The Muribushi Project in Okinawa, Japan, is breaking new ground for residency training in Japan by explicitly emphasizing clinical skills training and primary care. The core philosophy of the Project is defined by seven "concepts" that commit to (i) establishing cooperation between several hospitals to educate good clinicians; (ii) providing the best learning environment at multiple training sites; (iii) following global standards of practice; (iv) focusing on primary and emergency care of common diseases; (v) emphasizing faculty development through international exchange; (vi) providing residents with opportunities to obtain training abroad; and (vii) improving the quality of medical care through residents. Observations by the author during two week-long visits, one year apart, reveal that the Muribushi Project is fulfilling conceptual goals (iv), (v) and (vi) by emphasizing primary care and encouraging international exchange for faculty and students. The opportunity exists to fulfill goals (i) and (ii), but it is not being exploited because programs at member hospitals are not integrated, so that residents spend the duration of their residency at one location, and there is no formal system of rotations that would broaden their clinical experience. The Project is failing to meet a sixth goal of following global standards of care (goal #iii) and it is too early to say if it's pioneering approach to residency training is having an impact on healthcare in Japan (goal #vii). On balance, the Project's success in implementing elements of its core philosophy for residency training in the tradition-bound environment of Japan is particularly laudable.

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Chemoradiotherapy improves therapeutic outcome in many different types of cancer. However, there is concern about the occurrence of delayed complications, as patients are surviving longer. Because patients with esophageal cancer receive a wide range of irradiation field to the mediastinum and the heart, they may have delayed complications of heart and lung functions as previously reported in Hodgkin's disease. We presented a case of death related to uncontrollable pleural and pericardial effusions in a patient with advanced cancers of the esophagus and stomach who achieved a complete remission following chemoradiotherapy and salvage gastric resection, focusing on detailed pathophysiological conditions related to concurrent chemoradiotherapy.

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A 68-year-old woman with schizophrenia after a cerebrovascular accident resulting in right medial temporal and occipital damage developed Frégoli syndrome. Neuropsychological testing revealed that she had impairment in facial recognition compatible with prosopagnosia. The Frégoli syndrome disappeared in three month when, remarkably, her prosopagnosia also disappeared. Our findings are consistent with the hypothesis that combination of hyperactivations of temporo-limbic connection and frontal dysfunction may account for the development of Frégoli syndrome.

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