The International Trend in Continuing Medical Education / 医学教育

1)Continuing medical education (CME) systems were researched in 10 countries. In all countries but one CME is mandatory. Only Spain has voluntary CME, as does Japan.<br>2)The traditional CME systems in many countries were changed after 2000. We believe this change reflects a global revolution associated with a new wave of medical risk management.<br>3)To provide better medical services, we must keep improving Japan's CME system. Such improvement is an important responsibility to society.

Stroke-free duration and stroke risk in patients with atrial fibrillation: simulation using a Bayesian inference

Background: Prior stroke or transient ischemic attack (TIA) is a major predictor of stroke in patients with atrial fibrillation (AF). It may be regarded as a Bayesian predictor by which some underlying causes can be inferred from the result. Similarly, stroke-free duration may be a predictor of freedom from stroke, but this subject has remained unaddressed. Objective: To evaluate the above hypothesis by simulating how stroke-free duration can affect estimated stroke risk in patients with AF using a Bayesian inference. Methods: The development of stroke was modeled as a yearly Bernoulli trial. A Bayesian inference method was applied to the model with correction for the risk increase by aging. The model was composed of two risk parameters: prior stroke (or TIA) and aging. The parameters were treated as random variables. Their distributions were determined to agree with the clinical data reported in the meta-analysis by Stroke Risk in Atrial Fibrillation Working Group. In the simulation, we noted the stroke risk after 1,..,10 stroke-free years for initial risk 1,..,8 %/year. Results: Increasing stroke-free duration reduced the estimated stroke risk, offsetting the risk increase by aging. In patients whose stroke (including TIA) risk was 3%/year or less, the estimated risk remained almost constant with aging if they were stroke-free. In patients whose risk was 4%/year or higher, the risk decreased if they were stroke-free. Conclusion: Our analysis predicted that stroke-free duration in patients with AF is an important predictor of freedom from stroke. Increasing stroke-free duration will reduce the estimated stroke-risk, which may influence our decision to start anticoagulation. Stroke-free duration should be considered when estimating stroke risk in patients with AF.

A Course of Post-primary Clinical Training at Anjo Kosei Hospital / 医学教育

1) Anjo Kosei Hospital has nearly 40 years of history of the post-primary clinical training course.<BR>2) More than 90% of the young doctors, passed through 2 years of the primary clinical training course, have chosen further training at Anjo Kosei Hospital. During this course they began to start the experience for their own career for specialist.<BR>3) This education program is closely coordinated with Medical Colleges such as Nagoya University and Nagoya City College of medicine. After 4 or 5 years of training at Anjo Kosei Hospital, they continued their training at Nagoya University Hospital or Nagoya City College Hospital for the further career.

Economic Effect of the Prevention of Diabetic Complications / 日本農村医学会雑誌

We estimated the medical expense of treating patients with diabetes mellitus under the health insurance system in Japan. The expense was summed up to 5.07 million yen for a patient who developed NIDDM at the age of 40 and died at the age of 75 without diabetic complications throughout his life. If he had diabetic retinopathy, neuropathy, hypertension and hyperlipidemia, and needed insulin injection, the cost would have increased 2.4 times to 12.32 million yen. It was also estimated at 25.22 million yen for a patient who developed IDDM at the age of 20 and died at the age of 70 without diabetic complications. If the patient had with diabetic retinopathy, neuropathy and hypertension and needed hemodialysis because of nephropathy for 20 years, the figure would have reached a whopping sum of 76.17 million yen. From the viewpoint of medical economy, more effort to prevent diabetic complications should be made.

Bacterial Contamination from Insulin Vials Used by Self-Injecting Patients / 日本農村医学会雑誌

Patients who need self-injection of insulin are educated beforehand to handle vials and syringes without bacterial contamination. However, not a few of them forget what they were told about the sterile technique during a long period of injection at home. Since 1988 a pen-typesyringe, which is considered to be more potent against bacterial contamination because of its mechanical structure, has become available in Japan. The aim of this study is to detect the percentage of contaminated vials in the patients' home and to compare traditional vials with pen-type vials in terms of potency against contamination. Two hundred eight vials were collected from 168 patients. Four traditional vials out of 163 (2.4 %) and 1 pen-type out of 45 (2.2%) were contaminated. Propionibacterium acnesgrew up from 2 vials, staphylococcus epidermidis from 2 vials and unidentified gram (+) rods from 1 vial. The patients using contaminated vials were from 30 to 65 in their age, enough skillful to handle syringes, good or poor in the control of DM and without disturbed vision. Thus, the contamination may have been derived from their technical deterioration after several years of injection at home. Therefore, re-education to keep their sterile technique should be given to them at appropriate intervals at the out-patient clinic.