I had an opportunity to attend the 10th Forum of Leaders of Medical Education, which was sponsored by the Japan Medical Education Foundation. Guest lecturers were Dr. Michael Rosenblatt, Executive Director of Harvard Medical School/Beth Israel Hospital Foundation for Research and Education, and Dr. Frank Harris, Dean of the Faculty of Medicine, University of Leicester. Both their lectures gave implicit suggestions for the future reform of Japanese medical education. The main suggestions to improve medical education were that 1) lectures on the clinical medicine should be minimized and self learning through a tutorial system should be encouraged; and 2) except for the basic medical sciences, teaching in medical schools and hospitals should be limited to the training of skills, including communication skills, for medical examinations. In addition, the system for evaluation of instructors at Harvard Medical School is impressive because it stresses educational ability and educational achievements rather than research achievements.

Radical changes were made last year in the educational program of liberal arts at Juntendo University School of Medicine. The number of required courses was decreased, and students were given more freedom to choose electives. A survey at the end of the first semester evaluating the reforms showed great satisfaction on both sides: students were highly motivated to study, and the teachers were ready to answer their needs.

Upper ministernotomy is frequently selected in aortic valve replacement by minimary invasive cardiac surgery. However, retrograde cardioplegia cannulae cannot be inserted to some sites. CT examinations in our department revealed that lower ministernotomy can be used for surgery of the aortic valve in many Japanese cases. The usefulness of 2 approaches was examined in 68 cases with aortic valve disease who received aortic valve replacement by minimary invasive cardiac surgery from January 1997 to March 2002: Those who received upper ministernotomy (U group) and those who received lower ministernotomy (L group). Retrograde cardioplegia is frequently used in aortic valve replacement for myocardial protection. Those in the L group showed effectiveness in myocardial protection and in securing the operation field except in cases who were switched to full sternotomy. In the L group, the MAZE operation was performed and no significant differences were observed in aortic cross-clamping time, artificial cardiorespiratory time, operation time, bleeding amount and other factors. Lower ministernotomy was more effective than upper ministernotomy in myocardial protection by retrograde cardioplegia and securing the operation field in aortic valve replacement by minimally invasive cardiac surgery.

Minimally invasive cardiac surgery (MICS) for treating valvular disease was introduced in our division in July 1997, and we have treated a total of 236 cases by July 2002. Among the various types of surgical treatment, there were 21 cases (M-group) of double valve replacement (DVR) to treat combined valvular disease. There had been 8 cases (F-group) of DVR by means of conventional full sternotomy during the period from January 1990 to June 1997, before the introduction of MICS. A comparison of the results of these surgical treatments yielded the following results. There were no differences in operation time and blood loss during the operations between the 2 groups, whereas the aortic cross clamp time and cardiopulmonary bypass time were significantly longer in the M-group than the F-group (M-group: 189±6 and 228±7min; F-group: 132±18 and 183±16min, respectively). There were significantly more cases of concomitant maze operation in the M-group than in the F-group. There were no differences in the durations of postoperative intubation or ICU stay. The days required from operation to starting walking were significantly shorter in the M-group compared to in the F-group (M-group: 2.4±0.2 days; F-group: 3.3±0.2 days), while there were no differences in the postoperative hospitalization periods. There were no major postoperative complications, and 1 case each there was 1 death in each group during the hospitalization period. Although the aortic cross clamp time and cardiopulmonary bypass time were longer in the M-group than in the F-group, the postoperative course and surgical outcome were good. So MICS for DVR was considered acceptable. In addition, MICS was thought to provide high patient satisfaction with regard to cosmesis or thoracic fixation, although early discharge from the hospital, which was possible in cases of single valve MICS, was not obtained.

A conventional reoperation via full sternotomy approach is associated with a higher risk of heart injury compared with first time operations. We employ a minimally invasive cardiac surgery (MICS) for valve reoperations in order to minimize dissection of sternal adhesions. We evaluated MICS for mitral reoperation in this report. We retrospectively analyzed 20 patients (group P) who underwent mitral reoperation via partial lower hemisternotomy (PLH) from July 1997 through March 2002, and 13 patients (group F) who underwent mitral reoperation via full sternotomy from April 1990 through June 1997. All patients received mitral valve replacement in both groups. Concomitant Maze procedures were significantly more frequent in group P (group P: n=8, group F: n=1). Aortic cross clamp times were significantly longer in group P (group P: 110±5min, group F:87±11min). The blood loss during operations was significantly less in group P (group P: 666±100ml, group F: 2, 405±947ml). Postoperative ventilation time and the length of intensive care unit stay were significantly shorter in group P. In group P and F the occurrence of a heart injury associated with sternotomy was 0/20 (0%), 2/13 (15%) respectively. Hospital mortality was 0/20 (0%), 2/13 (15%) respectively. There were neither any hospital deaths nor any postoperative major complications in group P. We conclude that PLH for mitral reoperations could be performed safely and is an alternative approach for mitral reoperations.

For the purpose of investigating weights in the era when the Shan Han Lun was set forth, the weight and measures described in the Ben Cao Jing Ji Zhu, written in the period slightly after the Shan Han Lun, were studied. Some descriptions of the metrological standards are confusing in the Ben Cao Jing Ji Zhu. We focused on the measuring container, whose volume is equal to that of the one cun square spoon (fang cun bi), shown in the dun huang version of the Ben Cao Jing Ji Zhu. The volume of this measuring container was calculated on the assumption that the measures in this text follow those of the Han Shu Li Li Shi, and a result of 5.07 cm³ was obtained. The result was confirmed by using the actual measured values of the crude drugs. The result was also considered to support measurements of the volume in the Ben Cao Jing Ji Zhu as following the Han Shu Li Li Shi. With those results, descriptions of the density of honey and lard were examined, and the weight in the Ben Cao Jing Ji Zhu was clarified to follow that in the Han Shu Li Li Shi.