An 81-year-old-woman was successfully treated with simultaneous minimally invasive direct coronary artery bypass (MIDCAB) and colectomy. The patient complained of effort angina and tarry stool and had a combination of Bormann type II transverse colon cancer with oozing bleeding and long segmental stenosis of the left anterior descending coronary artery (LAD). Angiography suggested that the anastomotic site on the LAD extramusclarly presented on the tortours LAD. We therefore carried out one-stage operation of MIDCAB and colectomy. First, MIDCAB to the LAD using the left internal thoracic artery was performed via left anterior thoracotomy. After closing the left thoracic wall, we carried out transverse colectomy with lymph node resection via upper median laparotomy. The total operation time was 3hr 30min, 2hr 10min for MIDCAB and 1hr 20min for Colectomy respectively. Postoperative coronary angiography showed good patency of the LITA. The resected colon specimen showed moderately differentiated adenocarcinoma: ss, n1, Po, Mo stage 3a. She was discharged 15 days after the operation.

A new educational program for the medical doctor was introduced at Tokyo Women's Medical College in 1990 with a 4-year tutorial education model as its core. To develop the program for educational training more efficiently, current facilities were reviewed on a large scale, and various types of equipment and supplementary materials were made available. We are now investigating utilization and problems of the current program. Supplies and materials of tutorial rooms and mirror rooms have been used effectively. The library has become increasingly useful as a place for independent study and research. However, audiovisual materials have not yet been made fully available. We suggest that further improvements to the system and fostering an environment of open access to information are necessary to increase the accessibility of the support system for tutorial education.

Tutors must understand their role in advance so that tutorial education can be conducted smoothly and effectively. These abilities and attitudes require training. At our school, tutors serve as faculty for basic courses and clinical courses. We assessed their training conditions and future tasks. Of the 1, 077 faculty members who received tutor training between 1988 and 1997, 935 are current faculty members who have completed in-service training (basic course, 115; clinical course, 820). Before 1989, training was on campus, but since 1990 it has been conducted at Shirakawa Seminar House with a 2-day program. The number of working tutors per year is 192, with a basic course to clinical course ratio of 3: 7. About half of the faculty members in the basic course have had four or more experiences as tutors, whereas most clinical course faculty members have had only one experience. Thus, many tutors have had no experience. In a questionnaire survey after undergoing the training program, most participants felt that they were able to understand the theory of tutorial education and the actual role of the tutor and that they were able to concentrate on off-campus training that was removed from their everyday work. To provide added impetus to tutorial education, we suggest that in the future, in addition to the understanding and mutual cooperation of those involved, it will be necessary to provide an advanced program to train tutors who have appropriate abilities and attitudes.

Tokyo Women's Medical University introduced tutorial education in 1990 for 1st-through 4th-year students. To examine the effectiveness of this system in a basic-medicine course, questionnaires were given to all 2nd-year students. Many students felt that they had become accustomed to performing self-learning tasks through collecting information themselves and discussing their findings in a group; in particular, they found that tutorial education markedly improved their communication skills. A few students thought that this method helped them develop the ability of logical/critical thinking and analytic skills from multiple viewpoints. These findings suggest that an assessment system should be established by which students themselves could recognize the extent to which they have developed their abilities, which was the aim of tutorial education.

Personal interviews and group discussions were conducted with all 2nd-year students to examine how they feel about tutorial education used as the core of the basic-medicine course and how they recognize the importance of developing their abilities, which was the aim of this course. Many students showed slight anxiety about the results of their learning with tutorials, felt inadequate in their self-learning ability, and hoped the guidance by instructors would be improved. These findings suggest that students' anxiety will decreased and their willingness to learn will increase if their developed abilities are evaluated appropriately and if they receive adequate feedback. These findings also suggest that a retraining program for experienced instructors is needed to improve their guidance skills and to reinforce the importance of their role.

A medical-ethics course was anonymously evaluated by first-year students over 2 years. The course emphasizes problem-based learning through group discussion of clinical cases and lectures on ethical issues. A tutorial system was added to the course in the second year. Students' evaluations indicated that most students had positive attitudes about the course and that both group discussion and lectures were helpful for achieving the general instructional objectives and specific behavioral objectives of the course. A comparison of the 2 years showed that a majority of evaluated items received higher evaluations from second-year students than from first-year students. We attribute the difference to the livelier discussion with the introduction of the tutorial system and the smaller discussion groups. These results indicate that students consider medical-ethics education to be useful.

Our medical ethics course emphasizes problem-based-learning (PBL) via group discussion of clinical cases. The significanceof instructors' assessments of PBL in ethics education was studied with different assessment tools during thelast 2 years. In the first year, students' behavior and level of functioning in group discussion were assessed on a group basiswith an 8-item instrument. In the second year, students' level of functioning and flexibility in response to differentopinions in group discussion were assessed on an individual basis with a 2-item instrument. Instsments ofstudent's performance in group discussion were positively but weakly correlated with scores of their reports derivedfrom group discussions. Instructors could consistently assess student performance in PBL in terms of behavior and levelof functioning in group discussions. Furthermore, instructors rated flexibility in response to other opinions as an importantfactor in group dynamics, including interaction between students and instructors. These results suggest that instructors'assessments can be used to help evaluate students in a medical ethics course. Instructors' assessments of studentflexibility during PBL can be particularly useful in this regard.

Background: The WHO classified pancreatic neuroendocrine neoplasms (pNEN) in 2010 as G1, G2, and neuroendocrine carcinoma (NEC), according to Ki67 labeling index (LI). However, the clinical behavior of NEC is still not fully studied. We aimed to clarify the clinicopathological and molecular characteristics of NECs. Methods: We retrospectively evaluated the clinicopathological characteristics, KRAS mutation status, treatment response, and the overall survival of eleven pNEC patients diagnosed between 2001 and 2014 according to the WHO 2010. We subclassified WHO-NECs into well-differentiated (WDNEC) and poorlydifferentiated NEC (PDNEC), the latter further subdivided into large and small cell type. Results: The median Ki67 LI was 69.1% (range, 40% - 95%) and the median tumor size was 35 mm. 11 WHO-NECs were subclassified 4 WDNEC and 7 PDNEC, and further separated PDNEC into 3 large cell and 4 small cell subtypes. Comparisons of WDNEC vs. PDNEC revealed hypervascularity on CT, 50% (2/4) vs. 0% (0/7) (P = 0.109); median Ki67 LI, 46.3% (40% - 53%) vs. 85% (54% - 95%) (P = 0.001); KRAS mutations, 0% (0/4) vs. 85.7% (6/7) (P = 0.015); response rates to platinum-based chemotherapy, 0% (0/2) vs.100% (4/4) (P = 0.067) and median survival, 227 vs. 186 days (P = 0.227). Conclusions: The WHO-NEC category may be composed of heterogeneous disease entities, namely WDNEC and PDNEC. These subgroups tended to exhibit differing Ki67 and KRAS mutation profiles, and distinct response to chemotherapy. Further studies for the re-evaluation of the current WHO 2010 classification is warranted.

Background: The WHO classified pancreatic neuroendocrine neoplasms (pNEN)in 2010 as G1, G2, and neuroendocrine carcinoma (NEC), according to Ki67labeling index (LI). However, the clinical behavior of NEC is still not fully studied.We aimed to clarify the clinicopathological and molecular characteristics ofNECs.Methods: We retrospectively evaluated the clinicopathological characteristics,KRAS mutation status, treatment response, and the overall survival of elevenpNEC patients diagnosed between 2001 and 2014 according to the WHO 2010.We subclassified WHO-NECs into well-differentiated (WDNEC) and poorlydifferentiatedNEC (PDNEC), the latter further subdivided into large and smallcell type.Results: The median Ki67 LI was 69.1% (range, 40% - 95%) and the mediantumor size was 35 mm. 11 WHO-NECs were subclassified 4 WDNEC and 7PDNEC, and further separated PDNEC into 3 large cell and 4 small cell subtypes.Comparisons of WDNEC vs. PDNEC revealed hypervascularity on CT, 50% (2/4)vs. 0% (0/7) (P = 0.109); median Ki67 LI, 46.3% (40% - 53%) vs. 85% (54% -95%) (P = 0.001); KRAS mutations, 0% (0/4) vs. 85.7% (6/7) (P = 0.015); responserates to platinum-based chemotherapy, 0% (0/2) vs.100% (4/4) (P = 0.067) andmedian survival, 227 vs. 186 days (P = 0.227).Conclusions: The WHO-NEC category may be composed of heterogeneousdisease entities, namely WDNEC and PDNEC. These subgroups tended to exhibitdiffering Ki67 and KRAS mutation profiles, and distinct response to chemotherapy.Further studies for the re-evaluation of the current WHO 2010 classification iswarranted.

A 43-year-old man with rheumatic arthritis was admitted to our hospital for symptoms of cough, left chest pain, and left elbow pain, and further examination revealed an elevated level of C-reactive protein. On day 2 after admission, he underwent esophagogastroduodenoscopy. On the morning of day 7, he developed a high fever of 39.7°C, several hours after bronchoscopy. On day 13, he underwent colonoscopy. Five minutes after the colonoscopy, he developed a high fever of 39.9°C, accompanied by stridor, indicating a decrease in arterial oxygen saturation level. An intradermal test for peracetic acid which was used for cleaning flexible endoscopy was positive. We suspect that he suffered from an allergic reaction to peracetic acid following the flexible endoscopy. This is the first case reported on suspicious allergic reaction to peracetic acid following a flexible endoscopy procedure.