We encountered with four child patients infected with a new type of influenza virus. All the cases were complicated by severe dyspnea. This study was to review the clinical picture of the influenza, and some problems that confronted us in the course of treatment. The four patients had not been vaccinated. Three of them had a history of bronchial asthma. Two developed a fever and dyspnea all at once, and the other two had acute dyspnea in less than nine hours after the attack of fever. Antiviral agents were totally useless for preventing the disease from worsening. The clinical features were exacerbated asthma, pneumonia, air leak, and plastic bronchitis. Two children were mechanically ventilated. All the patients were given corticosteroids in addition to antiviral drugs (the methylprednisolone pulse therapy given to three patients). Two patients were administered with sivelestat. All the patients recovered their illness. There was no incidence of nosocomial infestion. Keeping watch for any change in the condition of the respiratory organs is needed in the infantile case of a new type of influenza regardless of whether or not the patient has a history of bronchial asthma. The new influenza may suddenly become worse. It is almost impossible to contain the virus with antiviral drugs. Early vaccination is of cardinal importance before influenza spreads around the world in seasonal epidemics.

An 89-year-old man was referred to our hospital for treatment of hepatolithiasis causing recurrent cholangitis. He had undergone a prior Whipple procedure. Computed tomography demonstrated left-sided hepatolithiasis. First, we conducted peroral direct cholangioscopy (PDCS) using an ultraslim endoscope. Although PDCS was successfully conducted, it was unsuccessful in removing all the stones. The stones located in the B2 segment were difficult to remove because the endoscope could not be inserted deeply into this segment due to the small size of the intrahepatic bile duct. Next, we substituted the endoscope with an upper gastrointestinal endoscope. After positioning the endoscope, the SpyGlass digital system (SPY-DS) was successfully inserted deep into the B2 segment. Upon visualizing the residual stones, we conducted SPY-DS-guided electrohydraulic lithotripsy. The stones were disintegrated and completely removed. In cases of PDCS failure, a treatment strategy using the SPY-DS can be considered for patients with hepatolithiasis after a Whipple procedure.
Aged, 80 and over ; Bile Ducts, Intrahepatic ; Cholangitis ; Endoscopes ; Endoscopes, Gastrointestinal ; Humans ; Lithotripsy

In March 2001, Research and Development Project Committee for Medical Educational Programs proposed a model core curriculum for undergraduate medical education. In this curriculum, implementation of the clinical clerkship is strongly recommended. Two similar curriculum models were later presented by other organizations, and some differences were observed among them. We, Undergraduate Medical Education Committee, have evaluated and compared themodel core curriculum 2001 with the Japanese newer proposals as well as those of USA and UK. Here is reported our proposals for a better rewriting of the learning objectives in the model core curriculum 2001, with some emphasis on the nurture of the competence of the case presentation and decision making process.

In order to implement, or enhance the quality of clinical clerkship, it is necessary to develop good educational environment which will be appropriate to allow medical students participate in medical team services. Important things to be considered will be, (1) Systematic management of the individual department's program by the faculty of medicine, (2) Developing educational competency within the medical care team function, and (3) Nurturing students' awareness forself-diected learning and cooperative team work, and teaching- and medical staffs' awareness of their educational responsibilities. In this paper, to develop better educational environment for clinical clerkship, we propose a desirable situation of the educational organization, dividedly describing on the roles of dean, faculties, board of education, department of medical education, clerkship director, teaching physicians, residents and medical students.