We, the delegates of the 2016 Japan-UK exchange, herein report our experiences and impressions of British primary care: "the difference between the career paths of general practitioners from Japan and UK", "medical interpreters and care in a multicultural society" and "framework for development of clinical research". We described our experiences in UK with a literature review. The authors wish for the article to support the advancement of Japanese primary care.

Cardiovascular reoperations involve high-risk because of adhesions. We examined the strategies and clinical outcomes of the reoperations in our institute. From January 2003 to December 2008, 52 patients underwent reoperations, accounting for 4.5% of all adult patients. The duration from the previous surgery was 10.1±9.3 years. Reoperations were performed due to infection (n=10), after valve surgery (n=16), after coronary surgery (n=9), due to Marfan syndrome (n=3), after aortic surgery (n=7), after congenital surgery (n=4), and for other reasons. In the reoperations, the same surgical site was exposed in 65%, the femoral vessels were exposed before re-sternotomy in 77%, the inflow was on the ascending aorta in 35%, and cardiopulmonary bypass was initiated before re-sternotomy in 37%. Systemic cooling was needed in 4 patients and some maneuvers for patent internal thoracic artery grafts in 6 patients. The operation time of 9.6±2.5 h and the cardiopulmonary bypass time of 295±111 min, respectively. We experienced intraoperative injuries in 16 patients (31%). Platelet transfusion was needed in 90% and a second CPB in 15%. Postoperative complications included hemorrhage (14%), infection (13%), stroke (4%), respiratory failure (44%), and renal failure (1%). The hospital mortality was 7.7% (4/52) due to uncontrolled infection, liver failure, pulmonary hemorrhage, and left ventricular rapture. The 2-year survival rate was 83.1% with the mean follow-up of 24±18 months. In conclusion, although the risk of injuries at re-sternotomy was not high, limited surgical field due to adhesions resulted in fatal injuries and in the cardiac reoperations we experienced. We need to improve our strategies for further reduction in mortality and morbidities in reoperations.

Evidence suggests that sports activity can induce site-specific changes in bone mineral content (BMC) in athletes. Therefore, the first purpose of this study was to create a standard value for BMC (SV_BMC) that is independent of body size and physical exercise effect. The second purpose was to examine usefulness for the SV_BMC. In creating the SV_BMC, we recruited non-customer subjects who engaged in regular exercise but did not have site-specific changes to their bony structure. We studied 285 females (34.0±6.5 years) that were currently active, free from hormone treatment, and were not taking medication for any condition. Furthermore, all female subjects reported having a normal menstrual cycle. Bone area (BA), BMC and areal bone mineral density (aBMD) were measured by dual-energy X-ray absorption. Measurements of almost the complete skeleton, with the exception of the head, were taken (herein referred to as sub-total). This included scans of the entire spinal column, all 12 ribs, pelvis, full legs and arms. An allometry formula that relates BMC and BA was applied to determine the SV_BMC. To exclude the effect of body size, calculations were determined using the perpendicular distance from the data of each individual to that determined by allometry regression. Finally, the mean and standard deviation of the distance were converted into T-scores. In examination of reliability for the SV_BMC, we calculated the SV_BMC for three customer females who engaged in regular exercise. We found a significantly positive relationship between SV_BMC and weight/BMI. This correlation was weaker than the relationship between SV_BMC and BMC, as expected, or the relationship between SV_BMC and aBMD, with the exception of SV_BMC in the pelvis. In conclusion, this study suggests that SV_BMC is less affected by body size than by BMC or aBMD and the SV_BMC was provided highly useful in case study.

An 81-year-old man was referred to our hospital with bilateral multiple patchy opacities on chest radiography. His chief complaints were a few months’ history of intermittent mild cough and slightly yellow sputum. Chest computed tomography (CT) showed non-segmental air-space consolidations with ground-glass opacities. Amyloid deposition with organizing pneumonia (OP) was seen in transbronchial lung biopsy (TBLB) specimens from the left S8. Three months later, the infiltration originally seen in the left lower lobe was remarkably diminished, and new infiltrations in the lingual and right lower lobes were detected on chest CT. Amyloid deposition with OP was seen in TBLB specimens from the left S4. Transthyretin was detected following immunohistochemical examination. The presence of wild-type transthyretin (ATTRwt) was proven using genetic analysis. The present report describes a rare case of ATTRwt amyloidosis associated with OP.

A 60-year-old man with type 2 diabetes mellitus and severe obesity (height 170 cm, weight 160 kg, BMI 55) was admitted to our hospital because of acute inferior wall myocardial infarction due to acute thromboembolism of the right coronary artery (RCA). Because of three-vessel coronary diseases, we planned coronary artery bypass grafting after the medical therapy. The patient was intubated, then suffered congestive heart failure and pneumonia, and had a tracheotomy because of obesity hypoventilation syndrome. When his general condition improved after 14 months of medical therapy, we performed the operation. At that time, his weight had decreased to 107.5 kg, and BMI decreased to 37.2. We decided that tracheotomy was necessary to avoid respiratory complications. We chose a thoracoabdominal spiral incision for 2 reasons. Firstly we needed to avoid wound contamination by the tracheotomy stoma. Secondly we decided that the left internal thoracic artery (LITA) and the right gastroepiploic artery (RGEA) were sufficient for bypass grafts to the left anterior descending artery (LAD), the diagonal branches (D1), the posterolateral artery (PL) and the posterior descending artery (PD). Before the operation, epidural anesthesia was performed for postoperative analgesia to prevent respiratory dysfunction. In the right semi-lateral position at 30°, a 4th intercostal space thoracotomy was performed, and the LITA was harvested. The skin incision was extended to the midline of the abdomen and the RGEA was harvested. The end of the LITA was anastomosed with the free RGEA as I composite and the composite was anastomosed to the LAD, the D1, the 14 PL and the 4 PL without cardiopulmonary bypass. Without any perioperative blood transfusion, the patient was discharged with no perioperative complication, including mediastinitis. With this incision, we achieved secure prevention of wound contamination by the tracheotomy stoma, harvesting of a sufficient length of the LITA and RGEA and good visualization of the anastomotic sites with less cardiac displacement than median sternotomy.

Since the effect of the submaximal aerobic exercise on bone had been controversial, the aim of this study was to elucidate the effect of the bench step (BS), that seemed to deliver higher mechanical load on bone than any other aerobic exercises, on the total bone mineral content (BMC) and the bone metabolism of menopausal women. Sixteen menopausal women (65 ± 9 years old) as the exercise group (ExG) and 28 pre-menopausal women (43 ± 3 years old) as the control group (CG) were studied. ExG carried out BS training with the exercise intensity at lactate threshold (LT) for 21 weeks. In ExG, BMC was measured by dual energy X-ray absorptiometry (DXA) at one year before the intervention (A year before), pre-intervention (Pre) and post-intervention (Post). Serum osteocalcin (OC) as the marker of bone formation and serum type I collagen cross-linked N-telopeptide (NTx) as the marker of bone absorption at Pre, 11th week of the intervention and Post. In CG, BMC was measured annually without the intervention. In ExG, OC was not changed, but NTx was significantly decreased by intervention (p<0.05). The decreased amount of annual change in BMC between a year before and Pre (T1) was significantly higher compared to that between Pre and Post (T2) (p<0.01) and CG (p<0.001). There was no significant difference between T2 and CG. In conclusion, BS with LT could prevent decreasing BMC in menopausal women, and maintain the same level of BMC in pre-menopausal women by suppressing the bone absorption.

This study was performed by the purpose of early detection of Hand－Foot Syndrome (HFS) in patients receiving capecitabine therapy. Ten patients receiving chemotherapy with capecitabine after resection of colon cancer were included in this study. Surgeons decided the reduction or suspension of capecitabine when adverse effects were found. Pharmacists instructed the patients of the way of intake and side effects. Nurses instructed the patients how to make skin care with brochure and DVD. We called to or made an interview to the patients once a week in the first eight weeks of administration by evaluating the symptoms of HFS. Finally, a questionnaire was taken to evaluate the degree patients’ satisfaction. All of the ten patients continued the skin care in the study. HFS above grade 2 appeared in three cases, and early decision of reduction or suspension of capecitabine was achieved as the result of support by telephone call or interview. Support by either telephone call or interview by nurses in the medical team of chemotherapy can contribute to the completion of chemotherapy by capecitabine by detecting the HFS in the early stage which leads to the early decision of reduction or suspension and by reduce the anxiety of the patients. We also suggest the necessity of the construction of individualized support system to the patients in the future.