Thursday, 7 June 2007

Amazing Prof Stein

Today saw the return of Prof Stein to Japan for teaching his famous Problem Oriented System at our hospital.

He is quite an amazing person as despite a grueling flight from Florida yesterday, he was ready for lectures in history taking and physical examination and problem solving.

We had two exceptional cases, one of Wernickes Encephalopathy and one of bacterial pericarditis.

The famous Dr Makoto AOKI was also in attendance in the afternoon for the infectious disease case and he was able to provide his expert opinion along with Prof Stein's dissection of the case and evaluation of the data.

Prof Stein's system is very useful and it helped me to make difficult cases far more logical to interpret as a medical student and as a junior physician.

I now teach a similar way to Prof Stein with a British system emphasis on physical examination in addition to use of relevant history taking plus differential diagnosis formation.

Tomorrow sees yet more great cases for Prof Stein to solve and I hope the Jet-Lag with not be a problem for him.

I think this is a good opportunity for our residents to learn medical English plus other medical concepts that are more common in foreign countries.

Tomorrow is also the last day for my apprentice medical student from Kyorin University. I am hoping that he will be able to produce a summary of his experiences to publish on this blog. I hope that he will consider returning for residency at this hospital.

Monday, 4 June 2007


The following includes two cases of Measles in as many weeks, both in adults. The first case was a female patient who had not be vaccinated.

She had a mild rash, fever, conjunctivitis and Koplik spots. She did not appear to have any remarkable systemic compromise. She was allowed to go home but restricted to her home until she became well-- a self-imposed quarantine.

The next case was a young adult male with a one week history of fever, sore throat, malaise, rash and vomiting. He too had been

He was severely unwell with a high fever and sweating. He had multiple Koplik spots, a peripheral blanching maculopapular rash, although on his face, the rash had become confluent.
Examination of his chest revealed reduced air entry at his left base and abdominal examination showed mild hepatosplenomegally. This was indeed a severe case and a primary measles pneumonia was suspected. Liver function tests were mildly abnormal consistent with the physical findings.

There has now been an explosion of cases of measles of epidemic proportions and these cases have also occurred in the
unvaccinated adults.

With myself being trained in immunology, I recognise how important it is to adequately immunise the children and adults alike in an at risk population. The take up of MMR is Japan has been inadequate and even some doctors that I know have never been vaccinated and are therefore
at risk.

Immunising the bulk of the population generally ensures that such an infectious and potentially fatal illness cannot take hold in the population at large. Those individuals not immunised are protected by the 'herd immunity' of the population already immunised. However, if the take up rate of vaccine decreases, then a hiatus occurs which allows the infection the ability to return with catastrophic consequences.

The other problem that exists is that the number of available vaccines has almost been depleted and hence, even if people want to be vaccinated, they cannot easily find the vaccine. It would seem that Japan was taken unawares of the potential outbreak.

The current epidemic shows how important vaccination is to prevent disease. Side effects from vaccination, albeit rare, do not outweigh the benefit of life saving immunity.
The previous concerns about Crohn's disease and autism from combined MMR vaccination have never been proved and when this similar problem occurred in the UK, the Government at that time, did everything possible to ensure that vaccination was maintained to a high level. However, vaccination levels also dropped, as in Japan, and new cases of Measles began to occur.

However, the outbreak in Japan may be more extensive than that seen in the UK and there may be more cases of measles yet to occur. Case fatalities will occur as it is inevitable with this infection.

I only hope that the correct preventions are used by health care providers to ensure that spread is restricted as much as possible and that correct quarantine procedures are adhered to.
I hope that in the future Japan will see a higher level of vaccine uptake to ensure that an outbreak of measles never happens again and this disease become a medical relic in the textbooks like Smallpox !