Introduction: Recently, Escape Rooms have been included in educational content.　Method: An Escape Room style class was conducted for first-year medical students to review previously learned content and to learn how to collaborate with others. The class was 70 minutes in total, 45 minutes of that was spent playing games. These included not only puzzles and riddles but also simulation-based tasks such as BLS. Multi-ending style was also used to motivate students.　Result: In addition to the difficulty of making stories and puzzles, the management of staff and organizing of the games were also challenging for the class.　Discussion: There are few comprehensive studies on educational practices using escape rooms. Research is necessary to consider effective and practical training methods.

Introduction: It is important to educate undergraduates about communication errors in clinical sites, but it is difficult for clinically inexperienced students to imagine those errors. Therefore, in this study, a board game (BG) was developed and put into practice to encourage students' understanding.　Methods: The BG consists of a board on which the patient's name is written and cards on which drug names are written. Students place cards on the board according to the teacher's instructions. These instructions include multiple traps based on actual incident cases. Through the game, students experienced errors.　Reflection: This BG contains gamification elements that make learning contents simple and fun and simulation elements that reproduce errors with high fidelity. By combining these elements, it is possible for each aspect of the ARCS model to be provided in a well-balanced manner, even in patient safety education for clinically inexperienced students.

In patients with unresectable hepatocellular carcinoma (HCC) without both macrovascular invasion and extrahepatic metastasis, the initial treatment choice recommended is transarterial chemoembolization (TACE). Before sorafenib came into wide use, TACE had been pointlessly carried out repeatedly. It was in the early 2010s that the concept of TACE refractory was advocated. Two retrospective studies from Japan indicated that conversion from TACE to sorafenib the day after patients were deemed as TACE refractory improved overall survival compared with continued TACE, according to the definition by the Japan Society of Hepatology. Nowadays, phase 3 trials have shown clinical benefits of several novel molecular target agents. Compared with the era of sorafenib, sequential treatments with these molecular target agents have gradually prolonged patients’ survival and have become major strategies in patients with HCC. Taking these together, conversion from TACE to systemic therapies at the time of TACE refractory, compared with before, may have a greater impact on survival and may be considered deeper in the decisions-making process in patients with unresectable HCC who are candidate for TACE. Up-to-date information on the concept of TACE refractory is summarized in this review. We believe that the survival of patients with unresectable HCC without both macrovascular invasion and extrahepatic metastasis may be dramatically improved by optimal timing of TACE refractory and switching to systemic therapies.

While the number of medical schools with simulators is increasing, data pertaining to self-learning is scarce. We conducted a web survey, exploring the ownership and use of simulators at 82 medical schools in Japan; 29 medical schools responded. Twenty-eight of the medical schools owned one or more simulators. Twenty-four allowed undergraduates to engage in self-learning using simulators, and many imposed some restrictions on their use. The medical schools allowed the simulators to be used for a variety of reasons, including “examination preparation,” “improvement of clinical ability,” and “to meet strong demands from students.” Reasons for restriction on use were “equipment management” and “doubts regarding the outcome of self-learning without faculty.” The use of simulators in self-learning is widely supported at medical schools in Japan. In order to optimize self-learning with simulators, appropriate settings and optimal simulator choice should be explored.

Objective: We conducted a questionnaire survey to comprehend the situation regarding the collection, provision, and utilization of drug safety information at hospitals.  In addition, we asked pharmaceutical companies how they select medical institutions to provide drug safety information.  We also investigated the current situation of information provision to Tokyo Medial Center by pharmaceutical companies.
Method: A questionnaire was mailed to all hospitals in Japan.  The survey was conducted between January 13 and February 10, 2011.  Moreover, we asked thirteen pharmaceutical companies by telephone and e-mail about the implementation status of the provision of information and performed a survey at Tokyo Medical Center on the current situation of information provision by pharmaceutical companies regarding revisions to precaution sections in package inserts.
Results: The results of the questionnaire survey (response rate: 41.2%) showed that the major information sources for hospitals were medical representatives (77.8%), Drug Safety Update (50.3%) and direct mails (49.3%).  Furthermore, in the case of drugs prescribed exclusively for extramural dispensing, fewer hospitals responded that medical representatives of the pharmaceutical companies provided drug safety information and more hospitals responded that they did not obtain any drug safety information at all, compared with drugs listed in the hospital formularies.
Conclusion: To minimize the risks of drugs, healthcare professionals must collect a wide range of drug safety information and must utilize this information in their medical practice.  Therefore, it is important that pharmaceutical companies and regulatory authorities make an effort to provide suitable information dissemination to medical institutions.  Furthermore, medical institutions must also strengthen their systems for collecting drug safety information and providing such information to healthcare professionals.

A 64-year-old man who underwent aortic valve replacement with a 25mm Bjork-Shiley valve in 1993 began to have severe anemia and required repeated transfusions by November 2003. Doppler echocardiography showed only mild aortic regurgitation, but revealed turbulent flow around the mechanical valve. Autoimmune hemolytic anemia (AIHA) was diagnosed and he was treated with prednisolone (PSL) starting May 2004. Because of unremitting hemolysis requiring multiple transfusions and the occurrence of renal dysfunction, he underwent rereplacement of the aortic valve with a 25-mm Freestyle valve. His hemolysis and general condition immediately improved. This case suggests the possibility that mild regurgitant jet and turbulent jet stress can cause severe hemolysis when AIHA develops.

Our goal is to decipher which DNA sequences are required for tissue-specific expression of epididymal genes. At least 6 epididymis-specific lipocalin genes are known. These are differently regulated and regionalized in the epididymis. Lipocalin 5 (Lcn5 or mE-RABP) and Lipocalin 8 (Lcn8 or mEP17) are homologous genes belonging to the epididymis-specific lipocalin gene cluster. Both the 5 kb promoter fragment of the Lcn5 gene and the 5.3 kb promoter fragment of the Lcn8 gene can direct transgene expression in the epididymis (Lcn5 to the distal caput and Lcn8 to the initial segment), indicating that these promoter fragments contain important cis-regulatory element(s) for epididymis-specific gene expression. To define further the fragments regulating gene expression, the Lcn5 promoter was examined in transgenic mice and immortalized epididymal cell lines. After serial deletion, the 1.8 kb promoter fragment of the Lcn5 gene was sufficient for tissue-specific and region-specific gene expression in transgenic mice. Transient transfection analysis revealed that a transcription factor forkhead box A2 (Foxa2) interacts with androgen receptor and binds to the 100 bp fragment of the Lcn5 promoter between 1.2 kb and 1.3 kb and that Foxa2 expression inhibits androgen-dependent induction of the Lcn5 promoter activity. Immunohistochemistry indicated a restricted expression of Foxa2 in the epididymis where endogenous Lcn5 gene expression is suppressed and that the Foxa2 inhibition of the Lcn5 promoter is consistent with the lack of expression of Lcn5 in the corpus and cauda. Our approach provides a basic strategy for further analysis of the epididymal lipocalin gene regulation and flexible control of epididymal function.
Animals ; Base Sequence ; Carrier Proteins ; genetics ; Epididymis ; physiology ; Hepatocyte Nuclear Factor 3-beta ; genetics ; Humans ; Lipocalins ; Male ; Mice ; Molecular Sequence Data ; Multigene Family ; Promoter Regions, Genetic ; Prostate ; physiology ; Receptors, Retinoic Acid ; genetics ; Retinol-Binding Proteins, Plasma

A 56-year-old man was admitted with fever of unknown origin and congestive heart failure. Blood cultures grew Streptococcus gordonii. An echocardiographic examination showed vegetation attached to the bicuspid aortic valve and severe aortic regurgitation. Despite the aggressive therapy, an emergency operation had to be performed because it was otherwise impossible to control heart failure. Vegetation was attached to the aortic valve leaflets. There was no noticeable lesion on the aortic annulus, but a myocardial abscess was noted in the left atrial wall. Aortic valve replacement was performed after the myocardial abscess was drained. It was assumed that the myocardial abscess was due to the septic state from Infective endocarditis because it was recognized at a distant zone from the active valvular infection.

A 44-year-old man underwent implantation of a DDD pacemaker for third degree heart block at age 20. The cutaneous pocket for the pulse generator was situated in the left pectoral region. He visited our hospital because of skin ulcer over the pacemaker without any other complaint such as fever or pain. The patient received a new DDD pacemaker system in the right pectoral region and old pacing leads were translocated under the pectoral muscle. However, right pectoral skin ulcer appeared 1 month later. Patch tests revealed a positive reaction to silicon. Wrapping of the pacemaker with a polytetrafluoroethylene (PTFE) sheet proved to be effective.