The purpose of the present study was to determine whetehr differences exist between nine experimental conditions mixing 10°, 40°and 70°of hip joint angles with knee joint angles, when thirteen subjects performed the same response task. In the experiment 1, each subject was asked to stand on the inside two of the four mat switches (500×700 mm) and keep the assigned joint angles during a second of preparatory period. After the period, each subject was asked to respond with a step out on either the right or the left outside mat switch as quickly as possible. Then the data was collected analyzing the whole body choice response time (RESPONSE TIME) defined as the interval time from the signal to respond with step out, the whole body choice reaction time (REACTION TIME) defined as the interval time from the signal to reaction with lifting the leg for responding to the step out, and the movement time (MOVEMENT TIME) defined as the interval time subtracting RESPONSE TIME from REACTION TIME. Moreover, in the experiment 2, the data was collected and analyzed from the onset time of various forces from the two force platforms on which each subject stood instead of the mat switch and EMG which was led from the right side of m. rectus femoris, m, biceps femoris, m. gastrocnemius, m. tibialis anterior and the left side of m. quardriceps femoris, during performance of the response task. The results were as follows:
1. The subjects' posture with each 70°flexion of the hip and the knee joint revealed the shortest RESPONSE TIME, because of the shortened MOVEMNT TIME, compared with the other posture. Conversely, the posture with 70° flexion of the knee joint showed an expanded REACTION TIME.
2. The knee joint angle was an important factor effecting both REACTION TIME and MOVEMENT TIME, rather than the hip joint angle for the task of the experiment, since flexion of the knee joint expanded the REACTION TIME, but shortened the MOVEMENT TIME.
3. The result of the force platform measurements indicated that the posture with each 70°flexion of the hip and the knee joint was shorter than that with each 10°flexion of them at the onset time of the first reaction force after the reaction signal, and that the order of response for the task was beginning at the leg for responding, followed by the other leg for keeping stability.
4. Conclusive evidence for a shortened RESPONSE TIME was found in the facilitation of the central nervous system, which revealed the preliminary muscle activity and the stabilizing of the posture.

Between 1968 and 1992, a total of 174, 632 people were discharged from our hospital, of which 6, 265, or 3.6%, were dead. During the 25-year period, the number of discharges increased by 1.5 times, while the number of deaths by 2.6 times. We looked into, physicians' reports to find out the age, sex and the cause of death of the patients. Age-wise death rates have been on the decline among the younger patients and on the increase among the eledery patients of 60 years and above, during the period under review. Malignant neoplasms accounted for 62.2% of the causes of death. Especially worthy of note was the fact that deaths from lung cancer have increased at an alarmingly fast rate.

A 67-year-old man was admitted with heart failure. He had a past history of closed chest trauma due to a traffic accident at the age of 24. He had been complaining of a gradual increase of fatigue since a few years after the accident and received medical treatment. At approximately 40 years of age, he underwent cardiac catheterization and was given a diagnosis of Ebstein malformation. However surgery was not recommended. An echocardiogram showed a laceration at the tricuspid valve, enlargement of the tricuspid valve annulus and severe tricuspid regurgitation. The displacement of tricuspid valve was not present. His case was complicated with severe liver dysfunction of Child-Pugh class B and Model for End-Stage Liver Disease score 15. We performed tricuspid valve replacement with a Mosaic 31 mm tissue valve. The patient required pleurodesis for refractory severe pleural effusion at 2-months and was discharged 6 months after the operation.

Muscle blood flows by means of hydrogen gas clearance method were measured on hindlimb muscles in sedentary control (nE) and exercised (Ex) spontaneously hypertensive rats (SHR) . SHR and Wistar control rats (WCR) were divided into two groups at 7 weeks of age ; SHRnE, SHREx and WCRnE, WCREx. Exercised rats were bred in cages with rotating wheels capable of running voluntarily for additional 10 weeks. Body weights of exercised groups in both SHR and WCR were lower than those of sedentary controls, whereas food consumptions of exercised rats tended to be more than those of sedentary controls. Ratios of the heart weight to the body weight of SHR and WCR were higher in exercised groups. There was no significant difference in systolic blood pressure obtained by an indirect tail-cuff method between exercised and sedentary control SHR. Resting blood flows in both M. Gastrocnemius and M. Soleus showed lower values in SHR groups than those in WCR groups. Postexercise blood flows at 1 Hz and 5 Hz were higher in exercised groups. These results suggest that peripheral adaptability of blood flow control to the exercise is still normal on hindlimb muscles in SHR.

We report a case of a 74-year-old woman who suffered from uncomfortable heat under her right shoulder blade and felt anxiety about general fatigue that had been worsening mainly in the summer. She visited our Kampo clinic because of insufficient effect of various types of drug that had been prescribed by 3 doctors for about a year. We made the diagnosis of somatic symptom disorder and suggested Kampo therapy with decoction. We thought this might be caused by liver qi depression, blood deficiency, and blood stasis because he had symptoms of dry skin, cold of feet, deeply located fine pulse, pale and purple tongue with yellow thick fur, fullness in the chest and hypochondrium. Therefore we administered keppuchikuoto modified formula. Her symptom improved within about a month after taking this formulation. There was no recurrence of the physical symptom and fatigue in the summer during taking medicine for about 20 months. Evidence-based treatment in somatic symptom disorder has not been established and some cases are resistant to treatments in modern Western medicine. Kampo medicine may be useful and hopeful.

We report a case of a 51-year-old male who suffered from chronic idiopathic urticaria on every part of his body. Urticaria appeared especially in the morning and evening. He visited our Kampo clinic because of insufficient effect of antihistamine drug and tokiinshi that had been prescribed by a dermatologist for about a half year. We thought this might be caused by blood deficiency, blood stasis and liver qi depression because he had symptoms of sensitiveness of heat, dry skin, purple tongue with yellow fur, a deeply located string-like pulse,and fullness in the chest and hypochondrium. Therefore, we administered keigairengyoto and ryutanshakanto but the effect was insufficient. During this treatment, we revealed his state of having thick fur in tonguediagnosis. Finally we prescribed him seijobofuto and inchingoreisan because we concluded that it might be necessary to remove dampness-heat in this case. His symptom improved within about a week after taking this formulation. Some cases of chronic urticaria are resistant to standard treatments in modern western medicine. Kampo medicine may be useful and hopeful in these cases.

Sources of research funding: We gratefully acknowledge the support of the 17th Congress of the Japanese Society for Emergency Medicine support of this program.
Ethical considerations: The program was conducted after receiving approval from the Institutional Animal Experiment Committee of the Jichi Medical University, and in accordance with the Institutional Regulation for Animal Experiments and Fundamental Guideline for Proper Conduction of Animal Experiment and Related Activities in Academic Research Institutions under the jurisdiction of the Ministry of Education, Culture, Sports, Science and Technology of Japan. It was approved on April 9th, 2014. The approval number is 14-225.
Disclosure of conflicts of interests: We gratefully acknowledge the contributions of personnel from Panasonic Corp. who enabled the interactive communication system.
Abstract
Introduction: Live surgery demonstrations have been widely used in surgical education. However, they cannot be used to demonstrate trauma surgery due to the emergency situation and lack of informed consent. The aim of this study was to conduct a live demonstration of trauma surgery with a porcine model to increase educational opportunities in trauma surgery.
Methods: Live demonstration was conducted at the Center for Development of Advanced Medical Technology (CDAMtec) , Jichi Medical University, Japan. An experienced trauma surgeon instructed three trainees during a live demonstration using pre-planned injuries in a porcine model. A six-point Likert Scale was used on a written survey to determine the value of the program to the viewers. Free-form written comments were also obtained from the participants. Live images of the surgical field were transmitted to a lecture room by a closed wireless LAN with interactive bidirectional audio capability.
Results: Eighty-three participants viewed this live demonstration and completed the questionnaire. Participants were highly satisfied with the live demonstration (mean survey scores: 4.6-5.1/6) , and gave very positive feedback concerning the educational value of this program. Nine free-form comments were submitted, which revealed that the participants felt they could acquire concrete skills for trauma surgery.
Discussion: Live demonstrations for trauma surgery using a porcine model are a feasible and effective educational tool to demonstrate technical procedures and non-technical skills, with possible added advantages regarding the ethical considerations of performing a live surgery demonstration.

In patients with myocardial infarction (MI), anginal attacks, reinfarctions or sudden deaths occur occasionally during or after bathing. Therefore it is important to know well about influence of bathing on cardiac function. In this study we examined hemodynamic indices by means of Swan-Ganz catheter and blood flow pattern with Doppler echocardiographic method in comparison with cardiac events (CE) during and after admission.
Forty-nine patients with MI (mean age 58.9 years) were examined, including 14 patients with extensive anterior MI, 12 with anterior, 17 with inferior and 6 with anterior and inferior MI. Bathing was carried out at supine position in a tap water at 42°C during 5 minutes in the Hubbard tank. The patients was classified into two groups, one with CE (Group A), and the other without CE (Group B). Hemodynamic indices by means of Swan-Ganz catheter, peak velocities of blood flow (PV) at left ventricular outflow tract (LVOT) and blood flow pattern at left ventricular inflow tract (LVIT) with Doppler echocardiographic method were studied in comparisons.
Seven of 49 patients had CE (2 cases with sudden death, 2 cases with reattack of MI and 3 cases with heart failure), and 2 of theses 7 cases had CE during bathing (one with sudden death and the other with reattack of MI). Pulmonary capillary wedge pressure (PCWP) increased from 4.0±2.7mmHg to 12.5±4.6mmHg in Group B, while in Group A marked increases in PCWP on bathing were noted from 3.9±1.2mmHg to 18.1±4.8mmHg (p<0.001) and significant high level was maintained during bathing. Mean pulmonary arterial pressure (mPAP) in Group A also increased during bathing significantly compared with Group B. Six of 13 patients (46.2%) with decreased PV at LVOT and 3 of 8 patients (37.5%) with markedly increased A/R at LVIT on bathing had CE, which was noted at the higher rate compared with those with increased PV and without markedly increased A/R (each, p<0.001, p<0.05). In Group A, severe heart failure on admission into coronary care unit was significantly noted much (p<0.001), physical work capacity was lower in exercise tolerance test by bycyle ergometer and left ventricular ejection fraction was lower (26.9±6.1% vs 56.1±16.6%, p<0.001) with significance in cardiac catheterization, suggesting cardiac dysfunction.
In conclusion, bathing should be carried out carefully in patients with markedly increased PCWP or mPAP, with decreased PV at LVOT and with markedly increased A/R at LVIT.

Introduction : To promote disease management in the community, general physicians should refer their patients to specialists in a timely and appropriate manner. In this study, we propose an indicator for evaluation of such referrals.
Methods : We analyzed all referrals in an urban clinic from September 1, 2011 to August 31, 2012. Symptoms and diagnoses documented by general physicians were collected from medical records, and the final diagnoses by specialists were collected from their reports. The symptoms and diagnoses were classified using the International Classification of Primary Care second edition (ICPC-2). Referral rates, hospitalization rates, and place of referral were analyzed.
Results : The average number of encounters in the candidate clinic was 1402 per month, and the mean number of referrals was 23 (1.6% of encounters). Of patients who received a referral, 6.75 (29.1%) were admitted to hospitals. The symptoms and diagnoses of the referred patients were distributed across all chapters (A to Z) of ICPC-2. Diagnoses of admitted patients included pneumonia (R81) (24%), urinary tract infection (U70 and U71) (9%), and acute gastroenteritis with dehydration (D73 with T11) (9%).
Conclusion : We identified the referral rates, hospitalization rates, and distribution of referral patients as indicators of the triage function of primary care physicians. These should be evaluated further as potential indicators of “the quality of medical care.”

We report a case of a 3-year-old girl who suffered from alopecia areata and was successfully treated with rokumigan modified formula. Initially, alopecia areata appeared on her left temporal region at the age of 3. The hair loss range had spread rapidly over the whole head. She visited our Kampo clinic because of insufficient effect of antiallergic drug. We prescribed her yokukansan, shimotsuto and juzentaihoto but the effect was insufficient. Finally, we thought this might be caused by kidney yin deficiency and liver blood deficiency because she had symptoms of pale white complexion, fine pulse, pale tongue with thin fur, and night sweating. Therefore, we administered rokumigan modified formula : rokumigan, tokiinshi and lycium fruit. Her hair began to grow after administering this formulation. There was not the re-hair loss during taking medicine for about 4 months. According to the traditional Chinese medicine, alopecia areata can be classified into 4 types : blood heat type, blood stasis type, dual deficiency type of yin and blood, dual deficiency type of qi and blood. We diagnosed this case as a dual deficiency type of yin and blood and selected rokumigan modified formula. Rokumigan is effective for various symptoms of kidney yin deficiency, and rokumigan modified formula may be useful for the treatment of infant alopecia areata.