We describe a prototype seminar, inspired by the problem-based learning tutorial system, on pediatric emergency practice for young physicians working in 7 pediatric emergency centers in Yokohama. The seminar was received favorably by the participants, especially as an opportunity for individual learning. We expect that the seminar will contribute to the standardization of emergency practice in these pediatric centers and the establishment of an interhospital network.

Background : Left atrial reverse remodeling occurs when the left atrial load is reduced after mitral valve repair for mitral valve regurgitation. However, several reports demonstrate mitral valve stenosis after mitral valve repair with a mitral ring, which leads to impaired left atrial reverse remodeling. Objective : To examine the effect of ring size and body size on left atrial reverse remodeling after mitral valve repair. Patients and Methods : Sixty patients underwent transthoracic echocardiography before and after mitral valve repair for mitral valve regurgitation in our hospital. The left atrial volume (LAV) was compared pre- and postoperatively. Ring-size/BSA (mm/m2) was defined as values to express the mismatch between ring-size and body size after mitral valve repair with a mitral ring. In addition, we examined which factors correlated with the left atrial volume reduction rate including ring-size/BSA. The mean ring size was 28 mm. The study interval was 17±6 months. Result : LAV changed from 82±37 ml to 47±20 ml postoperatively. The left atrial volume reduction rate was 39.8±18.6%. The peak pressure gradient measured from the transmitral flow (TMF p-PG) was 7.5±3.0 mmHg. Ring size showed a stronger correlation with body height than BSA. The ring-size/BSA was 17.7±2.1 mm/m2. Multivariate analysis shows that correlates of the LAV reduction rate were ring-size/BSA, pre LAV and age. Ring-size, TMF p-PG, ring annuloplasty only and postoperative TRPG did not show a strong correlation with the LAV reduction rate. Conclusion : A mismatch between body size and ring size is a negative factor for left atrial reverse remodeling after mitral valve repair with a mitral ring. The ring-size/BSA may be a useful factor to express grade of the mismatch.

Objective: Bile duct tumor thrombosis in hepatocellular carcinoma (HCC) is a relatively rare event with a poor prognosis. Furthermore, bile duct tumor thrombus in HCC may be misdiagnosed when only imaging modalities are used. The efficiency of peroral cholangioscopy (POCS) in evaluating bile duct lesions has been reported.Patients: We present three cases of HCC with bile duct strictures in which POCS was performed as a preoperative evaluation.Results: In these three cases, diagnosing whether the lesion was a bile duct tumor thrombus on CT and endoscopic retrograde cholangiopancreatography was difficult. We performed POCS in three cases and were able to diagnose the presence of bile duct tumor thrombus of HCC, including differentiation from extrinsic compression of the bile duct.Conclusion: POCS for HCC with bile duct features is useful for the preoperative diagnosis of bile duct tumor thrombus, especially in cases where the surgical procedure depends on the presence of bile duct tumor thrombus.