Gifu University School of Medicine has introduced a new learning method for medical science, named tutorial system. To assess the efficacy of the method, we conducted a questionnaire survey of students' medical knowledge, attitudes to learning, communication ability, and social behavior. The questionnaire was given to instructors/attending physicians involved in clinical education. Results of the evaluation were compared to those of previous medical students. Our results suggest that the tutorial system in our medical school result in an improvement over the previous curricula.

In cases of stent-grafting for ruptured aneurysm, endoleak is a serious problem. We report 2 cases of ruptured aneurysms that were treated with endovascular stent-graft placement. Case 1: A 79-year-old woman had a ruptured thoracic aortic aneurysm that was treated with endovascular stent-grafting from the distal arch to the descending aorta. Although her infra-operative course was uneventful, she died suddenly the day after operation. Autopsy revealed re-rupture of the aneurysm due to endoleak from the proximal site. Case 2: An 84-year-old woman was treated with endovascular stent-grafting for ruptured abdominal aortic aneurysm. The stent-graft was inserted from the infra-renal abdominal aorta to the right common iliac artery with femoro-femoral crossover bypass placement. There was evidence of type II endoleak that occurred via the left internal iliac artery (IIA) and inferior mesenteric artery (IMA) 16 days after surgery. A CT scan performed 6 months after surgery revealed an increase in aneurysm size and persistent type II endoleak. Both embolization of the aneurysmal sac through the IMA and surgical ligation of the IMA failed, and endoleak from the IMA persisted. Re-rupture of the aneurysm occurred 10 months after initial surgery and emergency open surgery was performed. In stent-grafting for ruptured aneurysms, only the thrombus outside the graft resists the pressure caused by the endoleak. We conclude that endoleak after stent-grafting for ruptured aneurysm should be treated completely as soon as possible because of the risk of re-rupture.

To assess the effectiveness of a problem-based learning tutorial system introduced at Gifu University School of Medicine in 1995, we conducted a questionnaire survey of medical knowledge, attitudes about learning, communication ability, and social behavior in sixth-year medical students. The questionnaire was given to instructors and attending physicians at community hospitals who were involved in clinical education. Many of the evaluators felt that students who trained with the tutorial system showed improved understanding, a more active attitude toward learning, and a better attitude toward patients than did students who received traditional, lecture-based education.

In order to find an effective way to detect bacteria responsible for respiratory tract infections in children, we first examined as pharyngeal swabs, epi-pharyngeal swabs and nasal aspirates obtained from children hospitalized at our pediatric service during these five months from December 1997 to April 1998. In the rate of bacterial infection, it was found that nasal aspirates came out on top with 92.6%(25/27), followed by epipharyngeal swabs with 71.6%(53/74) and pharyngeal swabs with 26.2%(38/145). Single-species bacteria were found in 78.9%(30/38) of pharyngeal swabs, where as 45.3% of epi-pharyngeal swabs (24/53) and 52.0% of nasal aspirates (13/25) proved mixed infections with two-or three-defferent species. Thus it was suggested that nasal aspirates and epi-pharyngeal swabs would be far more adequate than pharyngeal swabs to detect bacteria with accuracy.
Next, based on the efficiency of bacterial detection, we compared culture media for the specimen obtained from in-patients and out-patients at our pediatric service. The rate of isolation of gram-negative rods was as low as 0.3%(1 of 314 strains) even when BTB agar plate, a selective medium for these bacteria, was employed. The sensitivety was not much different from those observed with nonselective blood agar plate. These results suggest that the conventional blood agar media can substitute for the more expensive type of BTB agar medium for the diagnosis of infections diseases of the airwaysin children.

Re-do open cardiac surgery may sometimes require complete ablation around the pericardium for the 2 major reasons of attaining better myocardial protection and obtaining effective DC cardioversion. However, this ablation may increase postoperative hemorrhage which may require blood transfusion. Hypothermia is based on the concept of myocardial protection during open heart surgery by suppressing myocardial metabolism, but recently the approach has been changed to maintaining myocardial metabolism with aerobic or anaerobic energy production. We have already reported that histidine-buffered cardioplegia which promote anaerobic glycolysis, provided an excellent functional recovery of myocardium post-ischemia with lower inotropic requirements in a range from 10°C to 37°C of myocardial temperature. Based on our theoretical background and clinical data, we tested the efficacy of this type of cardioplegia in patients receiving multiple surgical procedures with minimum ablation after sternotomy. First case, who had undergone a Bentall procedure for annulo-aortic ectasia 14 years previously had a thrombotic valve and mitral regurgitation. Aortic valve plasty and mitral valve replacement (MVR) was performed. The second case who had undergone MVR 15 years previously had malfunction of the prosthetic valve and underwent re-MVR. The third and fourth cases had ventricular septal defect (VSD) which were closed using Teflon patches. The third case had patch closure during second operation for residual shunt. The fourth case received tricuspid valve replacement (TVR) for tricuspid regurgitation due to a pacemaker lead implanted into the right ventricle through the left subclavian vein. The fifth case received coronary artery bypass surgery in a second operation for restenosis of the graft and progressing atherosclerosis. All hearts started beating spontaneously without DC cardioversion after the aortic unclamp. Ventricular fibrillation occurred in the first case while the patient was weaned from cardiopulmonary bypass and treatment was performed by aortic cross clamp, infusion of the cardioplegia followed by aortic unclamp to start own beat again. Two of 3 patients who were able to donate their own blood preoperatively did not require homologous blood transfusion. Due to advantages such as excellent myocardial protection under hypothermic or normothermic condition, ease of use and relatively lower potassium concentration, histidine-buffered cardioplegia can be an excellent candidate for myocardial protection in re-do cases with less ablation technique.

We report a case of vascular ring with tracheal stenosis, which might be related to a prolonged endotracheal intubation. A symptomatic 2-month-old boy was admitted to our institution after prolonged intubation without a definite diagnosis. His symptoms were stridor and dyspnea, but not dysphagia. Echocardiography detected a vascular ring and this was confirmed by computed tomography and magnetic resonance imaging (MRI) (Edwards IA type). The left anterior aortic arch was divided distal to the left subclavian artery through left thoracotomy and the ligamentum arteriosus was not identified. On postoperative day (POD) 2, endotracheal extubation was unsuccessfully attempted. Further examination such as MRI and bronchoscopy revealed intimal hyperplasia of the trachea with mild compression of the trachea from the outside. We performed aortopexy and division of the small long ductus which might not be a mechanism of the tracheal compression through right thoracotomy in the second operation with successful extubation on POD 3. The patient has been discharged from the hospital and followed up at the outpatient clinic without any symptom. Tracheomalacia was a common associated anomaly in vascular ring. However, other mechanisms such as inflammatory reaction associated with prolonged intubation should be considered and be avoided in the pediatric population.

In C1–C2 posterior fixation, the C1 lateral mass and C2 pedicle/translaminar screw insertion under spine navigation have been used frequently. To avoid the risk of neurovascular damage in atlantoaxial stabilization, we assessed the safety and effectiveness of a preoperative computed tomography (CT) image-based navigation system with intraoperative independent C1 and C2 vertebral registration. It is ideal when a reference frame can be linked directly to the C1 posterior arch for C1-direct-captured navigation, but there is a mechanical challenge. A new spine clamp-tracker system was implemented recently, which allows reliable C1- and C2- direct-captured navigation in nine patients with traumatic C2 fractures. In this way, there was no misalignment of C1–C2 screws. C1 lateral mass screws were used except for one case, and translaminar screws were primarily used as an anchor for C2. The C1 lateral mass screw locations, which are 19 mm laterally from the C1 posterior arch’s center, are taken to be constant. However, there is one unusual circumstance in which using a C1 laminar hook instead of a C1 lateral mass screw appears to be a beneficial substitute. The increase of surgical accuracy for posterior C1–C2 screw fixation without cost constraints is significantly facilitated by intraoperative C1- and C2-direct-captured navigation with preoperative computed CT images.

In March 2001, Research and Development Project Committee for Medical Educational Programs proposed a model core curriculum for undergraduate medical education. In this curriculum, implementation of the clinical clerkship is strongly recommended. Two similar curriculum models were later presented by other organizations, and some differences were observed among them. We, Undergraduate Medical Education Committee, have evaluated and compared themodel core curriculum 2001 with the Japanese newer proposals as well as those of USA and UK. Here is reported our proposals for a better rewriting of the learning objectives in the model core curriculum 2001, with some emphasis on the nurture of the competence of the case presentation and decision making process.

In order to implement, or enhance the quality of clinical clerkship, it is necessary to develop good educational environment which will be appropriate to allow medical students participate in medical team services. Important things to be considered will be, (1) Systematic management of the individual department's program by the faculty of medicine, (2) Developing educational competency within the medical care team function, and (3) Nurturing students' awareness forself-diected learning and cooperative team work, and teaching- and medical staffs' awareness of their educational responsibilities. In this paper, to develop better educational environment for clinical clerkship, we propose a desirable situation of the educational organization, dividedly describing on the roles of dean, faculties, board of education, department of medical education, clerkship director, teaching physicians, residents and medical students.