The utilization of generic drugs in medical practice has been promoted in Japan for the purpose of minimizing drug costs. In order to determine the clinical efficacy of the original preparation of glycyrrhizin, in comparison to its generic drug, a controlled longitudinal study was done of 82 consecutive patients with chronic hepatitis C receiving the original preparation of glycyrrhizin for 6 months. Patients treated with the original preparation of glycyrrhizin for 6 months at two hospitals were separated into two groups for study: Patients who changed from the original preparation of glycyrrhizin to a generic drug and then changed back from the generic drug to the original preparation of glycyrrhizin (Group A, n=46) ; and, patients who were continuously treated with the original preparation of glycyrrhizin (Group B, n=36) . HCV RNA levels were serially determined by Cobas Amplicor HCV Monitor assay. In Group A, the ALT level significantly elevated 3 months after switching treatment from the original preparation of glycyrrhizin to the generic drug (from 65.1 ±22.7 IU/L to 1 12.4±39.9 IU/L) (P<0.05), then significantly decreased 3 months after the change back to the original preparation of glycyrrhizin (from 112.4±39.9 IU/L to 62.1±23.0 IU/L) (P<0.05) . In Group B, however, the ALT level did not significantly change during the same observation period. The serum HCV RNA level did not significantly change in either group, even in Group A patients whose ALT levels significantly changed. The efficacy on ALT of the original preparation of glycyrrhizin and the generic drugs differed in patients with chronic hepatitis C.

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BACKGROUND: Prior research indicates that patients with medically unexplained symptoms and doctorshopping behavior are more likely to have psychological distress. In patients with somatic symptoms, we hypothesized that high scores on COOP/WONCA Functional Assessment Charts, in addition to the presence of medically unexplained symptoms and doctor-shopping behavior, might have an important role in diagnosing psychological distress.
METHODS: Between November 2002 and March 2003, the patients who presented themselves to the hospital for the first time with somatic symptoms were enrolled in this study. In this study, we defined psychological distress as disease conditions, including Mood disorders, Anxiety disorders, Adjustment disorders, and Somatoform disorders, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV) . Symptoms that, in the doctor's judgment, could not be medically explained were regarded as medically unexplained symptoms. Doctor shopping was defined as those patients with a complaint of sustained and unsolved symptoms for more than one month who had visited two or more medical facilities prior to visiting our hospital and arrived without any physician's referral.
RESULTS: One hundred and six patients out of 496 were diagnosed as having psychological distress. Among these 106 patients, 49 (46.2%) had doctorshopping behavior, 86 (81.1%) had medically unexplained symptoms, and 95 (89.6%) showed high scores on COOP/WONCA charts. Odds ratios and 95% confidence intervals of medically unexplained symptoms and doctor shopping were 24.12 (11.91-48.84) and 4.18 (2.16-8.07), respectively. High scores on COOP/WONCA charts 2, 3 and 6 were significantly associated with the presence of psychological distress, and the odds ratios (95% confidence intervals) of these three items were 1.41 (1.01-1.98), 1.41 (1.02-1.94), and 2.88 (1.68-4.95), respectively.
Positive and negative likelihood ratios for 4 items (i.e., age of not less than 45 years; duration of symptoms of not less than 6 months, ; doctorshopping behavior; and, medically unexplained symptoms) were 1.16 and 0.85; 1.43 and 0.55; 3.16 and 0.63; and, 3.96 and 0.24, respectively. Positive and negative likelihood ratios for high scores on COOP/WONCA charts were 1.42 and 0.28. Under ROC curves for the diagnosis of psychological distress, the information of COOP/WONCA charts, in addition to that of clinical data, medically unexplained symptoms, and doctor shopping behavior, increased the accuracy in diagnosing psychological distress.
CONCLUSIONS: In patients with somatic symptoms, COOP/WONCA charts increased diagnostic accuracy in predicting psychological distress when patients showed sustained symptoms for more than 6 month, doctor shopping, and medically unexplained symptoms.

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BACKGROUND: An effective approach to lifestyle-related factors could be a main treatment for hypertensives. The components of blood pressure (BP) have been reported to have different clinical implications; however, the relationship between various lifestyle-related factors and BP components has not been thoroughly studied in hospital-based general medicine.
METHODS: This relationship was cross-sectionally investigated in a population of outpatients with hypertension but free of other diseases (136 subjects, aged 30 to 75, mean 54.2 years) . A self-administered questionnaire, which included items related to demographics, smoking, alcohol use, affinity for salt, habitual exercise, and sleep status, was used.
RESULTS: After controlling for lifestyle-related factors, multiple regression analysis revealed that body mass index (BMI) and smoking were significantly and positively correlated with systolic BP (SBP) and pulse pressure (PP) . For diastolic BP (DBP), age had a significantly negative, and lack of sleep had a significantly positive, correlation. BMI was also significantly and positively correlated with mean BP (MBP) .
CONCLUSIONS: Our results suggest that lifestyle-related factors are associated with differing BP components. Weight control should receive more attention in SBP, MBP and PP control, anti-smoking in SBP and PP control, and sleep management in DBP control.

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We recently encountered a case of fatal pneumococcal infection in a previously healthy 19-year-old female. She had no history of splenectomy, but on autopsy she was found to have hyposplenism. It has been widely reported that life-threatening pneumococcal infection can occur after splenectomy, though cases of hyposplenic or asplenic adults, without a history of splenectomy, are very rare. We report this case and review the literature dealing with 6 similar cases.

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OBJECTIVE: The purposes of this study were to assess the clinical features of cardiac auscultatory events in outpatients in general internal medicine, and to make teaching suggestions for education on cardiac auscultatory skills in primary care medicine.
METHODS: The subjects included 104 consecutive outpatients with chest symptoms, and cardiac auscultatory findings were assessed prospectively.
RESULTS: Cardiac auscultatory events were found in 32 (30.8%) among the 104 subjects. The subjects with cardiac auscultatory events were significantly older than those without cardiac auscultatory events (p<0.05) . The cardiac auscultatory events of the 32 subjects were as follows; splitting of the first heart sound in 2 subjects, mid-systolic click in 2 subjects, fourth heart sound in 3 subjects, systolic murmur in 24 subjects (including one subject with both systolic and diastolic murmurs), and diastolic murmur in 2 subjects. Aortic stenosis was diagnosed in 2 subjects, and mitral regurgitation was diagnosed in one subject of the 24 subjects with a systolic murmur. One subject with both systolic and diastolic murmurs was considered to have a relative systolic murmur with aortic regurgitation. The other 20 subjects with a systolic murmur were considered to have innocent murmurs. The 2 subjects with a diastolic murmur were diagnosed as having aortic regurgitation.
CONCLUSIONS: We suggest that the following cardiac ausculatory events should be given educational priority in primary care; 1) Fourth heart sounds as an extra heart sound. 2) Innocent murmurs: characteristics of innocent murmurs and discrimination from systolic murmurs caused by organic heart disease. 3) Systolic murmurs caused by aortic stenosis or mitral regurgitation. 4) Diastolic high-pitched murmurs caused by aortic regurgitation.

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BACKGROUND: Japanese medical education has undergone dramatic changes over the last 5 years. Clinical exercises and ambulatory-care training are now stressed to prepare medical students and residents for work in primary and continuing-care settings. For comparative purposes, we conducted a review of the undergraduate and residency training programs for ambulatory care at the University of Toronto in Canada. This report will examine the problems of training programs for ambulatory care in Japan by comparing the Canadian and Japanese models.
METHOD: From December 2004 to March 2005, the first author observed the ambulatory training systems at the University of Toronto.
OUTLINE OF CANADIAN AMBULATORY TRAINING PROGRAMS: There are three typical types of ambulatory training programs in Canada: community-office based programs for undergraduate students in family and community medicine; hospital/clinic based programs for junior residents in internal medicine; and consultation service programs for senior residents in internal medicine. Undergraduate and residency training programs are largely consistent with each other. The current trend in medical education is towards increased consolidation and efficiency in teacher and student training systems, with a reduction in the number of teaching hospitals and integration of teaching staff and curricula. Moreover, team-based training for ambulatory care appears effective.
DISCUSSION: To improve the Japanese ambulatory training system, it is desirable to increase communication and contact between undergraduate-program educators and residency-training program educators in order to achieve integration and consistency between programs.

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