Mixed-methods study of medical students' attitudes toward peer physical examinations in Japan.

BACKGROUND: Most Japanese medical schools likely continue to rely on peer physical examination (PPE) as a tool to for teaching physical examination skills to students. However, the attitudes of medical students in Japan toward PPEs have not be identified. Therefore, we evaluated students' attitudes toward PPE in a Japanese medical school as a preparation for developing a PPE policy tailored to the context of Japanese culture. METHODS: We conducted a mixed-methods study with an explanatory sequential approach, in which qualitative data were used to interpret the quantitative findings. Surveys and interviews were conducted with medical students and junior residents at a Japanese university. A total of 63 medical students and 50 junior residents responded to the questionnaire. We interviewed 16 participants to reach theoretical saturation and investigated the attitudes of medical students toward PPE and the themes emerging from the interview data, providing detailed descriptions of the quantitative findings. RESULTS: Female participants were significantly more likely than male participants to report varying degrees of resistance to being a model patient during PPE (male: 59.7%, female: 87%, p < 0.001). Most of the participants who took on the role of patients that involved undressing were males. The participants expected improvements in issues related to the guarantee of freedom to refuse to be a model patient and measures to protect confidentiality. Approximately 22% of the participants reported that they witnessed incidental findings (including variations within the normal range) in front of other students during PPE. CONCLUSIONS: The findings imply that medical students expect high levels of autonomy and confidentiality when volunteering as model patients during PPE. Thus, developing a PPE policy suitable for Japanese culture may be effective in establishing a student-centered PPE environment.

Elucidation of the needs for telecritical care services in Japan: a qualitative study.

OBJECTIVE: To clarify the reasons for consultation, advice sought by frontline physicians and relationship between the patient's pathology and the type of advice provided to guide the future development of telecritical care services. DESIGN: Secondary analysis of transcripts of telephone calls originally recorded for quality control purposes was conducted using a thematic content analysis. The calls were conducted between December 2019 and April 2021 (total cases: 70; total time: ~15 hour). SETTINGS: Intensivists provided consultation services to frontline physicians at secondary care institutions in the Kansai and Chubu regions. PARTICIPANTS: Non-intensive care frontline physicians working in five secondary care institutions in the Kansai and Chubu regions and intensivists providing a consultation service (n=26). INTERVENTIONS: Not applicable. PRIMARY AND SECONDARY OUTCOME MEASURES: The main outcome was the themes emerging from the language used during telephone and video consultations, indicating the gap filled by the telecritical care service. FINDINGS: We analysed 70 cases and approximately 15 hours of anonymised audio data. We identified the following reasons for consultation: 'lack of competence in treatment and diagnostic testing' and 'lack of access to consultation in their own hospital'. Frontline physicians most often sought advice related to 'treatment', followed by 'patient triage and transfer', 'diagnosis' and 'diagnostic testing and evaluation'. Regarding the relationship between the patient's pathology and type of advice provided, the most commonly sought advice by frontline physicians varied based on the patient's pathology. CONCLUSION: This study explored the characteristics of 70 telecritical sessions and identified the reasons for and nature of the consultations. These findings can be used to guide the future provision and scale up of telecritical services.

Association between Grit and depressive symptoms at the timing of job start among medical residents during the COVID-19 pandemic in Japan: a cross-sectional study.

INTRODUCTION: The COVID-19 pandemic had an additional negative impact on the mental health of healthcare workers, including residents. Previous studies revealed that grit, which is an individual trait to achieve long-term goals unrelated to intelligence quotient, is not only positively associated with academic achievement and career success but also negatively correlated with depression. This study aimed to examine the association between grit and depressive symptoms among residents at the time of job start during the coronavirus disease 2019 (COVID-19) pandemic in Japan. MATERIALS AND METHODS: This cross-sectional study used data from all post-graduate year 1 residents from March 2020 to April 2022 at Tokyo Medical and Dental University, Tokyo, Japan. Grit was measured by the Japanese version of Grit-S. The resident's depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale. The association of interest was examined using logistic regression analysis. RESULTS: Among 221 residents, 28 (12.7%) have depressive symptoms. One unit increase in Grit-S score after adjusting for age, sex, graduated university, and sleeping hours was associated with lower odds of having depressive symptoms by 63% (odds ratio [OR]: 0.37; 95% confidence interval [CI]: 0.19-0.74). Further, the perseverance of effort subscale score was associated with lower odds of having depressive symptoms after covariate adjustment (OR: 0.43; 95% CI: 0.22-0.84). CONCLUSIONS: Higher grit scores were associated with lower odds of having depressive symptoms among residents at the timing of job start during the COVID-19 pandemic. Regular mental health assessment is particularly important for residents with low grit scores at entry.

Light Chain Deposition Disease Recurrence in Renal Allograft after Long-Term Remission.

Light chain deposition disease (LCDD) is a rare manifestation of monoclonal gammopathy, which can lead to renal failure. We previously reported a detailed recurrence process in a case of LCDD after renal transplantation. To the best of our knowledge, no report has described the long-term clinical course and renal pathology findings of recurrent LCDD in patients after renal transplantation. In this case report, we describe the long-term clinical presentation and changes in renal pathology of the same patient after early LCDD relapse in a renal allograft. A 54-year-old woman with recurrent immunoglobulin A λ-type LCDD in an allograft was admitted 1 year post-transplant for bortezomib and dexamethasone therapy. At 2 years post-transplantation, a graft biopsy performed after complete remission was achieved, showing some glomeruli with residual nodular lesions similar to the pre-treatment renal biopsy findings. However, the enlarged subendothelial space disappeared. She remained in complete remission serologically for 6 years. Subsequently, the ratio of serum κ/λ-free light chains decreased gradually. She underwent a transplant biopsy approximately 12 years after renal transplantation due to increased proteinuria and decreased renal function. Compared with the previous graft biopsy, almost all glomeruli showed advanced nodule formation and subendothelial expansion. Because the LCDD case relapsed after long-term remission following renal transplantation, protocol biopsy monitoring might be necessary.

Toxic benzyl alcohol inhalation: Altered mental status with metabolic acidosis and hyperammonemia.

This report presents the case of a patient whose inhalation exposure to benzyl alcohol led to clinical manifestations similar to toluene intoxication, including sudden altered mental status, metabolic acidosis, hypokalemia, hypophosphatemia, and hyperammonemia. Toxicity from benzyl alcohol inhalation is quite rare, and hyperammonemia associated with renal tubular dysfunction in poisoning cases has not been reported in the past.

Experience of disruption of capsule endoscopy after prolonged retention.

Capsule endoscopy is an effective tool for evaluating small bowel diseases. Capsule retention is a complication of capsule endoscopy, but capsule disruption after retention has not been thoroughly studied. Only a few cases of capsule disruption have been reported. We report a case of capsule disruption after prolonged retention. A 73-year-old woman underwent capsule endoscopy for the evaluation of anemia. One week later, capsule retention was observed on radiography. Capsule removal was advised, but she refused because she did not have any symptoms. After 20 months, computed tomography revealed disrupted capsule fragments. Capsule removal was strongly recommended, and the patient agreed. All disrupted capsule fragments were removed using double-balloon endoscopy without complications. Intestinal perforation had been prevented by removing the disrupted capsule before the battery fluid leaked into the intestinal tract. Capsule retention, documented by imaging, should be addressed by removing the retained capsule immediately before capsule disruption occurs.

Facilitators and barriers to implementing shared decision making: A cross-sectional study of physicians in Japan.

OBJECTIVE: Shared decision making (SDM) is a collaborative process in which patients and healthcare providers jointly make a medical decision. This cross-sectional study aimed to identify the facilitators and barriers to self-reported implementation of SDM in Japan, and to explore if there is effect modification by hospital types. METHODS: A total of 129 physicians in Japan completed a questionnaire that asked about their perception of SDM based on SDM-Q-Doc and its facilitators and barriers, which corresponded to each construct of the integrated behavioral model (IBM). The association between facilitators and barriers and SDM-Q-doc score was assessed using linear regression analysis. Stratified analysis by hospital types was also performed. RESULTS: Significant facilitators included physicians' attitude, injunctive norm, intention and habit. Significant barriers included physicians' unfavorable attitude, lack of self-efficacy, knowledge, salience and experience. Moreover, experiential attitude (concerning patient characteristics), injunctive norm (concerning patient preferences), and physician's habit were significant facilitators for physicians working in university hospitals when compared to those working in municipal hospitals. CONCLUSION: The facilitators and barriers to implementing SDM in Japan were identified. PRACTICE IMPLICATIONS: More opportunities for training on SDM are needed to provide knowledge and skills, which will enhance salience and contribute their habitual practice.

Facilitators and barriers to physicians' entrepreneurial ventures in major Japanese cities: A qualitative study.

BACKGROUND: The Japanese healthcare system currently faces numerous challenges, including a super-aging society and an excessive burden on medical workers; therefore, the need for innovative solutions from healthcare ventures to tackle these issues has increased. Meanwhile, as physicians play important roles in healthcare ventures, the need for Japanese physician entrepreneurs is more important than ever. Given the lack of research examining barriers to physicians starting ventures and what skills, knowledge, and surrounding environments act as facilitators, this study aimed to identify the facilitators and barriers faced by physicians to start ventures. METHODS: Between September and November 2019 and in May 2021, qualitative interviews were conducted with 33 participants, which included eight physician entrepreneurs; two administrative officers at the Ministry of Health, Labour and Welfare and the Ministry of Economy, Trade and Industry; three faculty members at Tokyo Medical and Dental University (in-depth interviews); and 20 medical students (focus group discussions). The interviews were deductively coded based on the social ecological model. The inductive approach was applied to coding any knowledge necessary to start a business. We conducted member checking with three physician entrepreneurs and seven medical students to improve our results' credibility. RESULTS: The factors influencing a physician's decision to launch a new business include their willingness to contribute to society, the unique environment in which an individual is placed while in medical school and afterward, negative aspects of the lack of diversity in physicians' careers, the financial stability provided by a medical license, and self-efficacy. CONCLUSIONS: Our study revealed facilitators and barriers to physicians' entrepreneurial ventures. Knowledge about these factors might be useful in supporting physicians to launch or become involved in healthcare ventures.

Reduced Human α-defensin 6 in Noninflamed Jejunal Tissue of Patients with Crohn's Disease.

BACKGROUND: Mucosal barrier dysfunction is considered a critical component of Crohn's disease (CD) pathogenesis after the identification of susceptibility genes. However, the precise mechanism underlying mucosal barrier dysfunction has not yet been elucidated. We therefore aimed to elucidate the molecular mechanism underlying the expression of human α-defensin 6 (HD6) in patients with CD. METHODS: HD6 expression was induced by the transfection of an atonal homolog 1 (Atoh1) transgene and was assessed by reverse transcription polymerase chain reaction. The HD6 promoter region targeted by Atoh1 and ß-catenin was determined by reporter analysis and chromatin immunoprecipitation assay. HD5/HD6/Atoh1/ß-catenin expression in noninflamed jejunal samples collected by balloon endoscopy from 15 patients with CD and 9 non-inflammatory bowel disease patients were assessed by immunofluorescence. RESULTS: Both promoter activity and gene expression of HD6 was significantly upregulated by the Atoh1 transgene in human colonic cancer cell line. We identified a TCF4 binding site and an E-box site, critical for the regulation of HD6 transcriptional activity by directly binding of Atoh1 in the 200-bp HD6 promoter region. The treatment with ß-catenin inhibitor also decreases HD6 promoter activity and gene expression. Moreover, HD6 expression, but not HD5 expression, was found to be decreased in noninflamed jejunal regions from patients with CD. In HD6-negative crypts, nuclear accumulation of ß-catenin was impaired. CONCLUSIONS: HD6 expression was found to be regulated by cooperation between Atoh1 and ß-catenin within the HD6 promoter region. Downregulation of HD6 in noninflamed mucosa may contribute to mucosal barrier dysfunction of patients with CD.

Lineage-specific expression of bestrophin-2 and bestrophin-4 in human intestinal epithelial cells.

Intestinal epithelial cells (IECs) regulate the absorption and secretion of anions, such as HCO3(-) or Cl(-). Bestrophin genes represent a newly identified group of calcium-activated Cl(-) channels (CaCCs). Studies have suggested that, among the four human bestrophin-family genes, bestrophin-2 (BEST2) and bestrophin-4 (BEST4) might be expressed within the intestinal tissue. Consistently, a study showed that BEST2 is expressed by human colonic goblet cells. However, their precise expression pattern along the gastrointestinal tract, or the lineage specificity of the cells expressing these genes, remains largely unknown. Here, we show that BEST2 and BEST4 are expressed in vivo, each in a distinct, lineage-specific manner, in human IECs. While BEST2 was expressed exclusively in colonic goblet cells, BEST4 was expressed in the absorptive cells of both the small intestine and the colon. In addition, we found that BEST2 expression is significantly down-regulated in the active lesions of ulcerative colitis, where goblet cells were depleted, suggesting that BEST2 expression is restricted to goblet cells under both normal and pathologic conditions. Consistently, the induction of goblet cell differentiation by a Notch inhibitor, LY411575, significantly up-regulated the expression of not BEST4 but BEST2 in MUC2-positive HT-29 cells. Conversely, the induction of absorptive cell differentiation up-regulated the expression of BEST4 in villin-positive Caco-2 cells. In addition, we found that the up- or down-regulation of Notch activity leads to the preferential expression of either BEST4 or BEST2, respectively, in LS174T cells. These results collectively confirmed that BEST2 and BEST4 could be added to the lineage-specific genes of humans IECs due to their abilities to clearly identify goblet cells of colonic origin and a distinct subset of absorptive cells, respectively.

Histological diagnosis of follicular lymphoma by biopsy of small intestinal normal mucosa.

Due to advances in double-balloon endoscopy, various types of malignant lymphoma of the small intestine have been observed at very early stages. We report here that after remission of diffuse large B-cell lymphoma, follicular lymphoma recurred in the mucosa of the small intestine. Furthermore, these lesions were diagnosed by biopsy from normal mucosa as diminutive erosions and reddish looking. If a small intestinal lesion is suspected of being a malignant lymphoma, a double-balloon endoscopy should be carried out, and a biopsy should be taken and inspected.

Modified single-operator method for double-balloon endoscopy.

Applications of double-balloon endoscopy (DBE) have expanded widely to areas beyond small-intestine endoscopy. Two endoscopists are required for standard insertion, but it is preferable to have DBE carried out by one endoscopist to optimize control of the procedure and because of human resources issues. We previously reported on the Single-Operator Method, but here we describe newly modified insertion techniques that facilitate and enhance the performance of DBE by a single endoscopist. Our new technique consists of Hooking Technique, Outside Support, Grasp Scope and Overtube, Continuous Overtube Infusion and Double-Overtube Method. These new techniques make it easier to carry out the Single-Operator Method.

Endoscopic ultrasound with double-balloon endoscopy for the diagnosis of inverted Meckel's diverticulum: a case report.

INTRODUCTION: Inverted Meckel's diverticulum has usually been misdiagnosed in the cases based on computed tomography images presented in the literature. The final diagnosis was made intra-operatively or by pathology reports after surgery. Despite this, preoperative diagnosis could be made successfully by using endoscopic ultrasound with double-balloon endoscopy prior to surgery. CASE PRESENTATION: A 60-year-old Japanese woman with severe anemia complained of several episodes of black stool over the preceding 2 years. Abdominal computed tomography showed a 3.0-cm low-density tumor in the ileum, suggesting a diagnosis of intestinal lipoma. Examination of the tumor by endoscopic ultrasound with double-balloon endoscopy revealed a hypo-echoic layer corresponding to the muscularis propria, and a hyper-echoic layer corresponding to the fat tissue. These findings, which suggested that the tumor included areas outside the intestinal serosa, are not typical for a lipoma, despite the existence of a hyper-echoic layer corresponding to fatty tissue. We then considered a diagnosis of inverted Meckel's diverticulum. CONCLUSION: Lipoma and inverted Meckel's diverticulum are difficult to differentially diagnose by computed tomography. Polypectomy is the preferred therapeutic approach when a lipoma is present; however, polypectomy in a patient with Meckel's diverticulum requires full-thickness resection. Situations where polypectomy is performed without preparing for full-thickness resection can be avoided by first making a precise diagnosis using double-balloon endoscopy and endoscopic ultrasound.

Magnetic resonance enterocolonography is useful for simultaneous evaluation of small and large intestinal lesions in Crohn's disease.

BACKGROUND: We developed novel magnetic resonance enterocolonography (MREC) for simultaneously evaluating both small and large bowel lesions in patients with Crohn's disease (CD). The aim of this study was to evaluate the diagnostic performance of MREC by comparing results of this procedure to those of endoscopies for evaluating the small and large bowel lesions of patients with CD. METHODS: Thirty patients with established CD were prospectively examined by newly developed MREC. Patients underwent ileocolonoscopy (ICS) (24 procedures) or double-balloon endoscopy (DBE) (10 procedures) after MREC on the same day. Two gastroenterologists and two radiologists who were blinded to the results of another study evaluated endoscopy and MREC findings, respectively. RESULTS: In colonic lesions the sensitivities of the MREC for deep mucosal lesions (DML), all CD lesions, and stenosis were 88.2, 61.8, and 71.4%, respectively, while the specificities were 98.1, 95.3, and 97.7%, respectively. In small intestinal lesions, MREC sensitivities for DML, all CD lesions, and stenosis were 100, 85.7, and 100%, respectively, while specificities were 100, 90.5, and 93.1%, respectively. Endoscopic scores were significantly correlated with MREC scores. Eleven (46%) of the 24 patients who were clinically not suspected to show stricture were observed to demonstrate stricture by radiologists. CONCLUSIONS: Our results demonstrated that MREC can simultaneously detect the CD lesions of the small and large intestine. MREC can be performed without radiation exposure, the use of enema, or the placement of a naso-jejunal catheter. MREC and endoscopy have comparable abilities for evaluating mucosal lesions of patients with CD.

Longitudinal cell formation in the entire human small intestine is correlated with the localization of Hath1 and Klf4.

BACKGROUND: Double balloon endoscopy (DBE) enables the observation and collection of viable specimens from the entire intestine, thereby allowing more detailed investigation of how the structure and function of the human small intestine are regulated. The present study aimed to elucidate the regulation of cell formation in the human small intestine using biopsy specimens collected from an entire individual small intestine by DBE. METHODS: The expression and the localization of representative genes for the differentiation program were analyzed in the entire small intestine of 10 patients. The functional correlation between Hath1 and Klf4 was analyzed in an intestinal cell line by using a Tet-On system. RESULTS: In longitudinal cell formation in the small intestine, it was shown that goblet cells, but not Paneth cells, increased toward the ileum in each individual small intestine. Immunohistochemistry showed that Hath1-expressing cells migrated from the base of the crypt to the top of the villi in the terminal ileum, while Klf4-expressing cells migrated from the top of the villus, resulting in the colocalization of Hath1 and Klf4 in the terminal ileum. Coexpression of Hath1 and Klf4 upregulated the expression of phenotypic genes for goblet cells following the downregulation of those for Paneth cells. CONCLUSIONS: Using mapping biopsy by DBE, we have demonstrated, for the first time, the molecular basis of the villus structure in the entire human small intestine in vivo. The present study showed that longitudinal cell formation was regulated by the colocalization of Hath1 and Klf4 that converted Paneth cell differentiation into goblet cell differentiation.

Single-operator double-balloon endoscopy (DBE) is as effective as dual-operator DBE.

BACKGROUND AND STUDY AIMS: Double-balloon endoscopy (DBE) is a new device that allows diagnosis and treatment throughout the entire small intestine. Although the originally described method requires two operators, we have recently developed a method to perform DBE by a single operator. We here assessed the clinical usefulness of this one-person method in comparison to the conventional two-person DBE. PATIENTS AND METHODS: One hundred sixty-two patients (102 men and 60 women, mean age 59 years) underwent 303 DBE procedures. Total observation time, completion rate of total intestinal and colonic observation, lesion-discovery rate, and complication rate were retrospectively compared between the one-person method and the conventional two-person method of DBE. The one-person method consists of the Grip and Pinch technique and Keep (or Hold) and Slide technique. RESULTS: The total observation times were 95.5 +/- 35.1 min and 96.7 +/- 47.5 min by one-person and two-person antegrade DBE, respectively, and 103 +/- 29.8 min and 111 +/- 30.1 min by one-person and two-person retrograde DBE, respectively. The completion rate for examination of the entire small intestine was 74.2% in one-person DBE and 76.5% in two-person DBE, respectively. The lesion-discovery rate was 69.0% in one-person DBE and 65.5% in two-person DBE, respectively. No significant differences between two methods were found in all measures. Also, no difference was observed in complication rate of the two methods. CONCLUSIONS: The single-operator method for DBE was as efficient as the dual-operator DBE without any higher risk of complications and, therefore, could replace the conventional dual-operator method in the future.

[Case of severe ulcerative colitis successfully treated with intravenous cyclosporine without high dose corticosteroid].

A 44-year-old women developed marked myopathy one year earlier, when she was treated with intravenous prednisolone for acute severe exacerbation of ulcerative colitis. When she was admitted to our hospital for another severe exacerbation, intravenous cyclosporine A was administered as monotherapy because she could not tolerate corticosteroid. The treatment was successful and she obtained complete remission. Cyclosporine A monotherapy is considered to be a valuable alternative to proctocolectomy for severe ulcerative colitis patients who cannot tolerate corticosteroid.

[A case report: Severe bone marrow suppression caused by 6-mercaptopurin in Crohn's disease patient].

A 23-year-old man was admitted for treatment of acute exacerbation of ileitis and perianal abscess caused by Crohn's disease. After incision and drainage of the abscess, coupled with antibiotic therapy, 6-mercaptopurine (6-MP) was commenced. His white blood cell (WBC) count on day 12 after initiation of 6-MP was not decreased. However, on day 24 he was re-admitted because of severe myelosuppression (WBC: 300/microl), which was complicated by the recurrence of the perianal abscess. Myelosuppression was prolonged and required the administration of granulocyte colony stimulating factor (G-CSF). G-CSF was continued for 17 days to achieve recovery of his WBC count to a normal level.