[Implementation of Clinical Practice in Adult Nursing (Chronic Care) During the COVID-19 Pandemic: Report on the Development and Implementation of a Training Program for Clinical Shadowing].

Before the outbreak of COVID-19, "Clinical Practice in Adult Nursing (Chronic Care)", a professional course to acquire basic nursing practice skills for the care of adult patients with chronic diseases, was conducted on site in the wards of internal medicine, outpatient departments, and the admissions support office for a total of three weeks. Due to the spread of the COVID-19 epidemic, however, clinical practice was carried out online from May 2020, and was resumed on site at our university hospital in October 2020. A restriction was placed on the length of time spent at the hospital for on-site training, referring to the training standards based on our university's new coronavirus response manual, and a training program was developed for hospital ward training, consisting mainly of shadowing practice performed without speaking or coming into contact with patients. In principle, two students were assigned to one patient: one in the morning and the other in the afternoon. In addition, for practicing the acquisition of patient information through conversation and the provision of nursing assistance, the perspectives used in the process of shadowing were clearly defined so that students could maintain active attitudes in clinical practice, and support was provided so that students could have the experience of engaging with patients, using nurses as mediators. In the results, the students evaluated the contents of the prepared assistance based on their own nursing plan in reference to the practice of the nurse as a mediator, and compared that with the assistance practiced by the nurse based on clinical judgment, which contributed to acquiring practical learning supported by the grounds for clinical judgment. However, the students could not experience the process of building supportive relationships and the implementation of nursing skills, which remained an issue.

[Nursing Students' Learning and Issues in Gerontological Nursing in Online Practical Training].

The aim of this research is to clarify student learning and the issues they faced in the practice of gerontological nursing that our students completed online from home during the COVID-19 pandemic. A survey was conducted involving 71 third-year students who completed practical training in October 2020, and their choice of answers regarding "students' online learning environment" and free text answers regarding "what they have learned through practical training" were investigated through e-Learning systems. A total of 68 valid responses were analyzed, and the following 5 categories regarding students' learning were extracted: 1. the pleasure of experiencing that their understanding about patients can improve the care and the pleasure experienced from interacting with the elderly; 2. the importance of verbalizing and transmitting information in a way that others can understand; 3. the reconfirmation of records to avoid mixing facts with assessment and discussion, and the development of behavioral goals for personal growth: 4. the multidisciplinary cooperation and care necessary to support the lives of patients; and 5. the importance of maintaining independence during the online practice and increasing the motivation to learn. This study revealed that the benefits of learning from on-site training could be obtained in part, by providing opportunities for students to be connected with both clinical practice instructors and patients. The results suggest the possibility that online practical training, where more time is shared among teachers and students, may help students understand the importance of learning behavior and independence generated from teacher-student interactions. It was suggested that there is a need for the improvement of the student's online learning environment and practical training goals.

[Development of Clinical Practice in Adult Nursing (Chronic Care) During the COVID-19 Pandemic - Building and Implementing an Online Training Program].

The Department of Nursing, School of Health Sciences, University of Occupational and Environmental Health provides the specialized course "Clinical Practice in Adult Nursing (Chronic Care)" as a compulsory subject for third- and fourth-year students to acquire the basic skills required in nursing practice for adult patients with chronic diseases. Students are trained in hospital wards and in outpatient medical departments/admission support units for a total of 3 weeks to communicate directly with patients with chronic diseases, and to deepen their learning about the specialty of chronic nursing care. The COVID-19 pandemic forced the Department of Nursing to hold prompt discussions and determine an appropriate method to provide clinical training under this situation. It decided to cancel the conventional face-to-face training program, which was scheduled to start in May 2020, and to implement an online training program instead. Remote training was provided using the online conferencing system Zoom. The online training program was designed to realize simultaneous bidirectional training. To prepare for the training, simulated cases and simulated medical records were created. Faculty members played the roles of "simulated patients", "clinical supervisors", and "faculty members", while adopting elaborate approaches to help students develop nursing practice in real time. As a result, students were able to participate in training with a real feeling, even in an online environment, as they communicated with simulated patients daily, similarly to the case of clinical training. They also realized the limitations of learning without using the five physial senses and providing patient support with appropriate timing, revealing challenges specific to online training.

[Nursing Care Students' Image of Shame -Comparison Between First and Second Year Nursing Students].

It is not easy for nurses to estimate a patient's degree of shame, as the sense of shame depends on each person's personality, but nurses are requested to evaluate it as correctly as possible and to reduce the patient's mental load. We presume that most of the sense of shame is generated by body defects or disadvantages recognized by the patient. In this study, we tried to measure the degree of shame and to improve the basic nursing curriculum, depending on students' school year, under the assumption of what cases the nurses would frequently meet in a hospital. We prepared 13 figures that show common cases in hospitals. In these figures: 1) 6 figures show cases in which a nurse touched a patient's body; 2) 3 figures show common daily life; and 3) 4 figures show cases in which there are other people around the patient. A questionnaire was given to the first and second year students in A Nursing University, and we allocated scores of 1 to 10: 1 is "no-shame", and 10 is "very much shame". The students answered that patients must feel shame when: 1) they take off their clothes, 2) they show their disability to another person even without taking their clothes off, and 3) having people other than medical staff around them. In the results, as 2) appeared more strongly in the second year students than in the first, we thought that the second year students could surmise a patient's position in a hospital through the effect of the nursing education.

Nursing Education Trial Using a Virtual Nightingale Ward.

Nursing department students are expected to correctly grasp the entire concept of nursing through their education. The authors created a movie of a Nightingale ward (virtual ward, hereafter) with an architectural computer design software for education. The students' reaction to the virtual ward was categorized into three viewpoints: that of nurses, of patients, and of nurses and patients in common. Most of the reactions in each viewpoint were: "easy to observe patients" in the nurses' viewpoint; "no privacy" in the patients' viewpoint; and "wide room" in the common viewpoint, respectively. These reactions show the effectiveness of using a virtual ward in nursing education. Because these reactions are characteristics of a Nightingale ward, and even students, who have generally less experiences, recognized these characteristics from the both viewpoints of nurses and patients.

Development of Teaching Materials in Basic Nursing Using Virtual Reality －Ceiling Image Teaching Materials of a Hospital Room－.

It is difficult to understand nursing practically for students who have just started studying nursing, because they cannot imagine the actual medical scene. The authors expect that they can improve nursing learning through experiences in virtual medical environments supported by ICT (information and commnication technology). We developed teaching materials in nursing education, and in a previous study we reported that the use of a virtual hospital was useful for students who had not had medical experience. The aim of the present study was to have students consider the meaning of a hospital room ceiling. First, we showed them a few ceiling patterns, and they selected the best one among the patterns. After that, we showed the same one in a virtual hospital room. They had negative opinions about what they had thought was the best one at this time. This demonstrates that the virtual hospital room is effective when students evaluate the ceiling as a part of the hospital room.

[Implementation of Objective Structured Clinical Examination I of the Department of Nursing--Introduction of Simulation-Based Education].

The Department of Nursing of the university revised its curriculum for students admitted in 2012 or later, including the introduction of integrated subjects. With the aim of improving the practical clinical skills of students and integrating knowledge, skills, and techniques, the following integrated subjects: Objective Structured Clinical Examination (OSCE) I held in the first term of the third-year (15 hours as one credit), and OSCE II held in the second term of the fourth year (30 hours as one credit), were adopted, and simulation-based education was introduced. In this report, we summarized our experience of a simulation education system for nursing students in the year 2014 aiming to improve students' skill of wheelchair transfer of a patient with left hemiplegia and patient's living environment. Many positive responses, such as usefulness in future nursing training, were obtained upon the introduction of the simulation education system. Issues to be addressed in the future, including lack of sufficient time to practice and availability of rooms, were also noticed.

[Evaluation of Educational Effect of Problem-Posing System in Nursing Processing Study].

The nursing processing study is generally difficult, because it is important for nursing college students to understand knowledge and utilize it. We have developed an integrated system to understand, utilize, and share knowledge. We added a problem-posing function to this system, and expected that students would deeply understand the nursing processing study through the new system. This system consisted of four steps: create a problem, create an answer input section, create a hint, and verification. Nursing students created problems related to nursing processing by this system. When we gave a lecture on the nursing processing for second year students of A university, we tried to use the creating problem function of this system. We evaluated the effect by the number of problems and the contents of the created problem, that is, whether the contents consisted of a lecture stage or not. We also evaluated the correlation between those and regular examination and report scores. We derived the following: 1. weak correlation between the number of created problems and report score (r=0.27), 2. significant differences between regular examination and report scores of students who created problems corresponding to the learning stage, and those of students who created problems not corresponding to it (P<0.05). From these results, problem-posing is suggested to be effective to fix and utilize knowledge in the lecture of nursing processing theory.

[Nursing Education Utilizing Experiences in a Virtual Hospital Ward].

Environmental design should be required at medical facilities for conducting medical practice safely and for making hospitalization comfortable. Many medical nursing students cannot imagine medical facilities, especially hospital wards, when they study medical environments in a basic nursing lecture. As a result, they cannot connect well with patient assistance. We employed a computer assisted designing software, "3D My Home Designer" (Mega Soft Company) that runs on Windows 8, and considered the usefulness of it for lectures on environmental design showing how to design a hospital ward for patients' optimal hospital stay. We drew a medical facility in 2-D first, transformed it into 3D images, and then created movies of a virtual hospital ward in which a patient walked around. These movies consisted of 3 kinds: a) hospital room with changeable wall color, b) different allocations of hospital room and nurse station, and c) a blurred ward which corresponded to how a patient with poor eyesight (cataract) would see a ward. We prepared as controls: a') still images of a hospital room, b') still images of ward, and c') a documentation on how a ward is seen by a patient with a cataract. We gave a questionnaire to students and nurses about these movies and still images (controls). In a) and b), there were no differences between the movies and still images in both students and nurses. In c), both students and nurses had a viewpoint from the patient with poor eyesight. From these results, we consider that the students, who have fewer experiences in a hospital, may understand the environments well by movies and the application of a virtual movie ward to nursing education may be useful in a lecture, depending on the readiness of the students.

Attenuation of lipopolysaccharide-induced acute lung injury after (pro)renin receptor blockade.

PURPOSE/AIM: We performed a randomized, prospective animal study to investigate whether inhibiting the renin-angiotensin system with a (pro)renin receptor blocker (PRRB) prevents acute lung injury (ALI) in a rodent model. MATERIALS: We used Thirty-six male Sprague-Dawley rats. We administered lipopolysaccharide (LPS; 2 mg/kg) intratracheally with or without PRRB pretreatment (1 mg/kg/d). METHODS: We performed bronchoalveolar lavage (BAL) and lung removal at 4 h after LPS administration and measured levels of inflammatory cytokines, high mobility group box 1 (HMGB-1) protein, and total protein in bronchoalveolar lavage fluid (BALF). Myeloperoxidase (MPO) activity was detected in lung tissue homogenates using a sensitive ELISA. We performed hematoxylin and eosin staining and immunohistochemical staining for nonproteolytically activated prorenin in the left lung. RESULTS: The PRRB decreased leukocyte counts and total protein, tumor necrosis factor (TNF)-α, interleukin (IL)-1ß, IL-2, IL-6, and IL-10 levels in the BALF and MPO activity in lung tissue. The PRRB reduced interstitial edema, hemorrhage, and the neutrophil count in the lung tissues. Consistent with the reduction in lung tissue damage, immunohistochemical staining showed that the PRRB decreased the amount of nonproteolytically activated prorenin. CONCLUSIONS: The PRRB blocked LPS-induced inflammatory response in the lung and protected against ALI. Therefore, it is a potential therapeutic agent for preventing ALI.

(Pro)renin receptor blocker improves survival of rats with sepsis.

BACKGROUND: The renin-angiotensin system (RAS) affects inflammatory responses during sepsis. Nonproteolytic activation of prorenin by the (pro)renin receptor has recently been shown to stimulate the tissue RAS. In the present study, the effect of (pro)renin receptor blocker (PRRB) pretreatment on sepsis in a rat cecal ligation and puncture (CLP) model was investigated. MATERIALS AND METHODS: Male Sprague-Dawley rats underwent CLP and were randomly divided into two groups: PRRB-treated group and control peptide-treated group. Survival was analyzed for 7 d after CLP. The serum concentrations of cytokines and high-mobility group box chromosomal protein 1 (HMGB1) were measured at three time points (0, 3, and 6 h after CLP). Hematoxylin-eosin staining and immunohistochemical staining for nonproteolytically activated prorenin and HMGB1 were performed on the cecum to assess pathologic changes found 6 h after CLP. RESULTS: Treatment with PRRB improved the survival rate of the post-CLP septic rats (P = 0.023). PRRB also significantly reduced serum tumor necrosis factor-α, interleukin-1ß, and HMGB1 levels 6 h after CLP. In CLP rats that were treated with control peptide, the expression of activated prorenin was elevated in peritoneal foam cells. Moreover, expression of HMGB1 was increased in peritoneal inflammatory cells. In contrast, both were markedly suppressed in CLP rats that were treated with PRRB. CONCLUSIONS: PRRB significantly improved the survival rate of rats with clinically relevant sepsis, possibly by attenuating a sepsis-induced systemic inflammatory response. We propose that overactivation of the RAS by activation of prorenin in foam cells may be a significant contributor to sepsis.

Percutaneous endoscopic gastrostomy for decompression of malignant bowel obstruction.

BACKGROUND: Previous reports on percutaneous endoscopic gastrostomy (PEG) for bowel decompression have included a relatively small number of patients and the details of post-procedural outcomes and complications are lacking. The aim of the present study was to evaluate the outcomes and safety of PEG for bowel decompression in a relatively large number of patients with malignant bowel obstruction. PATIENTS AND METHODS: Over a 10-year period, 76 patients with malignant bowel obstruction were referred to the main referral cancer center in Shizuoka prefecture for PEG to obtain decompression. The method for gastrostomy was carried out by the pull-method, the modified introducer method and the percutaneous endoscopic gastrojejunostomy method. Patient demographics, procedural success, complications, elimination of nasal intubation, and survival were reviewed. RESULTS: Successful placement was achieved in 93% of patients (71/76). Procedure-related complications occurred in 21% ofpatients (15/71), of which the majority involved stomal leakage (eight patients), and wound infection (six patients). There were no procedure-related deaths. Among the 55 patients who required nasal intubation before PEG, a trans-gastrostomy intestinal tube was inserted in 16 patients. The need for further nasal intubation was eliminated in 96% of the patients (53/55). The median survival time was 63 days (range, 8-444 days) after PEG placement. CONCLUSIONS: PEG for bowel decompression in patients with malignant obstruction can be carried out with an acceptable risk of minor complications. In combination with a trans-gastrostomy intestinal tube insertion, the elimination of nasal intubation can be achieved in most patients.

Early gastric cancer with spreading to heterotopic gastric glands in the submucosa: a case report and review of the literature.

We report two cases of early gastric cancer (EGC) with spreading to heterotopic gastric glands (HGG). The first case was a submucosal-tumor-like EGC and proximal gastrectomy was performed. The second case was a slightly elevated EGC and endoscopic submucosal dissection was performed. In both cases, pathological results showed adenocarcinoma spreading to the HGG in the submucosa. The depth of cancer was diagnosed as intramucosal carcinoma because cancer was limited to the epithelium of HGG without invasion to the submucosal stroma. There is no clear guideline concerning the management of early gastric cancers with spreading to heterotopic gastric glands.

Well-differentiated villoglandular adenocarcinoma of the uterine cervix: assessment of cytological features by histological subtypes.

OBJECTIVE: Well-differentiated villoglandular adenocarcinoma (VGA) of the cervix involves papillae lined by different types of epithelial cells that are histologically subclassified into endocervical, endometrioid, or intestinal subtypes. The objective of the current study was to evaluate the definite cytological features of VGA by histological subtype. STUDY DESIGN: We examined 8 cervical smears from patients confirmed to have pure VGA and classified them into the 3 histological subtypes. RESULTS: The cervical smears were highly cellular and had a relatively clean background. The nuclei had minimal anisonucleosis and fine granular chromatin with almost inconspicuous nucleoli. The characteristic findings of the endocervical type were a palisading arrangement consisting of columnar or spindle-shaped cells with apical or elongated nuclei. Small but clear nucleoli were identified only in the endocervical type. In the endometrioid type, tumor cells consisted of cohesive sheets with smooth edges and very round nuclei. Cytoplasmic vacuolation was never observed in the endometrioid type. The tumor cells in the intestinal type were prominent with abundant cytoplasmic mucin. CONCLUSIONS: We demonstrated that the cytological features of this tumor can vary depending on the histological subtype and one should be aware of these features in order to improve diagnostic accuracy.

Gastric obstruction after endoscopic submucosal dissection.

BACKGROUND: Bleeding and perforation are two major complications of gastric endoscopic submucosal dissection (ESD). There are only a few reports concerning gastric obstruction related to ESD in the stomach. OBJECTIVE: The aim of this study was to clarify the clinicopathological features of patients who experienced gastric obstruction after gastric ESD. METHODS: Clinicopathological data of 1878 patients who underwent gastric ESD from September 2002 to December 2010 were retrospectively reviewed. Data of lesion location, circumference, circumferential extent of ESD ulcer, specimen diameter, depth of cancer, ulcer findings within the lesion, curability of ESD, number of simultaneous lesions, and occurrence of post-operative bleeding and perforation were collected. The risk of gastric obstruction regarding lesion and procedure related factors were assessed, and treatment for these patients was studied. RESULTS: Gastric obstruction was observed in 2.5% of the patients (47/1878). Symptoms occurred in a median of 24 days after ESD. The incidence among patients with lesions in the upper part of the stomach was 4.7% (17/316), 0.36% (3/818) in the middle, and 3.8% (27/699) in the lower part. In relation to the circumferential extent, the incidence was 50% (33/66) among patients with a resection of >75% of the circumference. Stenosis was observed in 87% (41/47) of patients with gastric obstruction. Endoscopic balloon dilation was performed in 45 patients. Perforation due to EBD occurred in four patients; one was referred to surgery. CONCLUSIONS: Patients with a wide resection of >75% of the circumference should be considered for early repeat endoscopy after ESD, and dilation should be performed with caution if found to have stenosis.

Endoscopic submucosal dissection for early gastric cancer in cases preoperatively contraindicated for endoscopic treatment.

BACKGROUND AND STUDY AIMS: Endoscopic submucosal dissection (ESD) is an optimal treatment for early gastric cancer (EGC) with negligible risk of lymph node metastasis; however, ESD is sometimes performed to treat lesions preoperatively contraindicated for the procedure due to various reasons. Here we aim to evaluate the treatment outcomes of ESD for lesions that were preoperatively contraindicated for ESD. PATIENTS AND METHODS: Clinicopathological data of 104 EGC lesions in 104 patients were reviewed retrospectively. The demographic characteristics of patients, reasons for ESD, treatment results, complications, and outcomes were assessed. RESULTS: The major reasons for undergoing ESD included advanced age, desire to undergo ESD, and the existence of comorbidities. En-bloc and complete resection rates were 97 and 71%, respectively. Perforation and postoperative bleeding rates were 13 and 9%, respectively. Resection was beyond the expanded Japanese criteria for endoscopic treatment of EGC in 87 patients (84%), 41 (47%) of whom underwent additional therapy, including subsequent gastrectomy (29 patients) and photodynamic therapy (12 patients). The median follow-up period was 47 months, during which seven patients died from recurrent disease. The 5-year overall and disease-specific survival rates were 70 and 91.5%, respectively. CONCLUSIONS: ESD is a technically demanding procedure for lesions preoperatively contraindicated for endoscopic resection. The curative resection rate was low, but the 5-year disease-specific survival rate of 91.5% was favourable. In experienced hands, ESD may be a treatment option for patients not suitable for radical surgery, and the relevant risk of complications must be considered before treatment.

Spherical sulfated cellulose adsorbs high-mobility-group box chromosomal protein 1 in vitro and in vivo.

High-mobility-group box chromosomal protein 1 (HMGB1) has recently been identified as a late mediator of various kinds of acute and chronic inflammation. A method for efficiently removing HMGB1 from systemic circulation could be a promising therapy for HMGB1-mediated inflammatory diseases. It is well known that the cationic portion of HMGB1 binds to heparin, which has abundant sulfates in its structure. In this study, we determined whether spherical sulfated cellulose (SC) efficiently adsorbed HMGB1, as well as other inflammatory mediators, in vitro. Then, we investigated the efficacy of hemoperfusion with the SC (SC group) or cellulose beads (control group) at adsorbing endogenous mediators, including HMGB1, in vivo. We have demonstrated that the SC adsorbed significantly larger amounts of HMGB1, interleukin (IL)-4, and IL-8 when compared with cellulose beads, in vitro. Hemoperfusion with the SC for 30 minute, starting 2 hour after an abdominal opening and closure operation, significantly reduced serum HMGB1 levels (p = 0.004) and consistently increased serum IL-10 levels, in vivo. These data suggest the potential benefits of hemoperfusion using the SC in treating HMGB1-mediated inflammatory diseases.

Neutrophil elastase inhibitor improves survival of rats with clinically relevant sepsis.

Sivelestat sodium hydrate is a selective inhibitor of neutrophil elastase, which is effective in acute lung injury associated with systemic inflammatory response syndrome. However, the effectiveness of sivelestat in sepsis has not been fully examined. In the present study, the effect of sivelestat on severe sepsis in a rat cecal ligation and puncture (CLP) model was investigated. Adult male Sprague-Dawley rats underwent CLP and were randomly divided into two groups: sivelestat-treated group and saline-treated controls. The serum concentrations of several inflammatory mediators were measured. Hematoxylin-eosin staining, and immunohistochemical staining for high-mobility group box chromosomal protein 1 (HMGB1), IL-8, and CD68 were performed on the lungs to assess pathological changes found 12 h after the CLP procedure. Treatment with sivelestat significantly improved the survival rate of the post-CLP septic animals (P = 0.030). Sivelestat also induced a significant reduction in serum IL-1beta (P = 0.038) and IL-10 (P = 0.008) levels in these CLP rats. Serum HMGB1 levels had no significant difference between the sivelestat-treated and the control group. The lungs from sivelestat-treated rats exhibited less severe pathological changes and decreased the numbers of HMGB1, IL-8, and CD68-positive cells (P < 0.001). Sivelestat significantly improved survival rate of rats with clinically relevant sepsis, possibly by attenuating sepsis-induced systemic inflammatory response and lung injury. This may explain the implicated health benefits of sivelestat in reducing morbidity and mortality from sepsis.

Identification and expression of a sialyltransferase responsible for the synthesis of disialylgalactosylgloboside in normal and malignant kidney cells: downregulation of ST6GalNAc VI in renal cancers.

Although disialyl glycosphingolipids such as GD3 and GD2 have been considered to be associated with malignant tumours, whether branched-type disialyl glycosphingolipids show such an association is not well understood. We investigated the sialyltransferases responsible for the biosynthesis of DSGG (disialylgalactosylgloboside) from MSGG (monosialylgalactosylgloboside). Among six GalNAc:alpha2,6-sialyltransferases cloned to date, we focused on ST6GalNAc III, V and VI, which utilize sialylglycolipids as substrates. In vitro enzyme analyses revealed that ST6GalNAc III and VI generated DSGG from MSGG with V(max)/K(m) values of 1.91 and 4.16 respectively. Transfection of the cDNA expression vectors for these enzymes resulted in DSGG expression in a renal cancer cell line. Although both ST6GalNAc III and VI genes were expressed in normal kidney cells, the expression profiles of ST6GalNAc VI among 20 renal cancer cell lines correlated clearly with those of DSGG, suggesting that the sialyltransferase involved in the synthesis of DSGG in the kidney is ST6GalNAc-VI. ST6GalNAc-VI and DSGG were found in proximal tubule epithelial cells in normal kidney tissues, while they were downregulated in renal cancer cell lines and cancer tissues. All these findings indicated that DSGG was suppressed during the malignant transformation of the proximal tubules as a maturation arrest of glycosylation.

PNA-in situ hybridization method for detection of HIV-1 DNA in virus-infected cells and subsequent detection of cellular and viral proteins.

We describe in situ hybridization protocols using peptide nucleic acid (PNA) as a probe for detecting HIV-1 DNA in virus-infected cells and the subsequent detection of cellular and/or viral proteins. Because a PNA probe of approx 20 bases was sufficiently long to detect a specific target sequence, a conserved sequence of such a short length was easily identified. Therefore, this probe is valuable even to identify quasi-species of HIV-1. In addition, we adopted a catalyzed signal amplification method to amplify weak viral DNA signals; thus, stringent washing was crucial for eliminating false-positive signals. Our double-staining method using PNA-in situ hybridization and subsequent immunostaining enabled the active and inactive proviruses to be distinguished.