Communication education is internationally recognized as a core element of medical education, and Japan is no exception. In Japan, it has been reported that “student attitude” is a significant barrier to communication education. The Communication Skills Attitude Scale (CSAS) has been translated and widely used in many countries to assess medical students’ attitudes toward learning communication skills (CS). However, a validated Japanese version had not yet been developed. This study aimed to develop and validate a Japanese version of the Communication Skills Attitude Scale (CSAS-J) and to support evidence-based, culturally appropriate CS education in Japan. The CSAS-J was developed through translation and back-translation of the original English version and reviewed by medical education experts. A total of 197 first- and fourth-year medical students participated in the final analysis. Principal factor analysis with Harris-Kaiser rotation was conducted, and internal consistency was assessed using Cronbach’s alpha (α). Factor analysis revealed a four-factor structure consisting of 15 items: “Learning Motivation” (α = 0.812), “Clinical Utility” (α = 0.805), “Skepticism toward Learning” (α = 0.645), and “Undervaluing the Importance of CS” (α = 0.582), with an overall α of 0.860. This study confirmed that the newly developed CSAS-J is a reliable and valid scale for assessing Japanese medical students’ attitudes toward learning CS. Notably, in addition to factors common to other countries, this study identified two negative attitudinal factors that appear to be unique to Japan: “Skepticism toward Learning” and “Undervaluing the Importance of CS.” These findings provide valuable insights for the design of educational interventions. Future studies should verify the CSAS-J’s validity across multiple institutions. It is expected that the CSAS-J will support the development of evidence-based communication education and contribute to safer and more reliable clinical practice.

Clinical clerkships are essential in medical education, but ethical and legal restrictions limit the invasive procedures performed by medical students in Japan. The 2023 revision of the Medical Practitioners’ Act permits students to conduct supervised procedures, such as venous blood collection and ultrasound examinations, after passing certain exams. This study investigates the public acceptance of these procedures, identifies barriers, and explores strategies to enhance medical student education patient–student collaboration. A cross-sectional internet-based survey was conducted in Japan from April 4–6, 2023, targeting 3,771 participants aged 18–79, stratified by sex and age. The attitudes and consent toward the medical procedures performed by students were assessed using a seven-point scale and bipolar adjective items. Demographic and socioeconomic factors were investigated as covariates. Open-ended responses were analyzed qualitatively. Linear regression with covariate adjustments was performed using Stata SE version 16. Out of 3,771 participants, 37.8

OBJECTIVES:The purpose of this study is to develop and refine PPE guidelines that address students' needs and concerns for the Peer Physical Examination (PPE) guidelines and to assess the feasibility of a Japanese version of such guidelines for managing PPE classes. METHOD:An action research approach was employed. Firstly, we sent a Questionnaire Survey 1 to the 5th and 6th year undergraduate medical students and junior residents to gather participants' expectations and suggested improvements for PPEs and their opinion about having a set of PPE guidelines. We drafted a set of PPE guidelines with reference to PPE policies overseas by reflecting participants' needs as identified through Questionnaire Survey 1. We then conducted interviews of 16 participants and revised our guidelines accordingly. Finally, we asked 632 medical students and 191 junior residents to fill out the form for obtaining informed consent (Questionnaire Survey 2) in order to check the feasibility of our PPE guidelines. RESULT:The majority of the participants supported the development of the PPE guidelines. The interviews identified 5 themes relating to participants' needs and concerns. In a pilot survey, students' refusal rate for being a model patient varied depending on body region and 74.2% had a desire to be informed of any abnormal findings confidentially. Additionally, the need to take a balance between respecting students' autonomy and securing model patients was noted. CONCLUSION:Medical students and junior residents generally supported the PPE guidelines. The right to refuse the model patient role and management of incidental findings should be included in the guidelines. In addition, informing students of educational benefits in being a model patient may be necessary to address the shortage of model patients.

ObjectivesAs more emphasis is placed on the acquisition of competencies in medical education, portfolios are increasingly being used for evaluation. EPOC2 (E-POrtfolio of Clinical training) is an e-portfolio system developed in Japan and is used by about 800 clinical training hospitals. The study objective is to identify the learning trajectory of junior residents to provide insights into the provision of better postgraduate and undergraduate medical education in Japan.DesignLongitudinal cohort study.SettingHospitals nationwide adopting EPOC2.Participants7671 residents who participated in clinical training programmes at hospitals adopting EPOC2 between April 2020 and March 2022.Primary outcome measureFormative evaluation scores assessed through self-evaluation by junior residents and evaluations by supervisors/senior physicians at the end of each rotation in each clinical department.ResultsFor all evaluation items, growth trajectories were divided into six groups, each with distinct characteristics based on the specific content of the evaluation form. For example, in the self-evaluation of medical knowledge and problem-solving (B-2), a lower percentage of respondents had adequate scores at the beginning of their training compared with other similar items. Compared with the self-evaluations of the other item groups (ie, forms A1–A4 and B1–B9), the self-evaluation of the item group related to seeing patients (ie, forms C1–C4) differed by showing a group that remained at or below 2 until the end, accounting for 2.8% to 7.0%, possibly indicating the relatively low confidence of the residents for these items.ConclusionsGrowth trajectories fall into six groups, each with its own characteristics depending on the content of the items. These findings offer valuable insights into the developmental trajectories of junior residents and may highlight opportunities for enhancing their training programmes in Japan. This underscores the usefulness of a nationwide evaluation system, enabling researchers to analyse clinical education outcomes across the country using uniform indicators.

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.

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.

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.

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.(c) 2022 Elsevier B.V. All rights reserved.

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.

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.

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 alpha-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 beta-catenin was determined by reporter analysis and chromatin immunoprecipitation assay. HD5/HD6/Atoh1/beta-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 beta-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 beta-catenin was impaired.Conclusions: HD6 expression was found to be regulated by cooperation between Atoh1 and beta-catenin within the HD6 promoter region. Downregulation of HD6 in noninflamed mucosa may contribute to mucosal barrier dysfunction of patients with CD.

Recommended therapy of bacterial infection is generally based on in vitro susceptibility of an organism to an infecting organism. Yet drug bioavailability based on solubility, protein binding and other factors along with host resistance and inflammatory-immune response importantly alter response to treatment. The objective of the study was to establish in vivo animal model to study antimicrobial therapy of C. difficile infection. C. difficile isolate with hyper-virulent factors (toxin A/B plus binary toxin and 18 base pair deletion in tcdC gene) was used in the study. The cultured C. difficile was stained with near infrared (NIR) dye. Stained C. difficilewere determined by using fluorescent microscope and confocal microscope. To monitor stained bacterial trafficking in the gut animals were imaged in real-time. The intestines from treated animals were dissected at the end of imaging study. The bacterial signal intensity and migration pattern were recorded and compared. C. difficile toxin secretion in the different segment of GI system was analyzed. Results showed the C. difficile can be stained by NIR dye. Stained bacteria can be imaged by NIR camera system to track the C. difficile traffic in the gut in real-time. Untreated control animal has different bacteria migration pattern than the animal with C. difficile infection treated with ciprofloxacin. TheNIR florescent probe can be used to visualize C. difficile trafficking in the gastrointentinal tract through culturing, staining and imaging. Fig. 1. Confocal images of C. difficile. Viable bacterial stained with NIR dye (A. Red) and dead bacterial determined with Sytox green (B. Green). Stain efficiency was determined by co-localized all cells (C. Green) and NIR (C. Red). Confocal microscope analyzed NIR dye binding at subcellular level (D). Red and green represent NIR and cell nuclei, respectively. Results demonstrate C. difficile can be stained by NIR dye. Most bacteria remain viable after the staining procedure.

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.

A 72-year-old man was diagnosed by endoscopy─which suggested well differentiated tubular adenocarcinoma Group 4─and admitted to our hospital. The lesion was located in the upper third of the stomach on the posterior wall, was flatly depressed (0-IIc), and had an undefined margin under indigo carmine dyeing. Histologically, the lesion was composed of cells resembling chief cells and indicated differentiation to fundic glands. Immunohistochemically the lesion indicated MUC6(+), MUC5AC(-), CD10(-), MUC2(-), gastric phenotype. We diagnosed this lesion as gastric adenocarcinoma, fundic gland type. Gastric adenocarcinoma of fundic gland type was proposed by Ueyama and Yao et al in 2010, and its clinicopathologic features reported. This type of lesion tends to invade submucosally and it is recommended to treat using ESD. For this reason we elected to perform endoscopic submucosal dissection (ESD) rather than endoscopic mucosal resection (EMR). The lesion─SM1 (250μm)─was completely excised. No relapse has been detected from surgery until follow up examination. Most of these cancers originate from normal mucous membrane, and are thought to be unassociated with H. pylori. As infection rate of H. pylori decreases, this type of adenocarcinoma should be considered in the future.

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.

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.