Objective: This study aimed to identify the characteristics of cases in which walking level improves even in the later stages of convalescent rehabilitation, and to predict such cases.Methods: The Walking LEVEL Scale (WaLS) was measured over time in 192 patients (brain-related and orthopedic diseases) admitted to a convalescent rehabilitation ward. The “delayed recovery group (DR)” was defined as the group showing improvement of WaLS in the later period, while the “non-delayed recovery group (NDR)” was defined as the group for whom improvement of WaLS did not extend into the same period. Then, changes in WaLS over time and each factor were compared to identify differences between DR and NDR. Using receiver operating characteristic analysis, cutoff values, sensitivity and specificity, likelihood ratios for the relevant factors were calculated and examined for the predictability of DR utilizing Bayesian estimation.Results: WaLS temporal changes showed a sigmoid curve only in the DR of brain-related disease. Other groups showed logarithmic curves. The WaLS score at admission was selected as a significant variable. The positive and negative likelihood ratios for the score at cutoff values of 4 or less were 2.00 and 0.19 for brain-related disease, and 1.49 and 0.63 for orthopedic disease, respectively. Adopting the DR frequency of the participants in this study as the prior probability, the DR posterior probability of brain-related disease was calculated to be 5% using the negative likelihood ratio.Conclusion: The negative likelihood ratio of the WaLS score at admission is useful for predicting DR for brain-related disease.

Objective: This study investigated and compared the responsiveness of the Walking LEVEL Scale (WaLS), Functional Independence Measure (FIM)-walk item, and Functional Ambulation Category (FAC) in patients hospitalized in a Convalescent Rehabilitation Ward (CRW).Methods: One hundred three patients participated in this study. Physical or occupational therapists assessed the three scales at two times of admission and discharge to determine the responsiveness. The amount of change, ceiling and floor effect, Effect Size (ES), and Standardized Response Mean (SRM) determined the responsiveness to change from admission to discharge. Their analysis was by severity and disease.Results: The amount of change in WaLS was larger than that of the FIM-walk item and FAC, except for the moderate gait disability group. More ceiling and floor effects were observed in FIM-walk item evaluation. Regardless of severity or disease, all rating scales showed moderate or better responsiveness (ES > 0.5). When ceiling or floor effects were observed, ES tended to be overestimated. The SRM of WaLS was larger than that of the other scales, except for the mild gait disability group.Conclusion: The results support WaLS as the most suitable instrument to detect walking level changes over time for patients in CRW.

　Social Medical Corporation Kojunkai Daido Hospital is aiming to be the best training hospital. By enhancing seminars in the hospital, we commenced a postdoctoral training program for medical instructors in February 2014 and November 2015. Since we received an accreditation for the clinical training program in 2014, we created an OSCE program on our own for trainees in August 2015 and June 2016. We also collaborated with the University of Nagoya for the OSCE program and held seminars in August 2015 and June 2016. We introduced the EPOC system for the evaluation of trainees in 2014, and Cybouze® for the constructive evaluation of and sharing of information on trainees in April 2016. Our residents obtained high scores for in the examination to evaluate knowledge of trainees held in February 2016, which shows the high quality of our educational program, established by the endless efforts of the educational committee and instructors.

　The higher level postgraduate education hospitals are required to have a system with well-developed programs, instruction, and supervision of doctors in clinical training. The Social Medical Corporation Kojunkai Daido Hospital has been maintaining efforts to be a clinical training hospital of excellence.

　In order to nurture supervisory doctors, the first workshop for supervisory doctors in clinical training was held at Daido Hospital on February 22nd and 23rd, 2014. With consciousness reform in mind, interprofessional relations between the many types of medical professional were established.

　Daido Hospital was evaluated by the Japan Council for Evaluation of Postgraduate Clinical Training on December 12th, 2014. It was an opportunity to recognize the need for further improvement as a clinical training hospital.

　On March 7th, 2015 the Objective Structured Clinical Examination for the second year of training doctors in Daido Hospital was held. Clinical training guidance doctors, Nurses, and paramedics learned the skills necessary for the methods and the evaluation in clinical teaching and evaluation.

　Daido Hospital continues making efforts by conducting a review of the clinical training based on the evaluation of the clinical ability of residents, the ability for education and the clinical skill of teaching doctors, and the training environment.

　To improve hospital quality, the development of authorized clinical instructors is urgently needed. Therefore, we held a workshop to develop clinical instructors. At a monthly meeting of the clinical training committee in June 2014, an agenda for holding a workshop was proposed. At the meeting in July 2014, most committee members said they were reluctant to hold a workshop because of heavy clinical duties. However, the hospital president strongly suggested that a workshop might be a foundation for reforming the stagnated hospital and persuaded committee members to hold a workshop to improve the instructors’ skill in teaching residents. At the September meeting, the workshop schedule was discussed. All members of the taskforce, except the chief coordinator and a lecturer, were selected from hospital physicians, and 3 preparatory meetings and 1 rehearsal were held. With the help of administrative staff, our first workshop for clinical instructors was held at Daido Hospital in February 2014. Our workshop helped create new hopes for improving educational tasks at our teaching hospital and improved the educational skills of participants. We also achieved mutual understanding as a team to accomplish a single goal.

1）To learn the techniques required immediately after the start of clinical practice, new residents were introduced to the skills laboratory during their orientation period.
2）We attempted to establish the Yanegawara style, which is an overlapping teaching style in which the second–year residents plan the entire training schedule and simultaneously teach the first–year residents while being supported in their teaching by more senior physicians.
3）Training with the new system resulted in greater rapport among all residents as well as a greater feeling of security among first–year residents.

  Since 2003, Clinical training center of Fujita Health University hospital has been cooperated with the Office for medical education of Fujita Health University, school of medicine, in reorganizing the previous training system based mainly on individual departments. After 9 years since then, we established Yanegawara style training system and the trainee–centered curriculums. Outcomes from new system are as follows:
1. Self–establishment by problem based learning became common understandings between trainers and trainees.
2. Teaching by trainers to trainees and between trainees （R2 to R1） became common in the hospital.
3. Trainees can learn the standardized approach in diagnosis and treatment of the patients in ER.
4. Unified understanding of the training system was established in the hospital.Although new system brought several good aspects, we found a large heterogeneity in fulfillment of our curriculums not only by the capability of individual residents but also by the effort induced by each department.

Left ventricular myxoma is very rare and only 13 cases have been reported in Japan. A 14-year-old girl was admitted to a local hospital in November, 1983, with a sudden onset of right hemiparalysis. Two-dimensional echocardiograms and left ventricular angiograms revealed two left ventricular tumors. The patient was transferred to our hospital for the operation which was performed one month later. Two tumors originating from the apical interventricular septum were removed with resection of the septum through a left ventriculotomy. The tumors were 2.0×1.7cm in size and 1.9g in weight, 1.9×1.5cm in size and 1.1g in weight, respectively. The pathological diagnosis was myxoma. Her postoperative course was uneventful, and there has been no recurrence for 15 years after surgery. Japanese literature on the subject was reviewed.

Urgent surgical repairs were successfully performed in four patients with blunt traumatic ruptures of the thoracic aorta. All 4 patients were involved in traffic accidents and had ruptures immediately distal to the aortic isthmus. The diagnoses were achieved by IV-DSA in case 1, by IV-DSA and enhanced CT in case 2 and by enhanced helical CT in cases 3 and 4. Intraoperative transesophageal echocardiography was performed in case 4. Operations were accomplished with the aid of temporary shunt in case 1, pulmonary-femoral artery bypass in case 2 and partial left heart bypass in cases 3 and 4. Prosthetic graft interposition was performed in cases 1, 3 and 4 and end-to-end aortic anastomosis was performed in case 2. There was no postoperative paraplegia in any patient. Early diagnosis and urgent surgical repair are important in treating blunt traumatic rupture of the thoracic aorta. Enhanced helical CT and transesophageal echocardiography are useful for the diagnosis of this type of injury.

A 58-year-old man was admitted for pneumonia after several business trips to Thailand, Vietnam, and Malaysia. Despite resolution of pneumonia on chest X-ray, high fever persisted. CT scan revealed a juxtarenal, atypical-shaped abdominal aortic aneurysm of 4.5cm in size, and this was thought to be the cause of persisting fever. After prolonged antibiotic treatment, surgical resection and prosthetic tube replacement of the aneurysm was performed. The aneurysm was a pseudoaneurysm, and histological examination showed chronic inflammation with no atherosclerotic change. It was thought to be of mycotic origin. On the 12th day after operation, he became febrile, and an arterial blood culture yielded Burkholderia pseudomallei. Antibiotics chosen according to sensitivity tests, were given. He was finally discharged with no exidence of persisting infection, on the 55th day after operation.