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Division of Rheumatology, Department of Internal Medicine
Department of Internal Medicine and Rheumatology(Graduate School of Medicine) | Japanese |  Index
 About Our Division
The Division of Connective Tissue Disease, Department of Internal Medicine, was founded in 1969 as the first university course specializing in the diagnosis and treatment of connective tissue disease (CTD) in Japan. Although a CTD/rheumatology department has now been established at many Japanese medical schools and hospitals, this division has been playing a leading role in clinical CTD practices in Japan since its inception, with plenty of clinical data and detailed analyses of CTD cases collected from across the nation. This division now treats more than 4,000 patients with CTD per month on an outpatient basis in addition to more than 50 hospitalized patients, while only a few CTD patients visit and receive treatment annually in an average Japanese general hospital. Furthermore, the division has the largest number of staff and resident physicians among other CTD/rheumatology departments in Japan, as well as many foreign students from various countries.
 Pathogenesis of CTD
In 1942, Paul Klemperer and his associates first used the term diffuse collagen disease to describe a group of disorders characterized by pathological features including the fibrinoid degeneration of collagen fibers resulting from an inflammatory reaction. However, subsequent studies have shown this syndrome to be associated with inflammation of not only collagen fibers but whole components of connective tissues, with a significant role of autoantibodies including the antinuclear antibody as well as an autoimmune process caused by autosensitized lymphocytes infiltrated into the joints and organs of the body. Clinically, CTD is classified as a rheumatic disease associated with musculoskeletal impairment since arthritis is a common clinical manifestation of the disease. In addition, since connective tissue is present in all areas of the body including skin, joints, muscle, blood vessels, nerves, and lymph nodes, CTD is referred to as a type of systemic disorder leading to multiple organ failure. The following diseases are included in the category of CTD: rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), mixed connective tissue disease (MCTD), systemic sclerosis, polymyositis/dermatomyositis, Sjogrenfs syndrome, Behcetfs disease, and a series of vasculitis syndrome.
 Clinical Characteristics of CTD and Treatment Options
Some clinical manifestations are common to all CTDs, while others are specific to individual diseases. The former includes systemic symptoms (e.g., fever, general malaise, decreased body weight) and localized disorders such as arthralgia, myalgia, and Raynaudfs phenomenon, a condition presenting with the loss of color of the fingers in cold temperatures. The latter disease-specific symptoms are, for example, a malar rash which develops in patients with SLE, a heliotrope rash and Gottronfs sign associated with polymyositis/dermatomyositis, sclerema as part of systemic sclerosis, sausage-shaped swelling of hand fingers noted in MCTD patients, and sicca symptoms (e.g., dry eyes, dry mouth) of Sjogrenfs syndrome. As described above, CTD is also involved in multiple organ diseases including interstitial pneumonia, glomerular nephritis, and interstitial nephritis. The treatment for these clinical manifestations has two objectives: the control of the inflammatory reactions and the normalization of the underlying immune abnormalities. Non-steroidal anti-inflammatory agents are usually used to suppress inflammatory reactions, while immune abnormalities are treated with a variety of immunosuppressive agents. In particular, corticosteroids, which have both a potent anti-inflammatory effect and immunosuppressive activity, are primarily used for management of various manifestations of CTD. However, caution must be exercised in the use of this class of drugs because they may cause some adverse effects such as infection, peptic ulcers, and osteoporosis, which can often result in significant disability. Recent immunological studies have led to the advent of biological agents for CTD treatment designed to target cytokines, a family of physiologically active proteins, and antigenic molecules on the cell surface. To date, these agents have been shown to be more effective for RA among other CTDs. Furthermore, non-pharmacological approaches such as plasma exchange that removes disease-related antibodies and leukocyte apheresis have also been employed.
 Undergraduate Education Programs
The third-year medical students have a course of clinical lectures on the basic diagnosis and treatment of different CTD symptoms, followed by a more integrated lecture course for the fourth-year students which contains the general pathogenesis of CTD, clinical conditions of individual diseases in the CTD category, interpretation of laboratory values, and treatment options. A clinical clerkship program is conducted from the second half of the fourth-year through the fifth-year. Every student sees a patient with CTD under the direction of the supervisory physician, in order to understand the issues regarding the clinical practice of CTD treatment and to apply skills and knowledge obtained through the clerkship program to management for other internal diseases. For the purpose of systematic learning of the actual disease condition and treatment strategy, students also make a presentation at the medical staff conference under the guidance of all professors and staff, regarding the clinical course of patients they followed up during the clerkship program. A pretest and posttest are administered to evaluate studentsf understanding and knowledge acquired during the clerkship period, and small-group seminars for clerkship students are also performed to obtain more extensive information about the mechanisms of CTD. The sixth-year students have a pre-resident clerkship course in which they learn a broader range of clinical practice by acting as a member of a multidisciplinary patient care team. In addition to the complicated pathogenesis, including the immunological mechanisms of this disease which have been gradually elucidated, a physician who treats patients with CTD should be familiar with the extensive knowledge required for an internist to deal with multiple organ involvement of this disease. It is also necessary to keep up with advances in the treatment strategies which enable us to achieve a significant improvement in the prognosis. In order to advance the current research on CTD, which is now becoming increasingly attractive to many medical students, all medical staff members of our division fully support any students who want to specialize in this field.
Department of Internal Medicine and Rheumatology(Graduate School of Medicine) | Japanese |  Index
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