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.

Nationwide common achievement test system for entering clinical clerkship will formally start from December 2005. Before the start, four times trial examination were carried out. Based on these trials, some problems for the test sytem were pointed out. We have analysed the problems proposed to induce more suitable examination system.

Objectives
 The present study aimed to elucidate issues in maternal and child health in suburban areas by comparing the effects of increases in population, economic power, and amount of information on health behaviors among mothers such as pregnancy, childbirth, and child care in village A in the suburbs of Kathmandu between 2001 and 2006.
Methods
 We conducted an interview survey on mothers of children aged 0-12month in village one in Lalitpur district in Nepal. Data from 2001 and 2006 were compared for the educated group, non-educated group, and all subjects.
Results
 The number of mothers in ethnic minorities increased in 2006. The most commonly used facility for pregnancy examinations, delivery, and child illnesses was hospitals, and their use tended to increase from 2001 to 2006 for each type of visit. In addition, the cost of pregnancy examination and delivery increased approximately 7-and 2-fold, respectively. Kaup index increased by one point for the condition of child development. Prevalence of general infections among children decreased.
Conclusion
 Subjects were polarized into the middle class, which included individuals who had increased income by working as migrants abroad, and an economically disadvantaged group which included individuals who had migrated from rural areas. The active use of health services at hospitals among pregnant women and children was attributed to recognition of the safety and comfort of hospitals as well as the consumer culture resulting from growth of the middle class. The economically disadvantaged group was considered to be at high risk with regard to maternal and child health, and was thus thought to require affordable and accessible support. Issues in child care appeared to be shifting from “nutritional improvement” and “infection control” to “nutritional balance”.

Seven patients with congenital heart defects suffered from multiple major hemorrhages from the lung after surgery and 5 of them died at 8 to 54 postoperative days because of respiratory insufficiency. In a patient with tetralogy of Fallot associated with pulmonary atresia, bleeding occured after the second shunt operation, presumably from rupture of bronchial collateral vessels. The clinical diagnoses of the other 6 patients were coarctation of the aorta (CoA) with common atrioventricular canal (CAVC) in 1, triple shunt in 1, persistent truncus arteriosus in 2, total anomalous pulmonary venous connection in 1 and CAVC in 1. Subclavian flap aortoplasty was performed without pulmonary artery banding in the patient with CoA and CAVC, whereas complete repair was performed in the other 5 patients. As these patients were associated with severe pulmonary hypertension preoperatively and 4 of them encountered pulmonary hypertensive crisis, the hemorrhage from the lung may be related to pre and postoperative high pressure of the pulmonary artery. Dilatation and rupture of the pulmonary capillary net was demonstrated in the patient with CoA and CAVC. These findings suggest the hypothesis that bleeding occurred due to rupture of the capillary net as a result of transmission of high pressure. Major bleeding from the lung is a rare but catastrophic complication after repair of congenital heart defects. As the treatment is difficult, early surgical intervention and treatment of postoperative pulmonary hypertension are important in complex lesions with severe pulmonary hypertension.

Adipose triglyceride lipase (ATGL) catalyzes the first step of triglyceride hydrolysis. The gene mutations cause neutral lipid storage disease with myopathy (NLSDM) and/or triglyceride deposit cardiomyovasculopathy (TGCV) . Here we give the first report on rehabilitation of a patient with NLSDM and TGCV. The 62-years-old patient was admitted to our hospital for rehabilitation for skeletal myopathy and rehabilitation for cardiac dysfunction (NYHA class Ⅲ , ejection fraction 20%) . He complaint of dyspnea during the activity of daily life and exercise torelance was low. Our rehabilitation program consisted of physical therapy, occupational therapy, nutrition and cardiac education. We had paid a special attention to the intensity of exercise (aerobic training and resistance training) due to the low cardiac function, energy dysfunction and myopathy. After rehabilitation for two months, muscle strength had increased and 6MWT, ATVO₂ had improved. Importantly, the reduction of dyspnea on exertion as well as the increase in exercise capacity are considered to have led to improvement of quality of life.

A 55-year-old man visited his neighborhood general practitioner complaining of headache, fever and wet cough on July 7, 2003, but there were no sigins that his symptoms would subside. Since an abnormal shadow was found on chest X-ray on July 11, he was referred to our department and hospitalized on the same day. We started to treat him on the assumption that he had community-acquired pneumonia due-to common pathogens. However, he developed severe hypoxemia, and abnormal shadows rapidly progressed to affect both lungs, which led us to suspect that he had acute respiratory distress syndrome (ARDS). We identified the pathogen by examining urinary antigens and serum antibodies and diagnosed of his case as Legionella pneumonia. Although he suffered complications of acute renal failure and shock, the respirator was withdrawn after 11 days of controlled mechanical ventilation, as he was steadily recovering from his illness. The patient was discharged from the hospital on September 9. Although the mortality of legionella pneumonia, when complicated by ARDS, acute renal failure and shock as in the present case, has been reported to be as high as 50 to 80%, we consider that the administration of neutrophil elastase inhibitors and steroids was effective against this disorder.
Shock ; Respiratory Distress Syndrome, Adult ; Pneumonia ; Kidney Failure, Acute ; Complicated