is considered. Overall, the long-term outcome is excellent in patients with complete biochemical responses, while life-long maintenance treatment may be required since the cessation of immunosuppressive agents frequently leads to the relapse of the disease. Acute-onset AIH does occur, and the diagnosis is very challenging due to the lack of serum autoantibodies or elevated IgG. The unmet needs include earlier diagnosis, intervention with disseminated clinical practice guidelines, and recognition and improvement of patients’ health-related quality of life with the development of novel corticosteroid-free treatment regimens.

Sclerosing cholangitis (SC) is defined as a condition with progressive stenosis and destruction of the bile ducts due to diffuse inflammation and fibrosis and currently includes three categories: primary sclerosing cholangitis (PSC), secondary cholangitis, and IgG4-related sclerosing cholangitis (IgG4-SC). SC categories share similar clinical features, such as cholestasis. Patients with SC present with cholestatic symptoms, including jaundice and pruritus, and blood tests reveal elevation of cholestatic enzymes. Cholangiography, endoscopic or magnetic, is inevitably required for making a diagnosis. Although the presentation of IgG4-SC and PSC are similar, the comorbidities, treatment response, and outcomes differ significantly, and therefore, it is strongly advisable to be familiar with these two diseases to make a correct diagnosis. Differentiation of cholangiocarcinoma from IgG4-SC and PSC is also extremely important. In this review, the clinical characteristics, comorbidities, treatment and outcomes of IgG4-SC and PSC will be outlined based on experience mainly from Japan.
Bile Ducts ; Cholangiocarcinoma ; Cholangiography ; Cholangitis ; Cholangitis, Sclerosing ; Cholestasis ; Comorbidity ; Constriction, Pathologic ; Diagnosis ; Fibrosis ; Hematologic Tests ; Humans ; Immunoglobulin G ; Inflammation ; Japan ; Jaundice ; Pruritus

  We describe a prototype seminar, inspired by the problem-based learning tutorial system, on pediatric emergency practice for young physicians working in 7 pediatric emergency centers in Yokohama. The seminar was received favorably by the participants, especially as an opportunity for individual learning. We expect that the seminar will contribute to the standardization of emergency practice in these pediatric centers and the establishment of an interhospital network.

Objective: We describe a case of lung cancer complicated with esophageal achalasia (EA), which was successfully treated with endoscopic pneumatic dilation (EPD). Case: A 66-year-old woman was admitted to our hospital because of frequent episodes of emesis and dysphagia after receiving an escalating dose of sustained release oxycodone (SRO) for cancer-related multifactorial back pain. She had been diagnosed with EA and treated with EPD at the age of 50. Her symptoms were refractory to the conventional anti-emetic agents such as prochlorperazine and metoclopramide. Computed tomography imaging showed marked dilatation of the esophagus with food residue. We diagnosed EA based on the presence of rosette-like esophageal folds on endoscopy and narrowing of the esophagogastric junction on esophagography, and subsequently performed EPD, which alleviated the symptoms. Discussion: The effects of opioids on esophageal motility have not been elucidated thus far. Recent studies using high-resolution manometry reported that long-term use of opioids was associated with esophageal dysmotility similar to that observed in EA. Although we have no evidence to directly demonstrate the causal relationship between the use of SRO and anti-emetic agents and EA, we speculate that our patient’s symptoms might be associated not only with SRO-related emesis during the gradual worsening of EA, but also partly with the SRO-induced esophageal dysmotility and the constrictive effect of dopamine D₂ receptor antagonists on the lower esophageal sphincter. Care must be taken to avoid drug-induced esophageal motor dysfunction, which might lead to deteriorate EA.

We performed surgery for atrial fibrillation and mitral valve disease on 3 patients along with atrial mapping. Macroreentrant circuits were found in 2 patients and the other patient showed a preexcitation ectopic focus in the left atrium. Right atrial excitation was chaotic in all three patients. Of the two patients with reentry circuits, one patient underwent biatrial incisions and the other patient had only a left atrial incision. In the patient with a preexcitation ectopic focus, we performed cryoablation of that focus and made a left atrial incision in order to prevent the reoccurrence of atrial fibrillation after surgery. Following surgery, one patient experienced transient atrial fibrillation, however, continuous atrial fibrillation was resolved by this procedure and all patients returned to a normal sinus rhythm.