To determine the effectivenss of “clinical clerkship (CC)” in undergraduate clinical training, a questionaire was sent to 105 students who had received the classical bed side teaching (BST) in 1990 and to 103 who have received CC from 1992 through 1994. The effectiveness of clinical training was pointed out by 53, 7% of group BST and 61.8% of group CC. The numbers of effectively learned items were larger in the order of psychomotor, affective and cognitive domains in the group BST, while there were in the order of affective, psychomotor and cognitive domains the group CC, indicating that CC is more effective in learning in the affective domain than BST (p<0.01). In the affective domain, students learned by observing physicians' attitudes to patients in BST, while they learned through their own personal interactions with their assigned patients in CC. CC is therefore believed to be quite effective for students to learn humanistic attitudes.

Learning of humanistic attitudes in undergraduate medical education is increasingly expected to provide holistic care and comprehensive medical service. However, there has been no report that deals with doctors' attitudes toward patients in relation to the educational subject. Medical students, who had been implemented a clinical clerkship for two months, evaluated doctors' attitudes by questionnairs after clerkship. They scored by checklists and rating scales. In this article, we report the views of medical students on doctors' attitudes, and discuss important points for the success of the learning attitudes during undergraduate educational prosses.

　　The first patient was a 33-year-old man with a history of fatty liver disease. Dynamic computerized tomography of a lesion in liver segment IV showed faint staining in the arterial phase and high signal intensity in the portal venous and equilibrium phases. The second patient was a 57-year-old woman also with a history of fatty liver disease. Magnetic resonance imaging (MRI) of a lesion in segment II in T1 out of phase revealed geographic morphology and high signal intensity. Furthermore, Gd-EOB-DTPA-enhanced MRI showed accumulation in the lesion in the hepatobiliary phase. In both cases, an aberrant left gastric vein and focal fat sparing area was diagnosed. Venous inflow to the liver other than via the portal vein may cause fatty degeneration of liver parenchymal cells or focal fat sparing due to imbalanced intrahepatic blood flow. In the present cases, imaging revealed a focal fat sparing area with an aberrant left gastric vein. Focal fat sparing area with aberrant inflow vessel identified in the background of fatty liver does not require biopsy or surgery. Therefore, further detailed evaluation of such images is warranted.

We evaluated our undergraduate clinical clerkship system in 1992, using the multiplication method advocated by the Working Group on “Evaluation of clinical skills of medical students ” of the Japan Society for Medical Education. We divided the clinical training period into three terms: the first term was held from May through June, the second from September through October, and the third from December through January. We determined scores using checklists and rating scales in ten categories, totalled the scores for each period, and compared them between periods. The total scores for the third period were the highest, followed by those for the second period. Scores for basic knowledge, data gathering, and basic technical procedures increased with increase in the number of training hours. However, scores for manner, attitude, and interviewing skills were already high in the first period. We conclude that the multiplication method is useful for objectively evaluating students' clinical skills.

During the past four years authors encountered a total of 25 tourists suffered from cerebral (CI: 14 cases) and acute myocardial infarction (AMI: 11 cases) while staying in Kusatsu Hot Spring. The subjects consisted of 13 males and 12 females, ranging from 49 to 85 years old (mean 68±9.5). Analytical study relating to the time of onset of diseases, bathing, drinking and others was performed in these patients. The results obtained were as follows.
1) Higher incidence was observed from May to October in CI, while from March to April and in September in AMI. A majority of the subjects suffered from CI or AMI within two days after arrival in Kusatsu. Attack occurred during bathing in one subject, within six hours after bathing in one, and from six to 24 hours after bathing in the others, respectively. Furthermore, a hourly distribution of the onset of disease showed the high incidence of CI between 3:00 and 9:00, and of AMI between 21:00 and 0:00.
2) Bathing was done one to four times within 24 hours before onset in all subjects. Meanwhile, drinking was in 56% of the subjects.
3) Out of 21 subjects investigated six cases were under medication with hypotensive drugs.
From the results above described, a role of bathing playing in pathogenetic mechanism in thrombotic diseases such as CI and AMI was briefly discussed.

Thirty-six spontaneous intracranial hypotension patients with multiple-level leakages of cerebrospinal fluid were enrolled in the study.After 30 patients received targeted epidural blood intervention for 2 times and 6 patients received targeted epidural blood intervention for 3 times,the clinical symptoms were completely relieved.During injection of autologous blood,pain at the puncture site occurred in 24 cases,radiating pain in upper extremities in 5 cases,numbness in the upper extremity in 9 cases,radiating pain in lower extremities in 6 cases,numbness in lower extremities in 7 cases,headache in 4 cases,dizziness in 3 cases and transient bradycardia in 3 cases.Most of these symptoms were self-relieved after the end of injection or after slowing the injection rate,and some were self-relieved hours later.Neck stiffness was found in 2 cases and self-relived within a few hours or days after operation,and no severe nervous systemrelated complications were found.Recurrence happened in 2 cases at 3 months after the end of treatment,and the symptoms were self-relieved after receiving targeted epidural blood intervention for a second time.The patients were followed up for 15-36 months,and no serious nervous system-related complications were observed.Therefore,targeted epidural blood intervention is safe and effective when used to treat spontaneous intracranial hypotension caused by multiple-level leakages of cerebrospinal fluid in patients.

Objective : To evaluate the necessity to complement the information obtained from pharmacists in the community pharmacy by that from the hospital pharmacy in Prescription-Event Monitoring in Japan (J-PEM) by using data in a J-PEM pilot study.
Methods : For each patient, two questionnaires were sent to the prescribing doctor and the pharmacist who registered the patient ID code in the pilot study. If the patient ID code was registered by the pharmacist in the community pharmacy and if a pharmacist inside the hospital where the prescription was issued was willing to co-operate, a third questionnaire for the same patient was sent to the pharmacist in the hospital pharmacy. The information given by pharmacists was analyzed for 150 pairs of questionnaires (on 150 patients) sent back from pharmacists in both community and hospital pharmacies. The questions in the questionnaire were categorized into [1] those on drugs used by patients (concurrent drugs, daily dose of the drug monitored, and compliance), [2] those on events which the patient had experienced after the prescription of the drug monitored, [3] those on patients (the first date of prescription, reason of prescribing the drug monitored, initial date when the disease developed, underlying diseases or complications and whether and when the patient was lost to follow-up). The questionnaires were examined to determine whether the answer was given to each question. When the answer was given, its quality and quantity were then assessed. The answer to each question given by the pharmacist in the community pharmacy (C) and that by the pharmacist in the hospital pharmacy (H) were compared by the McNemar test after the pairs of answers were classified into the following categories : [1] C is better than H, [2] H is better than C, [3] C and H are similar to each other, and [4] impossible to classify. The difference was considered to be significant where p<0.05.
Results and conclusion : For the initial date when the disease developed and 'underlying diseases or complications', H was significantly better than C. However, for concurrent drugs, compliance and events, C was significantly better than H. Otherwise, the difference was not statistically significant. Being compatible with the superiority of C over H in regard to concurrent drugs and events, the fraction of patients lost to follow-up during the observation period was small not only in H but also in C. This observation may be associated with the fact that almost all prescriptions were issued by a single hospital in more than 60% of community pharmacies in the pilot study, and most patients identified in the study were probably a regular visitor to one of such community pharmacies. The most important information to be provided by the pharmacists in J-PEM is that on events and drugs used by patients. It is thought to be not necessary to complement the information obtained from the community pharmacy by that from the hospital pharmacy.

The sudden onset of anuria in a 71-year-old man was found to be caused by the non-inflammatory (atherosclerotic) large abdominal aortic aneurysm compressing the bilateral ureters. A computed tomography scan demonstrated the bilateral extrinsic ureteral obstructions due to the large aneurysm of 13cm in diameter, left hydronephrosis and no thick layer of perianeurysmal fibrotic tissue. On the 9th day from the onset of anuria, an emergency operation was performed. There was no fibrotic adhesions around the aneurysm and mobilization of the aorta was easy. A straight Dacron prosthesis was inserted between the infrarenal aorta and the bifurcation of the abdominal aorta following resection of the aneurysm of the atherosclerotic origin. Soon after the operation, the patient had very good urinary output with adequate recovery of renal function. This case seems to be very uncommon, but very important in the surgical management of abdominal aortic aneurysm complicated by oliguria or anuria.