Although simulated patients (SPs) has become indispensable for the development of medical students' communication skills, few studies have analyzed the effects of SPs on medical students. In particular, no studies have examined the effect of the feedback that medical students receive from SPs during communication training sessions.
1) We invited students to complete a questionnaire and participate in a group interview; the responses and opinions obtained were then analyzed both quantitatively and qualitatively by two independent analysts.
2) Sixty-four percent of students were satisfied with SPs' feedback, whereas 28% of students preferred toreceive negative feedback as a way to improve their skills.
3) Some students criticized SPs' feedback and SPs themselves.
4) The SPs' feedback should focus more on the negative aspects of students' performances, and faculty members should provide a safe and secure educational environment for both students and SPs.

Objective: Serum 25−hydroxyvitamin D [25(OH)D] is a vitamin D metabolite and a good indicator of vitamin D nutritional status. Low 25(OH)D levels accelerate age−related bone loss in women. The aim of this study was to assess 25(OH)D levels using population−based samples from women in a community in Japan. Subjects and Methods: Of all 187 adult women living on a solitary island (Niigata, Japan), 150 (80.2%) were enrolled in a cross−sectional study in early June 1998. After excluding 6 subjects who were undergoing treatment for osteoporosis, 144 female subjects were analyzed. Serum 25(OH)D2 and 25(OH)D3 were determined by high−performance liquid chromatography. The sum of 25(OH)D2 and 25(OH)D3 was calculated, yielding 25(OH)D, for which a concentration of less than 30 nmol/L was defined as vitamin D insufficiency. Demographic data such as age, height, weight, and body mass index (BMI) were also recorded. Results: The average age of the subjects was 61.3 years (SD 12.8), ranging from 21 to 87. The average concentrations of 25(OH)D2 and 25(OH)D3 were 0.5nmol/L (SD 3.2) and 64.6nmol/L (SD 17.6), respectively. The number of subjects with 25(OH)D concentration less than 30nmol/L was 4 of 149(2.7%). Serum 25(OH)D concentrations were not significantly correlated with age (r=−0.065, p=0.441) or BMI (r=0.086, p=0.310). Conclusion: The present population−based study confirms adequate levels of 25(OH)D and low prevalence of vitamin D insufficiency in Japanese women. Further research should be directed toward clarifying which dietary factors determine vitamin D nutrition.
hydroxyl group ; Upper case dee ; Vitamin D ; Nutritional status ; Human Females

Community medicine clerkships are said to be an important element of current undergraduate medical education. However, little is known about what medical students actually learn from them.Therefore, we performed a study by means of significant event analysis to examine what medical students had learned from 2-week community medicine clerkships.
1) Students in 2006 took part in 2-week community medicine clerkships and then in sessions at the end of their clerkships to review their experiences.
2) The review sessions were recorded, and the students'impressions were extracted and categorized.
3) The depth of their impressions was categorized into 4 depth levels (describing, commenting, generalizing, and planning).
4) Students gave their impressions of the medical system, the role of physicians, patient-centered care, role models, and clinical ethics, and the impressions of most students were at the levels of commenting and generalizing.
5) Medical students learned system-based practice and medical professionalism during their community medicine clerkships, and significant event analysis was a valuable tool for understanding their experiences.

Levetiracetam (LEV), a relatively new antiepileptic drug, is now frequently used for treating partial or generalized seizures. Among the adverse effects of LEV, rhabdomyolysis is rare. We describe here a case of LEV-induced rhabdomyolysis in a 26-year-old woman. The patient’s seizures had been controlled with carbamazepine and phenobarbital for the previous 7 years. However, LEV was initiated at the age of 26 years because her seizures control deteriorated with seizures occurring monthly. She experienced lower limb weakness with a high level of creatine kinase 15 days after starting LEV. When LEV was discontinued, her creatine kinase levels decreased and her symptoms gradually improved. This case provide another example of rhabdomyolysis during the early phase of LEV treatment.
Rhabdomyolysis

Objectives Left ventricular systolic dyssynchrony is the most important determinant of response to cardiac resynchronization therapy (CRT), playing a vital role to predict improvement of systolic function or LV reverse remodeling. CardioGRAF is a novel programmer based on the ECG gated single photon emission computed tomography (G-SPECT) imaging to detect LV systolic and diastolic dyssynchrony simultaneously. This study was to investigate the prevalence of systolic and diastolic left ventricular (LV) dyssynchrony in patients with heart failure. Methods We retrospectively studied 69 patients with heart disease, including 31 patients who had symptoms of heart failure (NYHA class Ⅱ-Ⅲ), and 38 patients who had no symptoms of heart failure (NYHA class Ⅰ). G-SPECT data were analyzed by cardiaGRAF, and measurements included the time to end systole (TES), the time to peak ejection (TPE), the time to peak filling (TPF), TES+TPF and maximal difference (MD) of each parameters were obtained, using the 95th percentile of the control group as a cutoffof 150 ms for MD-TES, 139 ms for MD-TPE, 345 ms for MD-TPF and 315 ms for MD-TES+TPF. Results The prevalence of LV systolic dyssynchrony was significantly higher in heart failure patients with reduced LV ejection fraction (LVEF)<45% (72% for MD-TES; 64% for MD-TPE) compared with heart failure patients with preserved LVEF=45% (14% for both MD-TES and MD-TPE; P=0.002, P=0.005, respectively); The prevalence of MD-TES<150 ms was higher in NYHA class Ⅲ patients (64%) compared with NYHA class Ⅱ patients (27%, P=0.049). However, the prevalence of the LV diastolic dyssynchrony were high but not difference between NYHA class Ⅲ(47% for both MD-TPF and MD-TES+TPF) and class Ⅲ(63% for MD-TPF; 69% for MD-TES+TPF; P=NS) patients as well as between patients with preserved LVEF (43% for both MD-TPF and MD-TES+TPF) and patients with reduced LVEF(64% for MD-TPF; 72% for MD-TES+TPF; P=NS). Conclusions The prevalence of LV systolic dyssynchrony was high in heart failure patients with reduced LVEF. Diastolic dyssynchrony was common in patients with heart failure. CardioGRAF maybe a useful method to detect LV dyssynchrony.

A 40-year old man with chest pain was admitted to our hospital. A three-dimensional CT revealed an unruptured left coronary sinus of Valsalva aneurysm and mild stenosis of the left main trunk. An echocardiogram revealed severe aortic regurgitation. He was operated on with an aortic root replacement procedure. Though the procedure was itself uneventful, he could not be weaned from cardiopulmonary bypass because of unexpected coronary events ; relative stenosis of the RCA and stretched LMT due to a huge aneurysm of the sinus of Valsalva. Additional CABG with LITA to LAD and SVG to RCA led to weaning from cardiopulmonary bypass. Left coronary sinus of Valsalva aneurysm is rare, and it requires early surgical intervention for an increase in the diameter of the aneurysm together with myocardial ischemia due to compression of the coronary artery.

A 71-year-old man had sudden onset of left lower limb swelling and consulted an orthopedic surgeon 14 days later. Venous echography demonstrated compression of the left iliac vein and the thrombus of the common iliac vein. After emergency admission, conservative therapy was given for 7 days, but the symptoms did not sufficiently diminish and a thrombus was also present. We therefore performed femoro-iliac cross-over vein bypass using a 10mm ringed ePTFE graft. Symptoms were completely improved and the graft was shown to be patent by echography after 3 months.

A 62-year old man was referred to our hospital with endocarditis. Although the infection was improved by antibiotic therapy, he underwent surgery because of severe aortic and mitral valve regurgitation. Preoperative computed tomography revealed a pseudoaneurysm of 20 mm in diameter at the posterior wall of the ascending aorta. The non-coronary cusp was infected and there was a punched-out pseudoaneurysm at the ascending aorta adjacent to the sino-tubular junction. After resection of the aortic wall and the aortic valve, a modified Bentall operation with a composite graft and mitral valve plasty was performed. Postoperative whole body computed tomography revealed no other pseudoaneurysms. In case of endocarditis, we have to consider the possibility of aneurysm formation throughout the body.

The patient was a 68-year-old woman with chief complaints of severe lumbago, left lateral abdominal pain and high fever. Computer tomography (CT) at a local hospital showed a left psoas abscess and a low density area around the terminal aorta. Blood tests indicated a high inflammatory response and MSSA was detected in a blood culture. Control of the infection was first attempted with antibiotics, but CT showed a pseudoaneurysm at the terminal aorta, and therefore she was transferred to our hospital. We diagnosed infected abdominal aortic and left common iliac aneurysms complicated by an MSSA psoas abscess, and performed extra-anatomic reconstruction with axillo-bifemoral bypass, aneurysmectomy and omentopexy in the psoas abscess cavity. Because of massive intestinal edema and mesentery, we attempted temporary abdominal closure with the vacuum-assisted closure (VAC) technique, and finally succeeded in closing without abdominal infection in the 6th operation, 42 days after the first operation. Infected abdominal aortic aneurysm complicated by psoas abscess is extremely rare and life threatening. The VAC technique is very effective not only in avoiding abdominal compartment syndrome but also in avoiding abdominal infection.