Students in their 5th and 6th year of University of Tsukuba, School of Medicine, enter into a clinical clerkship. They record medical charts and flow sheets and they present at clinical rounds.
1) From 2000 to 2005, a questionnaire survey was conducted to evaluate the clinical clerkship in the rheumatology division. We also evaluated the influence of the introduction of infliximab therapy (October 2003) on the students' experience.
2) Evaluation of the clinical clerkship by the students was improved by attending the infliximab ward. Students felt more involved in the treatment of the patients by preparing drip infusion sets, disssolving infliximab, assisting with the drawing of blood and drip infusions, checking of the vital signs every 30 minutes, and recording charts.
3) Students realized the improvement of rheumatoid arthritis with therapy and the changes in the patients' emotional status after the introduction of infliximab.

Tuberculous spondylitis, or so-called Pott's disease, seems to be overlooked because of a lack of severe inflammation in the insidious generating process and tends to cause non-specific symptoms, such as back pain, fever, weakness, and weight loss. Diagnostic delay is common and the results can be disastrous. Discriminating between Pott's disease and other diseases, such as malignancy and pyogenic infection, is difficult. However, the inflammatory process in Pott's disease tends to spare the disk space, while that of pyogenic infection typically affects the area. Herein, we present a patient with Pott's disease who showed the characteristic clinical and radiological findings.

We conduct an outpatient escort program as a part of our early exposure curriculum for first-year medical students. Each student escorts one patient at the University of Tsukuba Hospital throughout his or her first visit. We evaluated this program from the points of view of both students and patients.
1) A questionnaire was distributed to all participating patients and students in 2006.
2) In their questionnaires, many students commented on the long waiting time, the structural problems of the hospital, and the attitudes of physicians.
3) Results of the questionnaire showed that both students and patients rated this program highly.
4) No significant differences were noted between the comments of the students and those of the patients. The patients tended to rate this program more highly than did the students. One patient, however, commented that being constantly accompanied by a stranger was somewhat stressful.
5) We conclude that this program can be efficiently carried out without being too much of a burden to patients and is a valuable part of an early exposure program for first-year medical students.

The patient was a 34-year-old woman who had been routinely monitored after receiving a childhood diagnosis of partial anomalous pulmonary venous connection, but unilaterally discontinued follow-up examinations after the age of 18. At 33 years of age, she was admitted to our hospital after a physical examination revealed an abnormal shadow on a chest X-ray. Transthoracic echocardiography detected an atrial septal defect (ASD), and contrast-enhanced computed tomography showed that the right lower pulmonary vein drained to the inferior vena cava. The patient was diagnosed with scimitar syndrome with ASD. Cardiac catheterization showed a pulmonary/systemic flow ratio (Qp/Qs) of 2.48 and a left-to-right shunt rate of 59.7%. Surgical treatment was deemed to be indicated. The right lower pulmonary vein was anastomosed to the anterolateral wall of the right atrium, and an intra-atrial baffle repair was performed from the orifice within the right atrium to the left atrium through the existing ASD using untreated fresh autologous pericardium. Two years after the operation, good blood flow was maintained within the baffle with no stenosis at the anastomotic site. This report describes a rare case of scimitar syndrome with ASD in an adult woman, and provides a review of the existing literature.

Objectives: Increasing activity levels in older people is important for maintaining quality of life and ameliorating the risks of morbidity related to falls, depression, and dementia. This study aimed to clarify the seasonal variation effects on total energy expenditure, number of steps, time spent in low- and moderate- or high-intensity physical activities, and daily activities performed.Patients and Methods: This was a cross-sectional study of 22 community-dwelling older individuals (3 men, 19 women; mean age, 75.1 ± 7.3 years) living in three districts of Gero, Gifu, who participated in the Gero Salon Project hosted by the Social Welfare Councils. Evaluations were conducted in each season from September 2016 to August 2017. We used a uniaxial accelerometer, the Lifecorder device, which measures physical activity, and the Physical Activity Scale for the Elderly to evaluate activities of daily living. Data were analyzed using the multiple comparisons (Bonferroni correction) method.Results: Total energy expenditure and time spent in moderate- or high-intensity activities did not show seasonal variations. However, the lowest number of steps was taken during the winter, and the number of steps increased significantly from winter to spring. The time spent in low-intensity physical activities was significantly longer in the spring and summer than in the winter. There was no significant seasonal difference in total Physical Activity Scale for the Elderly score, leisure activities, domestic activities, or work-related activities. However, there was a significant difference between the summer and winter scores in “outdoor gardening,” with the lowest score observed during the winter.Conclusions: With climate changes in the winter months, “outdoor gardening” becomes difficult, thus decreasing the number of steps taken. Therefore, it is necessary to identify other ways for older people to maintain physical activity during the winter season.

Blunt traumatic rupture of the heart carries a high mortality rate. Anatomical injuries have included the atrium, appendage and ventricle but injury to the left appendage has been reported very rarely. We present the case of a 71-year-old female who was a driver in a motor collision with major front-end damage where air bags were deployed. After being intubated and receiving pericardiocentesis for cardiac tamponade at an advanced critical care and emergency medical center, the patient was taken to our hospital and emergently to the operating room for exploration. There was brisk bleeding coming from a 2 cm laceration on the left atrial appendage. The injury was repaired using 4-0 polypropylene felt pledget-supported horizontal mattress sutures on the beating heart with the assistance of cardiopulmonary bypass. The present report describes this patient and our findings from a literature review.

We report a case of a 56-year-old woman. She had a history of emergent ascending aorta replacement due to type A dissection. Seven years later, aortic arch enlargement (55 mm) was detected on CT scan, and indicated secondary repair. Because of the existence of the aberrant right subclavian artery (ARSA), the safer surgical management needed to be discussed. Total arch replacement with the use of open stent-grafting technique and extra-anatomical reconstruction of ARSA was chosen for the treatment. In the operation, straight woven grafts (7 mm in diameter) were firstly anastomosed to the bilateral axillary arteries. Deep hypothermic circulatory arrest with antegrade cerebral perfusion through median sternotomy was established. The aortic arch was transected between the right and left subclavian arteries. The left subclavian artery was ligated at its origin, and an aortic open stent graft was inserted distally. An aortic reconstruction was performed between the left common carotid artery and the left subclavian artery with a 4 branched J-graft. The left carotid artery was reconstructed anatomically, and the tube grafts anastomosed to the bilateral axillary arteries were reconstructed in an extra-anatomical fashion. On the 11th postoperative days, coil-embolization of the ARSA was performed to complete the treatment. The patient had an uneventful post-operative recovery. Total arch replacement using an open stent-grafting technique was a feasible treatment option for the aortic arch aneurysm with ARSA.