More than 2 years have passed since the new postgraduate clinical training program was instituted in 2004 to improve the clinical ability of Japanese physicians. However, there have already been discussions about whether the undergraduate curriculum and the postgraduate program should be improved.
After the first physicians finished their training under the new program in the spring of 2006, questions were raised about whether the identical final goals of training could be achieved by transferring some items of postgraduate clinical training to the undergraduate period. Such a change might invigorate the undergraduate curriculum and enhance the effectiveness of the postgraduate program.
1) Are-evaluation of the final goals of postgraduate clinical training might allow some items to be taught during the undergraduate period.
2) Several questionnaires were sent to 211 supervising physicians and 184 first-year residents who had just completed the new internship program at 25 teaching hospitals (university hospitals and postgraduate training hospitals).
3) Both trainees and supervising physicians reacted positively about and expressed a willingness to participate in training items, including noninvasive diagnostic procedures and laboratory studies not harmful to patients, during advanced courses in the undergraduate period.
4) Both trainees and supervising physicians reacted negatively to participating in any invasive procedures that might affect a patient's welfare or sense of shame during the undergraduate period.
5) In the future, training with simulated procedures before actual patients are encountered and enlisting enough supervising physicians are essential for unifying the undergraduate medical school curriculum and postgraduate clinical training programs.

A 71-year-old man was given a diagnosis of saccular aneurysm of the aortic arch (maximum 48mm in diameter) at the age of 68. When he was 69 years old, he began to take steroids for autoimmune hepatitis (AIH). The following year, the aneurysm was enlarged to 52mm. Further examinations showed the aneurysm to extend to the ostium of the left subclavian artery. Since he had transient ischemic attacks, ultrasonography of the carotid arteries was performed. Bilateral internal carotid stenoses were detected, however, cold Xe CT showed an almost normal pattern of cerebral blood flow. We decided that operation was feasible using retrograde cerebral perfusion (RCP). Liver dysfunction due to AIH improved, and his steroid dosage was tapered. Using RCP, the no-touch technique and the elephant trunk procedure, he underwent the replacement of ascending aorta and aortic arch and was discharged without major complications. RCP and the no-touch technique might enable safer operations on patients with carotid stenoses.

STUDY DESIGN: Gait analysis of patients with cervical spondylotic myelopathy (CSM) by using a sheet-type gait analysis system. PURPOSE: The aim of this study was to compare the gait patterns of patients with CSM, evaluated by the Nurick grades, and to determine the threshold values of gait parameters predicting the occurrence of a fall by using a gait recorder. OVERVIEW OF LITERATURE: Gait disorder due to CSM may progress to severe paraplegia, following even a minor trauma such as a fall. The indications for the surgery of CSM without severe paralysis remain controversial. The quantitative gait analysis and the decision for decompressive surgery in patients with CSM are important in order to prevent severe paraplegia from a fall. METHODS: One hundred thirty-two subjects (normal, 34; CSM, 98) underwent gait analysis by using a sensor sheet. Measurements of gait cycle parameters included the step and stride length, step width, foot angle, swing phase, and stance phase. CSM was assessed by Nurick grade. RESULTS: Although the clinical symptoms were lacking, Nurick grade 1 had significant abnormalities in the parameters of velocity, step length, and step angle (p<0.05). Regarding the Nurick grade and walking phase, the length of the stance phase was increased to more than 70% of the entire walking cycle in Nurick grade 4. CONCLUSIONS: Gait analysis was an objective tool for evaluating the gait stability. Our results suggested that when the percentage of the stance phase in the gait cycle increases to above 70%, the CSM patients have an increased fall risk.
Foot ; Gait* ; Humans ; Movement Disorders ; Paralysis ; Paraplegia ; Physical Examination ; Spinal Cord Diseases* ; Walking

STUDY DESIGN: Radiological analysis of normal patterns of sagittal alignment of the spine. PURPOSE: This study aimed to clarify the characteristics of normal sagittal spino-pelvic alignment in Asian people. OVERVIEW OF LITERATURE: It is known that there are differences in these parameters based on age, gender, and race. In order to properly plan for surgical correction of the spine for Asian patients, it is necessary to understand the normal spino-pelvic alignment parameters for this population. METHODS: This study analyzed 86 Japanese healthy young adult volunteers (48 men and 38 women; age 35.9+/-11.1 (mean+/-standard deviation [SD]). The following parameters were measured on lateral standing radiographs of the entire spine: sagittal vertical axis (SVA), horizontal distance between the C7 plumb line and the posterior superior corner of the superior margin of S1, thoracic kyphotic angle (TK), lumbar lordotic angle (LLA), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). RESULTS: The values (mean+/-SD) of SVA, TK, LLA, SS, PT, and PI were 8.45+/-25.7 mm, 27.5+/-9.6degrees, 43.4+/-14.6degrees, 34.6+/-7.8degrees, 13.2+/-8.2degrees, and 46.7+/-8.9degrees, respectively. The Japanese young adults evaluated in this study tended to have a smaller PI, LLA, TK, and SVA than most Caucasian people. Regarding gender differences, SVA was significantly longer and TK was significantly smaller in men; however, there was no statistically significant difference in LLA, SS, PA, and PI. CONCLUSIONS: Japanese young adults apparently have smaller PI and LLA values than Caucasian people. When making decisions for optimal sagittal spinal alignment, racial differences should be considered.
Asian Continental Ancestry Group* ; Axis, Cervical Vertebra ; Continental Population Groups ; Female ; Humans ; Incidence ; Male ; Spine ; Volunteers ; Young Adult*

STUDY DESIGN: Normal cervical sagittal length patterns were measured by magnetic resonance imaging (MRI). PURPOSE: The aim of this study was to evaluate the relationship of sagittal length patterns between the cervical cord and the cervical canal in flexion-extension kinematics. OVERVIEW OF LITERATURE: Cervical dynamic factors sometimes cause a cervical spondylotic myelopathy in elderly subjects and an overstretching myelopathy in juvenile subjects. Previous studies showed the length changing of the cervical cord in flexion and extension. However, there is no detailed literature about the relationship between cervical vertebral motion and cord distortion yet. METHODS: Sixty-two normal subjects (28 male and 34 female, 42.1+/-8.5 years old) without neck motion disturbances and abnormalities on cervical X-ray and MRI were enrolled in this study. RESULTS: The cervical cord length was significantly longer in flexion and significantly shorter in extension in all cervical cord sagittal lines. The cervical canal length pattern was also the same as the cervical cord. The elongation of the cervical cord and canal was the largest at the site of the posterior cervical canal and the shortest at the anterior canal site. The positions of the cerebellar tonsils were verified at each neck position. CONCLUSIONS: The posterior elements of the cervical canal were most affected by neck motion. Movement directions of the upper cervical cord were verified among the various neck positions.
Aged ; Biomechanical Phenomena ; Female ; Humans ; Magnetic Resonance Imaging ; Male ; Neck* ; Palatine Tonsil ; Spinal Cord Diseases

PURPOSE: The purpose of this study was to quantify the target coverage, homogeneity, and robustness of the dose distributions against geometrical uncertainties associated with four whole breast radiotherapy techniques. METHODS: The study was based on the planning-computed tomography-datasets of 20 patients who underwent whole breast radiotherapy. A total of four treatment plans (wedge, field-in-field [FIF], hybrid intensity-modulated radiotherapy [IMRT], and full IMRT) were created for each patient. The hybrid IMRT plans comprised two opposed tangential open beams plus two IMRT beams. Setup errors were simulated by moving the beam isocenters by 5 mm in the anterior or posterior direction. RESULTS: With the original plan, the wedge technique yielded a high volume receiving > or =107% of the prescription dose (V107; 7.5%+/-4.2%), whereas the other three techniques yielded excellent target coverage and homogeneity. A 5 mm anterior displacement caused a large and significant increase in the V107 (+5.2%+/-4.1%, p<0.01) with the FIF plan, but not with the hybrid IMRT (+0.4%+/-1.2%, p=0.11) or full IMRT (+0.7%+/-1.8%, p=0.10) plan. A 5-mm posterior displacement caused a large decrease in the V95 with the hybrid IMRT (-2.5%+/-3.7%, p<0.01) and full IMRT (-4.3%+/-5.1%, p<0.01) plans, but not with the FIF plan (+0.1%+/-0.7%, p=0.74). The decrease in V95 was significantly smaller with the hybrid IMRT plan than with the full IMRT plan (p<0.01). CONCLUSION: The FIF, hybrid IMRT, and full IMRT plans offered excellent target coverage and homogeneity. Hybrid IMRT provided better robustness against geometrical uncertainties than full IMRT, whereas FIF provided comparable robustness to that of hybrid IMRT.
Breast Neoplasms ; Breast* ; Humans ; Prescriptions ; Radiotherapy* ; Radiotherapy, Intensity-Modulated

STUDY DESIGN: Retrospective study. PURPOSE: To investigate the relationship between preoperative total spinal sagittal alignment and the early onset of adjacent segment degeneration (ASD) after single-level posterior lumbar interbody fusion (PLIF) in patients with normal sagittal spinal alignment. OVERVIEW OF LITERATURE: Postoperative early-onset ASD is one of the complications after L4–L5 PLIF, a common surgical procedure for lumbar degenerative disease in patents without severe sagittal imbalance. A better understanding of the preoperative characteristics of total spinal sagittal alignment associated with early-onset ASD could help prevent the condition. METHODS: The study included 70 consecutive patients diagnosed with lumbar degenerative disease who underwent single-level L4–L5 PLIF between 2011 and 2015. They were divided into two groups based on the radiographic progression of L3–L4 degeneration after 1-year follow-up: the ASD and the non-ASD (NASD) group. The following radiographic parameters were preoperatively and postoperatively measured: sagittal vertebral axis (SVA), thoracic kyphosis (TK), lumbar lordosis, pelvic tilt, and pelvic incidence (PI). RESULTS: Eight of the 70 patients (11%) experienced ASD after PLIF (three males and five females; age, 64.4±7.7 years). The NASD group comprised 20 males and 42 females (age, 67.7±9.3 years). Six patients of the ASD group showed decreased L3–L4 disc height, one had L3–L4 local kyphosis, and one showed both changes. Preoperative SVA, PI, and TK were significantly smaller in the ASD group than in the NASD group (p <0.05). CONCLUSIONS: A preoperative small SVA and TK with small PI were the characteristic alignments for the risk of early-onset ASD in patients without preoperative severe sagittal spinal imbalance undergoing L4–L5 single-level PLIF.
Animals ; Female ; Follow-Up Studies ; Humans ; Incidence ; Kyphosis ; Lordosis ; Male ; Retrospective Studies

　　Chronic kidney disease (CKD) has recently been reported to be an independent risk factor for stroke. However, a detailed analysis was yet to be conducted according to stroke subtype. We attempted to determine the risk factors for stroke using data from the “specific health checkup” for metabolic syndrome conducted by the 9 hospitals affiliated with the Akita Prefectural Federation of Agricultural Cooperatives, and evaluate and determine the risk factors for stroke. There were 401 patients who had undergone metabolic syndrome checkups from 2007 and 2010 and suffered from stroke afterwards within 3 years after the screening. The controls were all 69,407 subjects who were screened during the same period. The predictors examined were sex, age, blood pressure, BMI, cholesterol values (HDL・LDL), history of diabetes mellitus, presence of atrial fibrillation, CKD, and drinking and smoking habits. Analysis was conducted using logistic regression. The risk factors for stroke as a whole were male sex, age, blood pressure, diabetes, atrial fibrillation, CKD, and smoking history. For cerebral infarction, the risk factors were male sex, age, blood pressure, diabetes, atrial fibrillation, CKD, and smoking habit. The risk factors for cerebral hemorrhage were age, blood pressure, and CKD. For subarachnoid hemorrhage, the risk factors were female sex, age, blood pressure, low HDLemia, and CKD. In conclusion, CKD is an independent risk factor for the 3 subtypes of stroke, and in particular plays an important role as a higher risk factor for cerebral hemorrhage. Smoking cessation and controls of blood pressure, diabetes and atrial fibrillation are the important measures for stroke prevention. In addition, the further intervention should also be targeted to those with the result of CKD revealed by specific health checkups.