1) We searched the Internet with Google and the key words "GIO," "SBO," "general objectives," and "behavioral objectives."2) Most of the top 100 Web sites found with searches using the key words "GIO" and "SBO" were related to Japanese medical education.3) Most of the top 100 sites found through searches using the Japanese key words "general objectives" and "behavioral objectives" were related to medical education.

A 2-day-old male baby was referred to our hospital because of a heart murmur. We diagnosed as a right cervical aortic arch, and coarctation between the right carotid and right subclavian artery. On echocardiography, the velocity at the coarctation was 1.8 m/s, the left ventricular ejection fraction (LVEF) was 53%, and he was asymptomatic during the neonatal period. A chromosome examination showed a deletion of 22q11 syndrome. At 1 month, he weighted 3.8 kg and was readmitted to our hospital for wheezing. Echocardiography showed a left ventricular dysfunction with LVEF of 24%. The coarctation velocity increased to 5.1 m/s. An urgent operation was performed because of a severely depressed cardiac function. His LVEF increased to 67%, and the velocity was less than 1 m/s postoperatively, and he was discharged on postoperative day 32. We report a rare neonatal surgical case of a right cervical arch with a coarctation.

Several problems have been reported following coarctectomy, especially in cases involving long-segment coarctation (COA). Although residual COA, proximal arch kinking, and airway compression may occur after coarctectomy, avoiding the use of artificial materials provides a better chance for the subsequent growth of the aorta. We successfully performed a modified end-to-end anastomosis with subclavian flap aortoplasty for a two-month-old boy with COA. A two-month-old boy was admitted to our hospital for nocturnal tachypnea and a feeding disorder. The initial echocardiography showed a preductal long COA beyond the left subclavian artery. A perimembranous VSD, a patent foramen ovale, and a patent ductus arteriosus were also noted. The left ventricular function was mildly depressed with an ejection fraction of 59%. Enhanced CT revealed a long-segment COA with a length of 15 mm. The blood pressure gradient between the upper and lower limbs was 40 mmHg. The operation was performed at the age of 2 months. The 4th intercostal space was opened through a posterolateral left thoracotomy incision. The distal end of the isthmus was so ligated as to maintain blood perfusion to the lower body through the PDA. The arch was clamped between the left carotid and the left subclavian artery (LSCA). The LSCA and the isthmus were divided as distally as possible, and the two distal ends were longitudinally incised and sutured to each other in a side-to-side fashion using a 7-0 polypropylene continuous suture. After complete resection of the ductal tissue, a newly created distal arch was anastomosed to the descending aorta. The left ventricular ejection fraction was increased to 74% at discharge. Catheterizations 3 years after the surgery did not reveal any stenosis or deformity in the aorta at normal PA pressure. The patient has been doing well and is free of complications 7 years after the surgery. At present, end-to-end anastomosis and aortic arch advancement with or without cardiopulmonary bypass are widely used procedures for coarctectomy ; however, a modified end-to-end anastomosis is still a viable option for cases involving long-segment coarctation.

A neonate, presenting with cyanosis, received the diagnosis of persistent truncus arteriosus with truncal valve stenosis with insufficiency. Her disease was classified as persistent truncus arteriosus Van Praagh type A1, or Collett and Edwards type I. At the age of 2 months, she underwent a modified Blalock-Taussig shunt, and her operative team was waiting for adequate body weight gain before performing further surgery. At the age of 1 year, however, she began to have repeated episodes of congestive heart failure due to severe tricuspid valve regurgitation and truncal valve insufficiency. When she reached 18 months of age, she underwent a definitive operation including a truncal valve plasty, VSD patch closure, and a right ventricular outflow tract reconstruction. Postoperative echocardiography 6 months after surgery showed a good truncal valve function with minimal regurgitaion. Truncal valve surgery is a challenging operation ; we report a successfully treated case, though the patient will require extensive follow-up.

A 29-year-old woman, who had been diagnosed with Ebstein's anomaly associated with paroxysmal supraventricular tachycardia due to Wolff-Parkinson-White (WPW) syndrome, was referred to our hospital for treatment of congestive heart failure and tachycardia. She had undergone a catheter ablation for WPW syndrome at the age of 28 years. Subsequently, surgical treatment for Ebstein's anomaly was indicated because of persistent symptoms of heart failure due to tricuspid regurgitation (TR). The echocardiogram and pathologic findings corresponded to Ebstein's anomaly of the Carpentier type B classification, with severe displacement of the septal and posterior leaflets resulting in moderate TR. A mobile anterior leaflet of sufficient size without a cleft enabled us to successfully perform Hetzer's procedure. In this procedure, the large mobile anterior leaflet was approximated to the opposing true tricuspid annulus with a mattress suture of 3-0 polypropylene passed from the anterior leaflet annulus to the true tricuspid annulus at the site of atrialized right ventricle near the coronary sinus. The postoperative course was uneventful, and the cardiothoracic ratio reduced from 56% to 48% with mild TR. In this adult case of Carpentier's type B adult Ebstein's anomaly, Hetzer's procedure allowed reconstruction of the tricuspid valve mechanism of “leaflet-to-septum” coaptation at the level of the true annulus by approximating the anterior leaflet. This was, effective in reducing the patient's moderate TR. We conclude that this procedure is a simple and reproducible method for repairing the tricuspid valve in Ebstein's anomaly, especially for cases with a large mobile anterior leaflet.

We surgically treated a case of anomalous origin of the left coronary artery from the pulmonary artery with the specific route of the left coronary artery in a 17-month-old boy. He had suffered persistent cough and poor weight gain since the age of 4 months. An ultrasound cardiography, at the age of 16 months, revealed retrograde blood flow of the left coronary artery into the main pulmonary artery. Moreover, a chest computed tomography showed an anomalous left coronary artery arising from the bifurcation of the right pulmonary artery and winding in contact on the posterior aortic wall. Though the anomalous left coronary artery shared adventitia with the aortic wall we were able to separate the coronary artery from the aorta, and the patient underwent direct transplantation of the left coronary artery. The postoperative course was uneventful and recovery was rapid.

We investigated the effects of evaluation of education by medical students using the minutes paper, which was developed by Professor Yasuoka, also of Tokai University. The minutes paper consists of 3 questions with 10 gradedchoices and of 8 questions with 2 graded choices. One of the 3 questions with 10 graded choices asks a general impression of a lecture. Every faculty member at the Tokai University School of Medicine should be evaluated once a year by students using the minutes paper. A total of 202 faculty members were evaluated in 1999 or in 2000, and 73 of these faculty members were evaluated in both 1999 and 2000. The faculty members were divided into 3 groups (low grade, moderate grade, and high grade) on the basis of their grades in 1999. In 2000, the low-grade group achieved higher evaluation scores, whereas the moderate-and high-grade groups did not. These results suggest that our evaluation system with minutes papers was effective for improving teaching faculty members with low grades.

A 60-year-old woman visited our hospital, complaining of hyperpigmentation and itching of the skin. The case was histologically diagnosed as acanthosis nigricans by skin biopsies. It is usually associated with malignancies, of which gastric cancer is by far the most common. Upper endoscopy revealed advanced gastric cancer (Borrmann type 3). Total gastrectomy was performed, but the patient died of peritonitis carcinomatosa 21 months after resection. It is important to examine the upper GI tract periodically when acanthosis nigricans is present from the early stage.

We held an integrated seminar program on community medicine for high school students. We used questionnaires to evaluate the usefulness of the seminar.
1)The seminar included lectures about community medicine, active–learning programs, and discussions about medical issues.
2)Before the seminar, 96% of the participants had been interested in a career in medicine.
3)After the seminar, 96% of participants were satisfied with the seminar.
4)The number of the participants who wanted to work in the community in Oita in the future increased from 43% before the seminar to 62% after the seminar.
Our results suggest that this integrated seminar program is useful for getting high school students interested in community medicine.

Introduction: The use of methadone in Japan is limited to cases being switched from the preceding use of strong opioids; the stop-and-go strategy is recommended in which the previously used opioid analgesic is discontinued and methadone is initiated at its full estimated dosage. Case: Refractory cancer pain due to an iliolumbar syndrome was temporarily exacerbated by the stop-and-go switching to methadone from morphine along with ketamine. Pain relief was achieved upon readministration and concomitant use of morphine with methadone after approximately two weeks. Discussion: Through examining this case, we believe that a stepwise switching strategy, rather than the stop-and-go strategy, could be more useful. Considering that overdosage may cause side effects, it is safer to initiate methadone with a small dose. However, more studies need to be conducted to decide whether the establishment of the initial dosage and dosage adjustment should be made more flexible to avoid pain intensification. Further investigation is required on whether the concomitant use of adjuvant analgesics such as ketamine, which similar to methadone is an NMDA receptor antagonist, should be continued when switching to methadone.