To develop problem-solving skills and to motivate learning, The Jikei University School of Medicine started a tutorial educational program for fourth-year preclinical students in April 1999. Student doctors' patient-care models focused on discovery learning and acquiring strategies for general medicine through problem-solving skills. After information was first provided by prepractice handouts, one or two tutorial sessions were performed each week. Minimum requirements for each step were established, and instructors provided printed materials, display materials, and detailed oral information to facilitate discovery learning. This program is based on problem-finding and problem-solving through selfdirected learning and feedback systems for tutorial sessions. Examinations used multiple stations to reconfirm program aims and to reinforce problem-solving skills. On a questionnaire survey, 85% of fifth-year students taking part in practical clinical education thought that the tutorial education was needed to acquire problem-solving skills necessary for fifth-year clinical training.

A 61-year-old woman had extracardiac unruptured aneurysms of the right and noncoronary sinuses of Valsalva, detected incidentally on electrocardiogram taken for a physical checkup. Two-dimensional echocardiography revealed that the sizes of the aneurysm of the right and noncoronary sinuses were 41×40 and 38×28mm respectively, but the shape of left coronary sinus was almost normal. The aortic valve leaflet was normal and the diameter of the aortic annulus and sinotubular junction was 23 and 27mm respectively. The Doppler color-flow echocardiogram showed moderate aortic regurgitation which resulted in prolapse of the right aortic cusp due to deformity of the annulus. We performed modified aortic root remodeling using a tailored Dacron graft to preserve the native aortic valve. Right and noncoronary sinuses of Valsalva were all excised with a small button of the aortic wall around the ostia of the right coronary artery. The left coronary sinus was left as it was. Then each commissure received sub-commissural annuloplasty and was pulled up. The defect of Valsalva was reconstructed with a 26mm Dacron tube graft, the proximal end of which was tailored to a scallop shape and that correspond to left coronary sinus was excised. The right coronary artery was reimplanted utilizing the Carrel patch method. Although we needed additional CABG to the right coronary artery and IABP support due to vasospasm of the right coronary artery, the postoperative course was uneventful. Echocardiography of the aortic valve before discharge showed a normal function without regurgitation.

Since November 1999 we have attempted to use a right heart bypass (RHB) system for beating heart coronary artery bypass grafting (CABG), which system produce better exposure of lateral and posterior wall of the heart and so enable us to facilitate bypass grafting to these branches. We report on our initial clinical experience with this system and the purpose of this study is to evaluate the efficacy of this system. To clarify the efficacy of the RHB system, we compared the intraoperative and postoperative clinical course, as well as outcome, between patients who underwent beating heart CABG with RHB and patients without RHB. Seventy-seven patients underwent beating heart CABG with RHB (RHB group) between November 1999 and December 2001. In the same period, 88 patients underwent beating heart CABG without RHB. Of these latter, 30 patients needed displacement of the beating heart in order to expose target coronary arteries (OPCAB group). Perioperative clinical parameters were compared between the groups. Patients in the RHB group received more grafts (2.4±0.6) than patients in the OPCAB group (2.0±0.2, p=0.002). There were no hospital deaths in either group. While displacing the beating heart, SvO₂ decreased and pulmonary artery pressure increased in both groups. Nevertheless, the value of SvO₂ was significantly higher in RHB group while displacing to expose the circumflex region (p=0.048) and the distal right coronary artery region (p<0.01). The effect of elevation of pulmonary artery pressure in the RHB group was lower than that in the OPCAB group, but it was not statistically different. Water balance during operation was 2, 898±1, 019ml in the RHB group and the 2, 237±807ml in OPCAB group (p=0.002). Body temperature following operation was 36.0±0.8°C in the RHB group and 36.5±0.8°C in the OPCAB group (p<0.01). However, no differences were found in postoperative blood loss, required transfusion, duration of mechanical ventilation, ICU stay and hospital stay. No patient had postoperative complications related to the RHB system. The introduction of the RHB enabled bypass grafting to posterior wall vessels with better exposure and under greater hemodynamic stability. Therefore we think it a very effective support system which enable multiple coronary revascularization on beating heart CABG.

In the past 9 years, 37 patients with infective endocarditis underwent valve replacement. The aortic valve was involved in 17 patients, the mitral valve in 10, and both valves in 10, respectively. 35 patients had native valve and 2 had prosthetic valve endocarditis. Bacterial findings were Streptococcus in 20 patients (54%), Staphylococcus in 5 (13.5%), gram-negative in 3 (8%), and undetected in 10 (27%). 10 patients developed aortic annular abscess. After aggressive debridement of all apparently infected tissue of annular abscess, the defects left in the left ventricular outflow tract were repaired by interrupted mattress sutures with pledgets in 4 patients, by autologous pericardial patch in 4, and by valved conduit in 2 PVE patients, respectively. Retrograde cardioplegic infusion from the coronary sinus not only facilitated operative manipulation but also provided superior myocardial protection in such patients. Operative mortality was 11% (4/37). Reoperation was necessary in 2 patients; one for periprosthetic leak, and the other for newly developed severe left coronary ostial stenosis after the first operation, but both died eventually. Late mortality was 8% (3/37). Mean follow-up of 31 months was achieved in all 30 survivors, in whom there was no recurrence of infection and clinical improvement was excellent.

Introduction
Essential hypertension is one of the leading causes of hypertension; responsible for more than 90% of such cases. Diet cure or drug treatment are usually prescribed for this disease. We drew notice to the antihypertensive effects of acupuncture.
Method
Subjects were healthy persons as well as patients complainig of simple essential hypertension. According to the WHO method, they were divided into three groups, e. g. normal, limitaneus, hypertensive. In situ needles were inserted in the antihypertensive points of both auricular sides for one week.
Effect
This treatment gave immediate results in 70% of the limitaneus and hypertensive groups. There was no observable effect for the balance. A number of these subjects were obese; a factor to be considered.
Evaluation
This method is very uncomplex and takes but minimal amount of time to treat patients.

Objective: Pharmaceutical documents such as the common technical document, package inserts (PIs), and interview forms (IFs) are available at the website of the Pharmaceuticals and Medical Devices Agency. However, because these documents were created with an emphasis on human readability in paper form, it is difficult to use the information included and interoperate these documents with computers. Using IFs, we will investigate how to structure pharmaceutical documents in the AI era to achieve both human and machine readability.Design/Methods: The IFs of arbitrary selected ten drugs were structured into Resource Description Framework (RDF) according to the Drug Interview Form Description Guidelines 2018 (updated version in 2019). The data were manually extracted from the IFs and entered into a spreadsheet before being converted to RDF by a written script. The PIs were converted to RDF in addition to the IFs. To examine the linkage with external databases, IDs in ChEMBL, which is a manually curated database of bioactive molecules with drug-like properties, were embedded in the RDF.Results: We demonstrated that the conversion of IFs and PIs into RDF makes it possible to easily retrieve the corresponding part of the PIs cited in the IFs. Furthermore, we quickly obtained the relevant data from ChEMBL, demonstrating the feasibility of linking IFs with an external database. Our attempt to RDFization of IFs is expected to encourage the development of web applications for healthcare professionals and the development of datasets for AI development.Conclusion: We could easily interoperate IFs with other pharmaceutical documents and an external database by converting IFs into RDF following the description guidelines. However, problems such as how to deal with items that were not described in the description guidelines were indicated. We hope that discussions will grow based on this effort and that related industries will move toward accomplishing effective use of these documents.