1)In medical education in the United Kingdom, departments of general practice organize the basic training in clinical skills and specialty training in primary care.
2)A clinical clerkship in primary care is a compulsory 5–week subject, as are clerkships in internal medicine, surgery, pediatrics, obstetrics/gynecology, and psychiatry.
3)As a tutorial training system has been established, general practitioners are contributing to medical education as clinical instructors.

We report a case of idiopathic thrombocytopenic purpura (ITP) accompanied by steroid-induced avascular necrosis of the femoral head in a 68-year-old woman. Extremely low platelet counts of ITP patients prohibit any surgical interventions. Her platelet count was 25,000/μL. We performed a total hip arthroplasty with high-dose immunoglobulin therapy and transfusion of platelet concentrates. Her platelet count increased to 94,000/μL just before the operation. No hemostatic complications were encountered perioperatively, and the postoperative course was uneventful. She left the hospital 20 days after the operation with a T-cane. Her platelet count decreased to 34,000/μL on the day she left the hospital. Three years after the operation, she had no groin pain and could walk without ambulatory assistive devices. We did not observe implant loosening.

A case report of spontaneous dissection of the superior mesenteric artery (SMA) in a 53-year-old man who complained of sudden colic-midabdominal pain is presented. In this case, ultrasonography is very usefull for early diagnosis of dissection, and this is successfully treated by Ao-AMS bypass with excision of the proximal segment of SMA. Postoperatively the patient has no symptoms for 2 years.

Four myosin heavy chain (MHC) isoforms were detected in rat hind-limb fast muscles. MHC isoforms are particularly good candidates for fiber type-specific markers in myofibril proteins. We studied the effect of running or jumping training on MHC isoform composition in 18, 6 month-old female rats. The animals were divided into three groups : sedentary (S; n=6), running (R; n=5) and jumping (J; n=7) at 4 months of age. Animals in group R were trained with treadmill running (30 m/min, 60 min/day and 5 days/wk) for 8 weeks. Animals in group J were trained with vertical jumping (40 cm high, 100 repetitions/day, 5 days/wk) for 8 weeks.
There was no significant difference in body weight among the groups. Muscle weight and muscle weight/body weight for the plantaris were significantly increased in both trained groups, but there was no significant difference in the protein concentration. With regard to MHC isoform composition, there was no significant difference in the compositions of the type I and type ha MHC isoforms. In the type lid MHC isoform, the values for both trained groups were significantly higher than that of group S (p<0.05) . The values for both trained groups in the type lib MHC isoform were lower than that of group S. In particular, there was a significant difference between groups S and J (p<0.05) .
These results indicate that a relative increment of the type lid MHC isoform is a typical adaptation phenomenon of the olantaris muscle in rats riven runninr and iumoinr training.

Effects of environmental (cold) stress and aging on cells in monocyte/macrophage lineage were investigated. We demonstrated that immune suppressive states seen in acute cold-stressed mice (8-10 weeks of age) is attributable to FcγRIIbright suppressor macrophages. Serum corticosterone levels were markedly increased in acute cold-stressed mice. In addition, expression of glucocorticoids (GC) receptor mRNA was observed in FcγRIIbright cells from these mice. The increase of FcγRIIbright cells in peritoneal exudate cells caused by acute cold stress was inhibited by adrenalectomy or administration of a saturating amount of the GC antagonist RU 38486 (mifepristone). On the contrary, administration of the GC agonist, dexamethasone, markedly increased the proportion of FcγRIIbright cells in peritoneal exudate cells of control mice. These results suggest that the generation of FcγRIIbright suppressor cells of monocyte/macrophage lineage by acute cold stress was mediated by action of GC through the GC receptor. We likewise found that the proportion of FcγRIIbright suppressor macrophages is increased in aged mice (22-24 months of age). Meanwhile, activated macrophages which function as antigen presenting cells were decreased in aged rats. Both the basal corticosterone concentrations in serum and the expression of mRNA for GC receptor in peritoneal macrophages increased significantly in aged animals, suggesting that these populational and functional changes of macrophages in aged animals were mediated, in part, by the increased basal levels of GC. This is probably being responsible for immunosenescence.
Neisseria gonorrhoeae ; Laboratory mice ; Acute ; Macrophages ; receptor

　　We investigated whether elderly patients who were treated for proximal femoral fracture and who lived with an elderly spouse in the community were able to return home and walk. We identified 85 patients aged over 65 years with proximal femoral fracture treated between January 2007 and December 2013 who were living with only their spouse. We recorded the number (proportion) of patients who were directly discharged to home and the duration of hospitalization, and their walking ability before the injury and at the time of discharge. We also investigated whether dementia and age affected the ability to return home. Thirty-two patients (36%) returned home directly from an acute care hospital, and 35 patients (83%) returned home directly from a rehabilitation hospital. The mean duration of hospitalization was 31 days (range, 17-71 days) at an acute care hospital, and 61 days (range, 5-143 days) at a rehabilitation hospital. The walking ability of all patients was worse at the time of discharge. Dementia and increasing age were each associated with not being able to return home.

Liver metastases from colorectal carcinoma commonly form nodular lesions in the liverparenchyma. We report a case of liver metastasis from rectal adenocarcinoma that extendedpredominantly into the bile duct. A 62-year-old Japanese man underwent low anteriorresection for rectal adenocarcinoma 9 years ago. Approximately 3 years later, he underwentradiofrequency ablation therapy for a metastatic liver tumor. Nine years after surgery, atumor in liver segment III exhibiting intrabiliary extension was discovered; it wasunclear if this was a metastatic liver tumor or intrahepatic cholangiocarcinoma.Accordingly, we performed a left hepatectomy with lymph node dissection. The tumor wasnegative for cytokeratins 7 and 20, and was histologically similar to the primary rectaladenocarcinoma; it was diagnosed as rectal carcinoma metastasis. The patient has survivedfor 3 years after the hepatic surgery, for 9 years after radiofrequency ablation therapy,and for 12 years after the primary surgery. This case shows that liver metastasis fromcolorectal carcinoma can present as a predominantly intrabiliary growth that mimicsintrahepatic cholangiocarcinoma on imaging. Moreover, our case provides evidence for thesuperiority of anatomical hepatectomy over partial hepatectomy for metastatic liver tumorswith intrabiliary growth arising from rectal adenocarcinomas.

The Medical Education Development Center has organized seminars and workshops for medical education 30 times from 2000 through 2008 throughout Japan. The participants have numbered more than 3200 and have included educators, physicians, students, and simulated patients. The topics of seminars and workshops have included problem-based learning tutorial systems, medical interview skills, objective structured clinical examinations, evidence-based medicine, coaching technology, simulations, and community medicine in response to educational needs. A questionnaire survey of 1793 participants of the 11th to 30th seminars and workshops (response rate, 85.6%) showed a high degree of satisfaction (4.33±0.13 of 5 points). Invited lecturers and directors from throughout the country often organized these workshops. The results of workshops are reported in our annual monograph, "Trends in Medical Education."

A 64-year-old man who underwent aortic valve replacement with a 25mm Bjork-Shiley valve in 1993 began to have severe anemia and required repeated transfusions by November 2003. Doppler echocardiography showed only mild aortic regurgitation, but revealed turbulent flow around the mechanical valve. Autoimmune hemolytic anemia (AIHA) was diagnosed and he was treated with prednisolone (PSL) starting May 2004. Because of unremitting hemolysis requiring multiple transfusions and the occurrence of renal dysfunction, he underwent rereplacement of the aortic valve with a 25-mm Freestyle valve. His hemolysis and general condition immediately improved. This case suggests the possibility that mild regurgitant jet and turbulent jet stress can cause severe hemolysis when AIHA develops.

The running behavior and muscle characteristics associated with voluntary running activity were studied in female Fischer 344 rats after 9 weeks of training in voluntary exercise wheel cages. The exercise wheel employed allowed a load to be added to the wheel axis. The running activity was recorded as the number of rotations every 10 s for 24 h, and the number of running bouts, running duration, running speed and distance run per day were varied. Addition of a load to the wheel axis allowed the running style to be changed, and reduced the running duration and speed in each bout. The voluntary running training was done with no load, 30% per body weight load, and 60% per body weight load, and as treadmill running (40 m/min, 60 min/day) .
In the voluntary training, a difference in the total running distance was observed with increased load. The total distance run under 0%, 30% and 60% load in the voluntary group was about 552, 475, and 438 km, respectively, after training for 9 weeks. As a result of training, the weights of dorsiflexor muscles tended to increase with treadmill running, whereas weights of plantar-flexor muscles increased significantly in the voluntary training groups. In the plantaris muscle, the cross-sectional area of all fiber types was not changed by treadmill training, but in voluntary training, almost every type of fiber was enlarged. Voluntary running with a 30% load increased the cross-sectional area of type I and type ha fibers in the plantaris muscle compared with no load exercise. However, no significant differences in the cross-sectional area of these fibers were observed between 30% and 60% load exercise. The fatigue tolerance of the plantaris muscle improved significantly in all training groups, and the 60% load group showed the highest value.
These results suggest that voluntary loaded running is more effective for muscle enlargement than treadmill training and/or voluntary training with no load.