BACKGROUND: Practice guidelines have been increasingly recognized as an important tool for improving the quality of medical care. However, few studies have evaluated the clinical effectiveness of practice guidelines.
PURPOSE: To gain an insight into the clinical impact of practice guidelines.
METHODS: MEDLINE was searched in order to review experimental or quasi-experimental studies on the clinical impact of therapeutic practice guideline developed by specialist organizations or national/regional agencies.
RESULTS: A total of 17 studies was found, 10 (59%) of which reported positive clinical impacts and seven did not. Among the seven negative studies, two reported poor adherence by providers to guideline recommendations and three did not mention adherence. It was thus not possible to determine whether negative results reflected poor adherence by the providers or ineffectiveness of the practice guidelines themselves. The studies varied so widely that a formal meta-analysis was impossible.
CONCLUSION: The use of practice guidelines tended to have a positive clinical impact. However, sub-optimal study design and/or lack of data on key items such as the extent of adherence to guideline recommendations at the provider's level made the interpretation of study findings difficult.

1) Although maternity leave can facilitate the professional success of female students.The extent to which maternity leave is implemented remains unknown.A cross-sectional questionnaire survey of all Japanese medical schools and postgraduate schools in medicine (N=81) was performed.Responses were received from 55 medical schools and postgraduate medical schools (response rate=67.9%).The results showed that no school had formally established a maternity leave policy for students.
2) We found that medical educators had reorganized clinical clerkship programs to accommodate the pregnancies of students but expressed confusion about how to manage such situations.
3) We also found that many female postgraduate students drop out because of pregnancy or child-care responsibilities. Medical schools and postgraduate schools should recognize the importance of maternity leave and should not close their doors to pregnant students who are contending with both motherhood and academic achievement.

Male mice of dd-strain, at 3 weeks of age were used at the start of the exercise training. The exercise training continued successively throughout the 3 to 7 weeks of age. The trained group was divided groups ; namely, light-, middle- and heavy-trained groups, which were exercised on a treadmill. The treadmill exercise program for light-, middle- and heavy-trained groups consisted of running at speeds of 6 m/min, 10 m/min and running up a 10% grade at a speed of 12 m/min for 10 min 5 times a week, respectively. The untrained group was used as control under normal laboratory condition. The skin and Achilles tendon of the four groups were sampled and their collagen content were examined by means of concentration of hydroxyproline. The collagen content in the skin of growing mice did not recognize significant difference among the four groups. On the other hand, the collagen content in the Achilles tendon of growing mice clearly recognized significant difference between the middle-trained and untrained groups and/or between the middle-trained and light-trained groups. However, middle-exercise training reduced the accumulation of collagen in the Achilles tendon of grow. ing mice.

Objective: The purpose of the present study was to clarify the efficacy of alendronate and raloxifene for preventing bone loss in patients with hip fracture by monitoring bone mineral densities (BMDs) and biochemical markers during the 9-month period after fracture. Patients and Methods: Eighty-two female hip fracture patients from 50 to 99 years old (mean ± SD: 81.6 ± 9.5) were randomly divided into two groups; there were 46 patients in the alendronate-treated group (group ALN) and 36 patients in the raloxifene-treated group (group RLX). Drugs were administered to patients six weeks after their operations. Lumbar spine BMD and neck, trochanter, Ward's and total BMDs of the contralateral proximal femur, serum intact osteocalcin (intact OC), bone-specific alkaline phosphatase (BAP) and urinary N-terminal telopeptide of type I collagen (NTX) were measured just before the start of drug administration and at 9 months thereafter. Results: Twenty-two out of 46 patients in group ALN and 23 out of 36 patients in group RLX completed the study. The most common reason for dropping out was the patient's failure to visit the outpatient clinic. Trochanter BMD in group ALN tended to increase by 8.4% compared with the baseline, and total hip BMD in group RLX showed a significant increase (5.7%), although neck BMD in both groups decreased during the 9 months of treatment (–8.7% for group ALN and –4.2% for group RLX compared with the baseline). Spine BMD did not change significantly in eithr group. Serum BAP and urinary NTX decreased significantly in both groups. Serum intact OC did not change significantly. Conclusions: Both alendronate and raloxifene have a favorable effect on trochanter and total BMDs of the contralateral proximal femur in the short period after hip fracture. However, both drugs could not prevent bone loss in the femoral neck during the 9 months of treatment.

We report a case of left internal iliac aneurysm that ruptured into the left common iliac vein and formed an arteriovenous fistula. A 79-year-old man who had general fatigue was admitted to our hospital with a diagnosis of left internal iliac artery aneurysm, left hydronephrosis, dehydration and low renal function. After dehydration and low renal function resolved rapidly by medical treatment, an enhanced computed tomography was performed. This demonstrated a 69 by 67 mm diameter left internal iliac artery aneurysm with an arteriovenous fistula. During the operation, left common iliac artery and left external iliac artery were resected and the stumps sutured. External iliac-external iliac artery bypass was performed. An occlusive balloon catheter was inserted from the left femoral vein and the balloon was dilated to patch the fistula before opening the aneurysm. After clamping the proximal artery the aneurysm was opened. Bleeding from the fistula was controlled by this maneuver and digital compression of the left common iliac vein where was proximal side of fistula. An arteriovenous fistula with a 18 by 3 mm orifice was found between the left internal iliac artery and left common iliac vein. The fistula was closed from the inside of the aneurysm. His postoperative course was uneventful.

Diagnosis of cardiac rupture caused by blunt trauma is sometimes difficult when multi-organ injuries are associated with profound shock. Only prompt diagnosis and urgent treatment can save the patients. We have encountered 16 cases of blunt cardiac rupture, including 4 that survived in the past 10 years. All cases of cardiopulmonary arrest on arrival were unable to be resuscitated. Also, all cases of profound hemorrhagic shock caused by multi-organ injury succumbed. Among the cases in which the region of cardiac rupture was identified, only cases of injury to the right heart chambers were saved. No case of rupture in the left heart chambers survived. It is definitely important to suspect cardiac injury and make a prompt diagnosis to save patients with blunt chest trauma. Ultrasonic cardiography is highly effective for urgent diagnosis of cardiac rupture because it can be performed readily, noninvasively and, therefore, repeatedly.

A 67-year-old man presented complaining of unstable angina. Coronary angiography revealed 50% stenosis of the left main trunk of the left coronary artery and a coronary artery aneurysm in the left anterior descending artery (LAD) #6. Furthermore, significant stenosis was noted in the peripheral LAD #7 and #9. The patient had hepatitis C, probably due to an earlier transfusion, and was suffering from liver cirrhosis (Child-Pugh classification grade A) and advanced thrombocytopenia. We anastomosed the saphenous vein graft (SVG) to the LAD and diagonal branch by off-pump coronary artery bypass grafting; we did not treat the aneurysm. There were no postoperative complications and the patient's progress was good. On postoperative coronary angiography, the aneurysm was occluded and the patency of the SVG was satisfactory.

We experienced the coronary artery bypass grafting (CABG) with essential thrombocythemia (ET). A case is a man of 73 years old. As for him, 3 vessel disease including left main trunk was recognized on coronary angiography, and it was planned CABG. However, we recognized blood cell aberration in blood examination, and it was diagnosed as ET. ET is classed as a chronic myeloproliferative disorder. It has two opposite tendencies, a bleeding tendency and thrombus tendency. Ischemic heart disease to merge ET is acute myocardial infarction by thrombus in case of most, and there are a few cases to need blood circulation reconstruction of coronary artery for angina pectoris. Perioperative hemorrhage and postoperative graft closure become a problem in CABG with ET. With the hydroxycarbamide which is DNA synthesis inhibitor of a platelet count, a function controlled it, and enforced CABG. He doesn't have any cardiac events and complications due to ET for 7 years post CABG. We report this case with a review of the literature.

Postoperative infections should be comprehensively controlled in the context of infection control, rather than as activities of individual surgeons. We started a surgical site infection (SSI) surveillance program in 2009 in which prophylactic measures for preventing SSIs were applied. These measures were as follows : 1) screening for nasal carriage of methicillin-resistant Staphylococcus aureus ; 2) dental checks and oral screening ; 3) antibiotic prophylaxis in the intra- and postoperative period ; 4) control of glucose levels to ≤160 mg/dl in the immediate postoperative period ; and 5) early removal of surgical drain. After the introduction of prophylactic measures, we reexamined SSI surveillance and added the following prophylactic measures at the beginning of 2011 : 6) data concerning SSI and compliance with prophylactic measures for all surgical and ward staff were published monthly, and the Infection Control Team (ICT) and surgeons performed weekly ward visits to assess SSIs ; 7) recommendations were made for wearing two pairs of gloves and surgical hoods to cover the hair, scalp, ears and neck ; and 8) collaboration with diabetologists was implemented to control glucose levels in diabetics. We compared incidences of SSI in cardiovascular surgery from the periods before (469 cases, Group B) and after (118 cases, Group A) introduction of the additional prophylactic measures. Clinical characteristics of patients in each group did not differ significantly. Operative time was significantly shorter in Group A (400±116 min) than in Group B (434±145 min). Compliance with antibiotic prophylaxis in the intraoperative period improved progressively from 93% in Group B to 99% in Group A. Compliance with control of glucose levels to ≤160 mg/dl on postoperative day 1 improved progressively from 71% in Group B to 81% in Group A. Duration of drain placement was significantly shorter in Group A (2.9±1.8 days) than in Group B (3.6±2.9 days). Incidence of SSI decreased significantly from 6.0% in Group B to 0.8% in Group A. Revision of preventive measures based on the results of surveillance and enhancement of cooperation between the ICT and surgeons could help to decrease the incidence of SSI.