Introduction: Tube thoracostomy (TT) complications are common in respiratory medicine. However, the prevalence of complications and risk factors is unknown, and data on countermeasures are lacking. Methods: This was a mixed -methods retrospective observational and qualitative study. This retrospective observational study included TT performed on patients admitted to the Department of Respiratory Medicine at our University Hospital between January 1, 2019, and August 31, 2022 (n=169). The primary endpoint was the incidence of TT -related complications. We reviewed the association between complications and patientand medical -related factors as secondary endpoints. In this qualitative study, we theorized the background of physicians' susceptibility to TT -related complications based on the grounded theory approach. Results: Complications were observed in 20 (11.8%) of the 169 procedures; however, they were unrelated to 30 -day mortality. Poor activities of daily living (odds ratio 4.3, p=0.007) and regular administration of oral steroids (odds ratio 3.1, p=0.025) were identified as patient -related risk factors. Physicians undergoing training caused the most complications, and the absence of a senior physician at the procedure site (odds ratio 3.5, p=0.031) was identified as a medical risk factor. Based on this qualitative study, we developed a new model for TT complication rates consistent with the relationship between physicians' professional skills, professional identity, and work environments. Conclusions: Complications associated with TT are common. Therefore, it is necessary to implement measures similar to those identified in this study. Particularly, a supportive environment should be established for the training of physicians.

In clinical clerkship (CC), medical students can practice evidence-based medicine (EBM) with their assigned patients. Although CC can be a valuable opportunity for EBM education, the impact of EBM training, including long-term behavioral changes, remains unclear. One hundred and nine fourth- and fifth-year medical students undergoing CC at a medical school in Japan attended a workplace-based learning program for EBM during CC (WB-EBM), which included the practice of the five steps of EBM. The program's effect on the students' attitudes toward EBM in CC was assessed through questionnaires. A total of 88 medical students participated in the program. Responses to the questionnaire indicated high satisfaction with the WB-EBM program. The most common theme in students' clinical problems with their assigned patients was the choice of treatment, followed by its effect. Based on the responses in the post-survey for the long-term effects of the program, the frequency of problem formulation and article reading tended to increase in the 'within six months' group comprising 18 students who participated in the WB-EBM program, compared with the control group comprising 34 students who did not. Additionally, the ability to self-assess problem formulation was significantly higher, compared with the control group. However, among 52 students who participated in the WB-EBM program more than six months later, EBM-related behavioral habits in CC and self-assessments of the five steps of EBM were not significantly different from those in the control group. The WB-EBM program was acceptable for medical students in CC. It motivated them to formulate clinical questions and enhanced their critical thinking. Moreover, the WB-EBM program can improve habits and self-evaluations about EBM. However, as its effects may not last more than six months, it may need to be repeated across departments throughout CC to change behavior in EBM practice.

Background: Functional exercise capacity in pulmonary hypertension (PH) is routinely assessed using the 6-min walking test (6MWT). However, alternative tests are useful because of resource requirements. This study aimed to evaluate whether the 1-min sit-to-stand test (1STST) is useful and safe in PH and whether it can replace the 6MWT. Methods: Adult patients with PH were recruited from our hospital between September 2023 and April 2024. The correlations between the number of 1STST repetitions (1STSTr) and 6-min walk distance (6MWD), pulmonary hemodynamic parameters, and quadriceps muscle strength; adverse events; and vital sign fluctuations during the tests were evaluated, and a questionnaire with an 11-point Likert scale (-5, 6MWT favor; 5, 1STST favor) was administered. Results: Twenty-one patients with PH were enrolled in this study. The 1STSTr and 6MWD were 23.8 f 7.8/min and 425.8 f 116.8 m, respectively, with a strong correlation (r = 0.771). 1STSTr was significantly correlated with brain natriuretic peptide, but not with other pulmonary hemodynamic markers, respiratory function, or quadriceps muscle strength. No serious adverse events or motor impairments occurred with the 1STST. The minimum SpO2 during the tests was significantly lower with the 6MWT (92.6 f 3.1 vs. 88.0 f 11.0). The questionnaire showed a predominant preference for the 1STST (3.2 f 2.6). Conclusions: To our knowledge, this is the first study in Japan to adapt the 1STST to PH patients. The 1STST is a reliable alternative to the 6MWT for measuring exercise capacity in PH patients. Trial registration: This study was registered with the UMIN-CTR (number UMIN000052010).

Background: The usefulness of lung ultrasound (LUS) has been demonstrated. However, it is unclear whether diagnostic techniques using LUS are accepted by all physicians. A simple simulation-based educational program may improve the LUS skills of beginners, but it has not been fully assessed. Objective: This prospective study was conducted to assess the educational outcomes of LUS training using a high-fidelity simulator. Methods: A simulator-based program for LUS was conducted. All clerkship students at the Department of Respirology at Chiba University Hospital participated in the program from December 2022 to April 2023. The participants watched a 30-minute teaching video on demand before a hands-on session lasting for 1 hour during the first week of the clinical clerkship. The readiness of the participants to learn LUS and the usefulness of the program were assessed using questionnaires administered before and after the program. The LUS skills were assessed using simulator-based tests during Weeks 1 and 4. Data on the accuracy and time required to answer the questions were collected during the tests. Results: Forty clerkship students participated in this study. Thirty-three (82.5%) had received other ultrasound education; however, only two (5.0%) had experience with LUS. Based on the questionnaire responses, the participants perceived LUS as useful (preprogram: 4.6 vs. postprogram: 4.8; P = 0.010; a 5-point Likert scale was used [1: not useful to 5: useful]). The simulator-based tests showed comparable accuracies at Weeks 1 and 4 for pneumothorax (Week 1: 47.5% vs. Week 4: 52.5%; P = 0.623), pulmonary edema (Week 1: 100% vs. Week 4: 100%; P = 1.000), and pleural effusion (Week 1: 37.5% vs. Week 4: 40.0%; P = 0.800). The time required for scanning was the same for each question. In addition, the test results did not differ with prior learning, previous knowledge, or experience during clinical clerkships on LUS. Conclusion: A short educational program consisting of on-demand learning and hands-on sessions with a high-fidelity simulator would be effective in equipping clerkship students with basic LUS skills. However, to increase its educational effectiveness to a practical degree, the program should be improved, and more opportunities for training using simulators should be provided.

Introduction The study aimed to evaluate visualization-based training’s effects on lung auscultation during clinical clerkship (CC) in the Department of Respiratory Medicine on student skills and confidence. Methods The study period was December 2020–November 2021. Overall, 65 students attended a lecture on lung auscultation featuring a simulator (Mr. Lung™). Among them, 35 (visualization group) received additional training wherein they were asked to mentally visualize lung sounds using a graphical visualized lung sounds diagram as an example. All students answered questions on their self-efficacy regarding lung auscultation before and after four weeks of CC. They also took a lung auscultation test with the simulator at the beginning of CC (pre-test) and on the last day of the third week (post-test) (maximum score: 25). We compared the answers in the questionnaire and the test scores between the visualization group and students who only attended the lecture (control group, n = 30). The Wilcoxon signed-rank test and analysis of covariance were used to compare the answers to the questionnaire about confidence in lung auscultation and the scores of the lung auscultation tests before and after the training. Results Confidence in auscultation of lung sounds significantly increased in both groups (five-point Likert scale, visualization group: pre-questionnaire median 1 [Interquartile range 1] to post-questionnaire 3 [1], p<0.001; control group: 2 [1] to 3 [1], p<0.001) and was significantly higher in the visualization than in the control group. Test scores increased in both groups (visualization group: pre-test 11 [2] to post-test 15 [4], p<0.001; control group: 11 [5] to 14 [4], p<0.001). However, there were no differences between both groups’ pre and post-tests scores (p = 0.623). Conclusion Visualizing lung sounds may increase medical students’ confidence in their lung auscultation skills; this may reduce their resistance to lung auscultation and encourage the repeated auscultation necessary to further improve their long-term auscultation abilities.

The effectiveness of wireless electronic stethoscopes as auscultation devices for medical examinations in clinical practice has been investigated.1, 2 Whilst these stethoscopes allow professionals to auscultate simultaneously, no studies have evaluated their usefulness by sound sharing in medical education in clinical settings. Thus, we applied a wireless electronic stethoscope to hospital ward rounds and evaluated the device's effectiveness. This open-label controlled study compared the usefulness of a wireless electronic stethoscope (β Fon-II, Kenzmedico, Japan) in ward rounds for medical education. Forty-nine students who underwent clinical clerkship at the Department of Respirology in Chiba University Hospital from September 2022 to March 2023 participated. Twenty-six participants used a wireless electronic stethoscope (wireless electronic group: EG), and the other 23 used conventional stethoscopes (conventional group: CG) (Figure 1). In a ward round with three to four students and attending physicians, all students performed chest auscultation concurrently with attending physicians in the EG, while in the CG, they followed the attending physician's examination. Thirty-nine patients (EG, 21; CG, 18) were examined by auscultation. Diseases presented by their patients were as follows: EG versus CG; interstitial lung disease, 5 (23.8%) versus 6 (33.3%); lung cancer, 8 (38.1%) versus 2 (11.1%); obstructive pulmonary disease, 1 (4.8%) versus 2 (11.1%); pleural disease, 2 (9.5%) versus 3 (16.7%); pulmonary hypertension, 3 (14.3%) versus 4 (22.2%); respiratory infection, 2 (9.5%) versus 1 (5.6%). The time of examination, including lung auscultation with attending physicians and students per patient, was measured during ward rounds. After the rounds, the participants reported auscultation findings for each patient to evaluate the diagnostic accuracy. Additionally, questions regarding the use of the electronic stethoscope were answered by the EG. The groups were compared using the Wilcoxon signed-rank test. Statistical significance was set at p < 0.05. All statistical analyses were performed using JMP version 15.0 (Cary, NC). This study was approved by the Research Ethics Committee of Chiba University (Approval No. 4106). All participants gave written informed consent. The study adhered to the TREND checklist. Students performed 147 chest auscultations (EG, 80; CG, 67). The auscultation accuracy did not differ (EG, 69/80 [86.3%]; CG, 60/68 [88.1%]; p = 0.809). However, the examination time was significantly shorter in the EG (3′46″ ± 1′22″ and 4′52″ ± 51″ in CG, p < 0.001). Most participants reported that the best feature of using the wireless stethoscope was sound sharing (21/26 [80.8%]). Sound sharing with this device reduced the examination time without affecting diagnostic ability and improved educational efficiency. Additionally, reduced examination time may improve the patients' burden, especially in patients with poor general or respiratory status. Regarding educational effectiveness, the absence of sound sharing is a limitation in cardiopulmonary auscultation.3 Sound sharing can help instructors identify the sounds listened to by students to provide appropriate feedback. This preliminary study had some limitations. First, the effectiveness of this device was shown in limited situations and learner populations. Second, the educational effects on students are not assessed by strict examinations. Therefore, further trials are needed to fully assess this device's effectiveness. Kenichiro Takeda: Conceptualization (equal); data curation (equal); formal analysis (equal); investigation (equal); methodology (equal); project administration (equal); writing – original draft (equal); writing – review and editing (equal). Hajime Kasai: Supervision (lead); writing – review and editing (supporting). Nami Hayama: Investigation (supporting); writing – review and editing (supporting). Mikihito Saito: Investigation (supporting); writing – review and editing (supporting). Chiaki Kawame: Investigation (supporting); writing – review and editing (supporting). Kanae Maruyama: Investigation (supporting); writing – review and editing (supporting). Takuji Suzuki: Investigation (equal); supervision (lead); writing – review and editing (lead). We would like to thank Editage (www.editage.com) for the English language editing. None declared. This study was performed in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of Chiba University—approval: 4106. All adult participants provided written informed consent to participate in this study. All individuals in the images have given permission to use the image combination for this publication. The data that support the findings of this study are available from the corresponding author upon reasonable request.

The possibility of combination therapy with atomoxetine (ATO) and oxybutynin (OXY) has been suggested for obstructive sleep apnoea (OSA). However, the effectiveness of this treatment remains uninvestigated in Japanese OSA patients. Therefore, we performed a randomized, crossover, phase II, single‐centre prospective trial to examine the effects of ATO–OXY therapy in Japanese OSA patients.