To improve doctors' understanding of dietary and nutritional therapy, clinical nutrition must be taught during undergraduate medical education. Using questionnaires given to every medical university in Japan, we examined how clinical nutrition education has been adopted into their curricula. Only 9 (12.9%) of 70 universities have adopted this topic as a cultural or professional subject. Many other universities are performing nonintegrated nutrition education by teaching nutrition-related items in basic and clinical subjects. Although many nutrition-related topics are included in the Essentials for the National Medical Board Examination published by the Ministry of Health and Welfare, only 1% to 5% of the 320 to 330 questions appearing on the national medical board examination are nutritionrelated. The present report suggests that the nutritional knowledge of doctors and medical students is not sufficient. We believe that national guidelines for problem-based nutritional education as part of an integrated curriculum must be established. The present situation of nutrition education in the United States, the United Kingdom, and Europe are also discussed.

Medical interviewing skills were assessed with the objective structured clinical examination using simulated/standardized patients (SP) in 36 5th-year medical students. ultaneously, assessment of cognitive-behavioral characteristics was performed using 7 kinds of scales (locus of control, social skills, self-esteem, general self-efficacy, medical interviewing-specific self-efficacy, person perception of self, and person perception of the patient) on the same students to clarify correlations with medical interviewing skills. Students who had attended a small-group mini-workshop session for medical interviewing skills showed only a significantly better ability to summarize. Personal familiarity with the patient was the only factor among the cognitive-behavioral factors studied which was a significantly correlated with medical interviewing skills. Among the six medical interviewing skills, only summarization and confirmation skills were positively correlated with the students' self-efficacy and the objective assessment with the objective structured clinical examination. We conclude that 1) medical interviewing skills can be taught regardless of the cognitive-behavioral abilities of each student; 2) teaching summarization and confirmation skills are especially valuable and important in teaching medical interviewing to medical students.

A program for teaching basic clinical skills to fifth-year medical students was started at Toyama Medical and Pharmaceutical University in 1999. The five units of basic clinical skills included: 1) medical interviewing, 2) general physical examination, 3) chest examination, 4) abdominal examination, and 5) neurologic examination. The educational strategies and evaluations in each unit consisted of: 1) lectures, 2) videotape demonstrations, 3) role-playing in small groups, 4) practice on patients in small groups, 5) written examinations, and 6) objective structured clinical examinations. The students evaluated each session of the program with a five-grade rating scale and comments. Small-group sessions (role play and practice on patients) and objective structured clinical examinations received the highest scores, followed by videotape demonstrations. Lectures received significantly lower scores than did other parts of the program. In addition, most students recommended standardization of educational content, increased practice time, and fewer lectures. We conclude that evaluation by students is essential for improving programs for teaching basic clinical skills.

Although it has been established that exercise is useful for health promotion, physical exercise may induce oxidative stress in humans. Our previous study showed that the concentration of plasma protein-bound sulfhydryl groups (p-SHs) was significantly decreased after strenuous exercise, i. e. full-marathon running and participation in an athletic training camp. Reactive oxygen species may cause oxidation of plasma proteins in vitro. To study whether moderate exercise for health promotion, e. g. jogging or walking, induces oxidative stress in human circulating blood, the authors examined the change in plasma p-SHs concentration following ergometric exercise at moderate intensity and of relatively short duration {Exercise 1: 80% ventilatory threshold (VT), 100% VT, and 110% VT; 30 min, Exercise 2 : 90% VT; 120 min} in 8 (23-28 yr; Exercise 1) and 6 males (23-28 yr; Exercise 2) respectively. The plasma p-SHs concentration did not changed significantly after Exercise 1 or 2. The data indicated that the exercise did not cause significant modification of plasma proteins, suggesting that it did not induce significant oxidative stress in the circulating blood.

To investigate a relationship between gender differences in recovery from skeletal muscle fatigue and muscle oxygenation, we examined whether there is a difference in oxygen supply and consumption of the working muscles after intermittent handgrip exercise between young males and females using near-infrared spectroscopy (NIRS). Healthy young subjects (25.8±3.9 years ; males, n=10 ; females, n=10) repeated static maximal voluntary contractions (MVC) with a handgrip for 5 seconds followed by 5 seconds rest for a period of 4 minutes in Study 1. The MVC force was measured before, each minute during the handgrip exercise, and 2, 5, and 10 minutes following the exercise. In Study 2, the selected 10 subjects (males, n=5 ; females, n=5) performed the same exercise and their total- and deoxy- hemoglobin/myoglobin level was measured using the venous occlusion NIRS method; and O₂ supply index (OSI) and O₂ consumption index (OCI) calculated before and after the exercise. In Study 1, females exhibited higher %MVC force at the end of the exercise and during the recovery period than males (p<0.05). In Study 2, the %OSI was significantly lower in females than in males at 5 and 10 minutes in the recovery period (p<0.05), but no significant differences were detected in %OCI. Furthermore, %MVC of the recovery period correlated with %OCI of the recovery period in females (r=0.724, p=0.015), but not in males. These findings suggest that female working muscles can convert consumed oxygen more effectively after an intermittent handgrip exercise, and therefore, be able to recover muscle force faster.

　　A 48-year-old man with jaundice was referred to our hospital. Endoscopic retrograde cholangiography showed primary sclerosing cholangitis. Endoscopic biliary drainage was not successful because of highly viscous bile, so we performed percutaneous trans-gallbladder drainage (PTGBD), which was able to reduce the total serum bilirubin level from 8 to 10mg/ml. Subsequently, an indwelling drainage catheter was placed in the gallbladder for 13 months. However, liver atrophy worsened with the gradual progression of hepatic failure. Twelve months later, he complained of dyspnea. Computed abdominal tomography showed that the drainage catheter had perforated the diaphragm and become exposed to the chest cavity. In spite of intensive care, the patient died of liver failure while waiting for a liver transplant. Careful attention should be paid to the possibility of this serious complication in such patients.

To clarify the core competencies developed through postgraduate clinical training, we analyzed the conditions of our residency program with qualitative research methods. Seven residents (6 first-year residents and 1 second-year resident) answered a questionnaire and underwent semistructured interviews about postgraduate training. We also worked with the residents as “participant observers” of the treatment team. We found that residents often had trouble formulating diagnostic/treatment plans and tended to rely excessively on laboratory data to make decisions. We attribute these problems to a lack of practice in questioning expectations. We hypothesized that mitate-ryoku, the ability to describe the course of a patient's illness, is an extremely important clinical competency. According to the hypothesis, we tried to listen to the residents' description and to discuss it logically as colleagues. The residents described the patients expected condition over the next few days, considering both data and information they obtained from interviews and physical examinations. They adapted their ideas through logical discussion and were thus able to make acceptable decisions by themselves.

A 68-year-old woman received aortic valve replacement (AVR) with a Freestyle stentless valve using a subcoronary technique for aortic stenosis and regurgitation in September 2000. She complained of chest pain, had low grade fever and findings of inflammation and was admitted to our hospital with a diagnosis of acute myocardial infarction in December 2000. She suffered from repetitive or recurrent myocardial infarction. Transesophageal echocardiogram revealed no abnormal findings of the Freestyle stentless valve, but her blood culture was positive for methicillin-resistant coagulase negative Staphylococcus aureus (MRCNS) and she underwent an emergency operation. The Freestyle stentless valve was removed and replaced with a mechanical valve. The patient's intraoperative tissue grew MRCNS and parenteral antibiotics were administered for 8 weeks after surgery. Her condition was complicated with multiple cerebral infarction, however she was discharged on the 113th postoperative day and is doing well without recurrence of infection 12 months after the operation.

A 69-year-old woman underwent aortic valve replacement (AVR) for prosthetic valve (Freestyle^TM stentless valve) endocarditis (PVE) in April 2001. The patient was admitted to our hospital with diarrhea and tarry stools in January 2002 and was treated with intravenous hyperalimentation. She had fever and inflammatory findings at 1 week after admission, and was given intravenous antibiotics. Symptoms and laboratory findings improved gradually, but transesophageal echocardiography revealed a mobile mass in the ascending aorta near the noncoronary sinus of Valsalva. The serum β_-D glucan level was elevated and blood culture was positive for Candida parapsilosis. These findings suggested fungal endocarditis of the ascending aorta, so the patient underwent surgery. Vegetation was attached to the aortic wall near the noncoronary sinus of Valsalva. It was removed with part of the ascending aorta, followed by reconstruction with a gusset xenograft. In addition, aortic valve replacement was performed with a mechanical valve. The resected tissue grew C. parapsilosis, so parenteral anti-fungal drugs were administered intravenously for 8 weeks after surgery. Although cerebral infarction occurred, she was discharged on the 133rd postoperative day. There was no recurrence of infection and she remained on oral anti-fungal medication for 24 months postoperatively.