Introduction and Methods: An immediate effect of the physician shortage is the return to clinical work by physicians who had earlier left. Therefore, the needs of returning physicians were examined by means of a self-administered questionnaire. The subjects were clinicians working in Gunma Prefecture.
Results: About 50% of female physicians and 25% of male physicians had left clinical practice. The reasons given for leaving were “studying abroad” for most male physicians and “pregnancy and child-rearing” for most female physicians. More than 70% of physicians who had left clinical work felt uneasy about returning. The degree of anxiety after returning did not differ significantly between male and female physicians. Problems encountered by returning physicians involved “changes in medicines,” “changes and progress in technology and medical theories,” and deterioration of their “skills and techniques.” Moreover, returning physicians felt a need for increased “practical skills training.”
Discussion: Our study has clarified the needs of physicians returning to clinical work. The development and adoption of a simple system that will help physicians return to clinical practice is required.

Introduction: Lifelong learning is important for physicians because of patient safety and the need to constantly improve the quality of medical practice. However, few studies have investigated the specific topics that are required.
Methods: We examined the lifelong learning needs of physicians by means of a self-administered questionnaire that was completed by 595 subjects, who were clinical practitioners working in Gunma Prefecture.
Results: Subjects of all ages needed lectures about the use of evidence-based medicine in medical examinations, clinical studies and the interpretation of epidemiological data, and diagnostic imaging. The younger subjects had a greater need for learning about clinical skills and techniques, such as advanced cardiac life support／intensive care life support, abdominal ultrasonic diagnosis, and cardiac ultrasonic diagnosis. Regarding the ideal times for these lectures, some physicians working at Gunma University Hospital expressed a preference for weekdays after normal business hours, while others preferred the weekends.
Discussion: The lifelong learning needs of physicians were clarified. Because physicians work on different shifts and at different institutions, scheduling training sessions that everyone can attend is difficult, especially for those who are off-campus. The timing of the training sessions, as well as the content of lectures, must be considered. Ideally, sessions should be held more than once to accommodate the busy schedules of physicians. We believe that providing an opportunity for lifelong learning will help attract more people to a career in medicine and thereby help address the physician shortage.

The present study investigated an effective method of eliciting medium and long latency cutaneous reflexes in normal human subjects. The effect of changes in stimulus conditions (number of pulse train, duration of electrical pulse and inter-stimulus interval) on cutaneous reflexes in the first dorsal interosseous muscle (FDI) following non-noxious electrical stimulation to the hand digits (digit 1 ; D1, digit 2 ; D2 and digit 5 ; D5) were investigated in seven healthy volunteers. Cutaneous reflexes were elicited while the subjects performed isolated isometric contraction of FDI (D2 abduction). Under all experimental conditions, the level of muscle contraction was set at 10% of the maximal EMG amplitude, which was determined during maximal voluntary contraction. Intensity of the electrical stimulation was set at 2.0 times the perceptual threshold under all experimental conditions.Although the amplitude of E2 (excitatory response, peak latency ∼60∼90 ms) was independent of the number of pulses (1, 2, 3, and 5 pulses, pulse frequency at 333 Hz), that of I1 (inhibitory response, ∼45∼60 ms), I2 (inhibitory response, ∼90∼120 ms) and E3 (excitatory response, ∼120∼180 ms) was significantly increased depending on the number of pulses (p<0.001). Amplitudes of E2 and I2 were significantly affected by the digit stimulated (p<0.01). For all four components of the cutaneous reflexes, there were no significant differences in magnitude even by alternating both the inter-stimulus interval (fixed at 1, 2 and 3 Hz and random between at 0.7 and 2 Hz) and the duration (0.1, 0.5 and 1 ms) of the electrical stimulation.These findings suggest that the susceptibility of responsible interneurons impinging on each reflex pathway to temporal summation of the test impulse differs depending on the digit stimulated. It is also likely that almost the same population of the cutaneous afferent fibers were activated by test stimulation with different durations as far as the same stimulus intensity was utilized. As a practical application, double or more pulses up to 3 Hz without causing pain is recommended to effectively evoke medium and long latency cutaneous reflexes in FDI, which would reduce possible effects arising from fatigue.

It has recently demonstrated that central fatigue during sustained maximal voluntary contraction (MVC) progresses faster in the presence of delayed onset muscle soreness due to eccentric contractions than in normal states (Endoh et al., 2005). However, it remains to be clarified whether these findings are related to muscle damage or muscle pain induced by eccentric contractions. The present study investigated which factor plays a more critical role in the earlier onset of central fatigue during sustained MVC with muscle pain induced by injecting hypertonic saline. Ten healthy male right-handed subjects (age, 21~32 yrs.) were asked to perform brief MVCs (~3 sec) before and after injection of isotonic saline (0.9%, 1.0 ml, ISO) or hypertonic saline (5.25%, 1.0 ml, HYP) into the left biceps brachii. The subjects then performed 1 min MVC (fatigue test) with isometric elbow flexion was done in ISO or HYP condition or intact control condition (CON). During these contractions, transcranial magnetic stimulation was delivered to the contralateral motor cortex to evaluate voluntary activation (VA), the motor evoked potential (MEP) and electromyographic (EMG) silent period (SP). Ratio of root mean square of the EMG and elbow flexion force (EMGrms/F) was also measured.The peak pain induced by the injection of HYP was significantly higher than that of ISO (p<0.01). There was no significant difference in either the maximum size of the M response or the twitch force between ISO and HYP (p>0.05). However, during the brief MVCs, both maximal force (p<0.01) and VA (p<0.05) for HYP were significantly decreased compared to those for ISO. During the fatigue test, although MVC, VA, MEP and SP were significantly altered (p<0.05~0.01), there was no significant difference among CON, ISO and HYP (p>0.05). There was no significant difference in EMGrms during the fatigue test (p>0.05).These results suggest that peripheral force-producing capacity remained intact after the injection of ISO and HYP during sustained MVC, and that progression of central fatigue during sustained MVC was less affected by the increased group III and IV afferent activity induced by HYP.

The purpose of this study was to investigate changes in sarcoplasmic reticulum (SR) Ca²⁺-sequestering capacity in rat fast-twitch plantaris (PL) and slow-twitch soleus (SOL) muscles during recovery after high-intensity exercise. The rats were subjected to treadmill runs to exhaustion at the intensity (10% incline at 50 m/min) estimated to require 100% of maximal O₂ consumption. The muscles were excised immediately after exercise, and 15, 30 and 60 min after exercise. Acute high-intensity exercise evoked a 27 % and 38 % depression (P<0.05) in SR Ca²⁺-uptake rate in the PL and SOL, respectively. In the PL, uptake rate remained lower (P<0.05) at 30 min of recovery but recovered 60 min after exercise. These alterations were paralleled by those of SR Ca²⁺-ATPase activity. On the other hand, SR Ca²⁺-uptake rate in the SOL recovered 15 min after exercise. Unlike the PL, discordant time-course changes between SR Ca²⁺-ATPase activity and uptake occurred in the SOL during recovery. SR Ca²⁺-ATPase activities were unaltered with exercise and elevated (P<0.05) by 25, 30 and 30% at 15, 30 and 60 min of recovery, respectively. These results demonstrate that SR Ca²⁺-sequestering ability is restored faster in slow-twitch than in fast-twitch muscle during recovery periods following a single bout of high-intensity exercise and suggest that the rapid restoration of SR Ca²⁺-sequestering ability in slow-twitch muscle could contribute to inhibition of disturbances in contractile and structural properties that are known to occur with raised myoplasmic Ca²⁺ concentrations.

The effect of voluntary exercise training and influence of saline loading on blood pressure and cholesterol metabolism in rats were investigated in this study. Experimental animals used were male Wistar strain rats, aged 7 weeks old. These rats were allocated respectively into four groups, each of which consisted of 10 rats; sedentary control (SC), sedentary with 1 % saline loading (SS), training control (TC), and training with 1 % saline loading (TS) . In each of groups rats were sacrificed at the 10 th week.
Following results were obtained in this study.
1) The mean values of systolic blood pressure remained unchanged in all four groups, 2) serum and hepatic cholesterol levels were lowered by 10 weeks of exercise training, 3) the ratio of HDL-cholesterol to total cholesterol increased significantly in the training groups compared to that in the sedentary groups, 4) the incorporation of ¹⁴C-acetate into liver cholesterol was significantly lower in the SS group than in the SC group, and 5) a direct correlationship was found between the increased exercise level and the incorporation of acetate into liver cholesterol in both TC and TS groups.

A 40-year-old woman visited our emergency room (ER) with fever and shaking chills. Blood cultures for suspicion of urinary tract infection revealed bacteremia two days later. Since Streptococcus mitis was detected, infective endocarditis was strongly suspected. In addition to her history of dental calculus removal, careful cardiac auscultation revealed a continuous murmur, leading to the existence of patent ductus arteriosus (PDA). PDA was confirmed by echocardiography and 3D-CT angiography. The patient was successfully treated by antibiotics and then received transcatheter PDA closure. Careful auscultation after detection of bacteremia led to a diagnosis of PDA.

We tested the hypothesis that a force reduction in soleus muscles from hyperthyroid rats would be associated with oxidative modification of myofibrillar proteins. Daily injection of thyroid hormone [3, 5, 3’-triiodo-_L-thyronine (T₃)] for 21 days depressed isometric forces in whole soleus muscle across a range of stimulus frequencies (1, 10, 20, 40, 75 and 100 Hz) (P<0.05). In fiber bundles, hyperthyroidism also led to pronounced reductions (P<0.05) in both K⁺- and 4-chloro-m-cresol-induced contracture forces. The degrees of the reductions were similar between these two contractures. These reductions in force production were accompanied by a remarkable increment (103% ; P<0.05) in carbonyl groups comprised in myofibrillar proteins. In additional experiments, we have also tested the efficacy of carvedilol, a non-selective β₁-β₂-blocker that possesses anti-oxidative properties. Treatment with carvedilol prevented T₃-induced oxidation of myofibrillar proteins. However, carvedilol did not improve the hyperthyroid-induced reductions in force production. These data suggest that oxidative modification of myofibrillar proteins may not account for the reductions in force production of hyperthyroid rat soleus muscle.

We have long advocated the usefulness, accuracy and safety of carbon dioxide angiogrphy for patients with iodine allergy and renal dysfunction. In addition to its utility, no specialized apparatus is necessary for carbon dioxide angiography. Carbon dioxide as a contrast material has been adopted by consensus for use in endovascular revascularization. Here we report 4 cases of endovascular revascularization using carbon dioxide angiography. Two of the four patients had an iodine allergy, one had renal dysfunction, and the remaining one was complicated by diabetes mellitus. All patients exhibited intermittent claudication and were treated for iliac arterial stenotic lesions with percutaneous angioplasty and sequential endovascular stenting using carbon dioxide gas as a negative contrast material. All cases demonstrated improvement of the chief complaint. There were no direct or indirect complications of carbon dioxide angiography and endovascular intervention after the procedures. All 4 patients were discharged without event within 1 week after the endovascular intervention. Carbon dioxide is useful not only as an angiographic contrast material but also for endovascular intervention in patients with iodine allergy or renal dysfunction.

We performed the Senning operation and pulmonary valvotomy in an 11-month-old baby with transposition of the great arteries (TGA) with an intact ventricular septum (IVS), and bicuspid pulmonary valvular stenosis associated with pulmonary hypertension (PH). Preoperative catheterization showed a pressure gradient (PG) between the left ventricle (LV) and main pulmonary artery (MPA) of 35mmHg, mean pulmonary artery pressure (MPAP) of 56mmHg, and pulmonary vascular resistance (PVR) of 11.2unit·m². The pure oxygen inhalation test showed a decrease in MPAP from 56 to 38mmHg, and a decrease in PVR from 11.2 to 5.5 unit·m². We could not perform lung biopsy to determine the surgical indications in terms of PH due to preoperative progressive congestive heart failure in this patient. Postoperative catheterization (28 days after the Senning operation) showed a decrease in PG between the LV and MPA to 8mmHg, and MPAP also decreased to 17mmHg. Two radical operations were possible in this patient. One was the arterial switch operation (ASO), and the other was the atrial switch operation, i. e. the Senning or the Mustard operation. We selected the Senning operation because there was the possibility that the new aortic valve might develop persistent stenosis and regurgitation after ASO and pulmonary valvotomy. The Senning operation may be an alternative in selected patients with TGA with IVS and pulmonary valvular stenosis.