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Abstract 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.

Abstract How do group size changes influence cooperation within groups? To examine this question, we performed a dynamic, network-based prisoner’s dilemma experiment with fMRI. Across 83 human participants, we observed increased cooperation as group size increased. However, our computational modeling analysis of behavior and fMRI revealed that groups size itself did not increase cooperation. Rather, interaction between (1) participants’ stable prosocial tendencies, and (2) dynamic reciprocal strategy weighed by memory confidence, underlies the group size-modulated increase in cooperation because the balance between them shifts towards the prosocial tendency with higher memory demands in larger groups. We found that memory confidence was encoded in fusiform gyrus and precuneus, whereas its integration with prosocial tendencies was reflected in the left DLPFC and dACC. Therefore, interaction between recall uncertainty during reciprocal interaction (i.e., forgetting) and one’s individual prosocial preference is a core pillar of emergent cooperation in more naturalistic and dynamic group formation.

Abstract Smartphones have become an integral part of modern life, raising concerns about their impact on mental health, especially among young people. However, previous studies yielded inconsistent results, possibly due to neglecting the possibility of interactions between offline and online communications. To explore potential interactions among different communication modes (online vs. offline) and communication types (private vs. public), we adopted the experience sampling method to track 418 Japanese individuals over 21 days and analyzed the data using multilevel models and psychometric network models. The findings revealed that digital use has only small direct effects on happiness and loneliness, especially through public (one-to-many) online communication. The increased digital use reduced offline communication time, indirectly influencing loneliness to a large degree. Overall, this study highlights the indirect effects of decreased face-to-face communication and the significant role of one-to-many online communication, which may explain a part of the diverse findings on this issue.

Efficient removal of oxygen (O) impurities from titanium (Ti) scrap is necessary to accelerate the recycling of Ti scrap. However, deoxidation of Ti is extremely difficult, both thermodynamically and technically. In this study, we developed a deoxidation technique that uses Yb (a rare earth metal with high vapor pressure at elevated temperatures) to directly remove O dissolved in solid Ti. Experimental results showed that deoxidation using Yb in halide salt fluxes such as LiCl and LiF produced Ti with O concentrations of 520-1400 mass ppm. The O concentration in deoxidized Ti samples was reduced to a level lower than that in Ti under the Yb/Yb2O3 equilibrium, probably owing to the decrease in the activity of Yb2O3, which was the deoxidation product, caused by its dissolution in the fluxes. In contrast, when vapor of Yb metal and halide salts were supplied to Ti samples via a gas phase, the Ti samples were deoxidized to the same O concentration as that under the Yb/Yb2O3 equilibrium. This deoxidation limit was controlled by the Yb/Yb2O3 equilibrium. The supply of halide salt vapor did not affect the deoxidation limit. The proposed deoxidation method is expected to help scale up the recycling of Ti scrap and ensure efficient utilization of resources.

Objectives As 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.Design Longitudinal cohort study.Setting Hospitals nationwide adopting EPOC2.Participants 7671 residents who participated in clinical training programmes at hospitals adopting EPOC2 between April 2020 and March 2022.Primary outcome measure Formative 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.Results For 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.Conclusions Growth 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:. Almost half of all spontaneously occurring keloids are acne keloids on the anterior chest. These keloids often grow in a crab-claw shape due to predominant tractional stresses on the scar; such stresses are risk factors for keloid growth/progression. To understand the relationship between acne keloid growth and mechanical stress, we conducted finite element analysis (FEA), measured the long/short dimensions of photographed acne keloids, and subjected acne keloids to microscopy. Methods:. FEA was conducted on 10 identically shaped ellipsoidal keloids whose long-axis length rose from 5 to 50 mm in 5-mm increments. They were embedded in the skin and subjected to traction. The stress on the keloid and its surrounding tissues was determined. Dimensions of 220 acne keloids were measured. Electron/light microscopy was conducted on the center, margins, and surrounding tissues of chest acne keloids. Results:. FEA showed that as the keloid “grew,” the tractional stress centered on its core, then became evenly distributed, and then focused increasingly on the tractioned keloid margin, especially its shallow dermis. This is associated with increasing stress in the surrounding tissues at the keloid margin. Clinical dimension measurements showed that acne keloids remained round until 4–5 mm, after which they elongated rapidly. Electron microscopy showed that in the surrounding skin, fragments of keratinocyte, fibrin, and numerous cell fragments were observed just below the epidermal basement membrane. Conclusions:. Keloid-prone acne should be treated with steroid tape or other keloid therapy when it reaches 4–5 mm in diameter.

Background:. The effectiveness of conservative treatment for congenital auricular deformities depends primarily on the plasticity of the auricular cartilage. However, the effect remains uncertain due to various confounding factors such as differences in the characteristics of the deformity and timing of treatment initiation. In this study, we investigated the optimal timing for initiation of conservative treatment. Methods:. We investigated the age at treatment initiation and surgical avoidance rate among 158 children with congenital auricular deformities who were treated with corrective devices at our hospital. In addition, we conducted and analyzed questionnaires containing items assessing treatment satisfaction and characteristics. Results:. Surgical avoidance rates decreased markedly among those starting treatment after 5 months of age, and satisfaction was significantly higher in the surgical avoidance group. Multivariate analysis showed that the only factor affecting the treatment effect was the age at treatment initiation. Conclusions:. This study suggests that the initiation of conservative treatment with corrective devices within 5 months of age for congenital auricular deformities may lead to avoidance of surgery and increased satisfaction. However, we should not judge the indication for conservative treatment solely based on age in months. Bearing in mind the effectiveness of initiating treatment within the first 5 months of age, we should initiate treatment at the earliest appropriate age with consideration of the individual patient's type and severity of deformity and cartilage elasticity.

Background:. In Japan, oral propranolol (PPL) and pulsed dye laser are available for infantile hemangioma (IH) treatment without patient cost-sharing. However, no standardized algorithm exists to guide treatment selection that balances efficacy, potential side effects, and aesthetic risks. This study presents a comprehensive approach utilizing a treatment algorithm and aesthetic risk scoring system. Methods:. This retrospective study analyzed outcomes from 156 patients with IHs. Oral PPL was used in IH patients with functional issues, whereas the rest underwent an aesthetic risk assessment that categorized them into low-, moderate-, or high-risk groups to guide treatment choices. Final treatment decisions depended on parental preference. The outcomes of algorithm-compliant and noncompliant patients were compared statistically. Results:. The risk score's interrater reliability was 0.973 (95% confidence interval 0.933–0.992), with a mean intrarater reliability of 0.968 ± 0.027 and a mean evaluation time of 14.1 ± 5.0 seconds per case. Among the 156 patients, 88% pursued the algorithm-recommended treatment, whereas 12% opted for different approaches. Algorithm-compliant patients experienced significantly fewer sequelae than did noncompliant patients (5% versus 33%, P < 0.001). Compared with noncompliant patients, algorithm-compliant patients tended to require shorter treatment durations (17.9 versus 25.4 mo, P = 0.08) and fewer laser sessions (5.8 versus 7.2, P = 0.30), with a younger age at resolution (21.3 versus 29.0 mo, P = 0.08). Conclusions:. Aesthetic concerns can be crucial for patients with IHs. This study introduces a comprehensive IH management algorithm to reduce the sequelae requiring surgical interventions and improve patients’ quality of life.

Abstract Background Papillary thyroid microcarcinoma (PTMC) management has evolved, with active surveillance (AS) gaining prominence as a management option. However, a key concern for both clinicians and patients is the potential for patient loss to follow‐up during AS. Aims This study aimed to determine adherence and loss‐to‐follow‐up rates in low‐risk PTMC patients undergoing AS versus surgical intervention, in order to gain insights into clinical pathways and safety profiles. Materials and Methods This cohort study analyzed the 2016 data from a single registered institution of Japan's public National Cancer Registry. Results We identified and retrospectively analyzed the cases of 327 patients diagnosed with low‐risk PTMC; 227 patients chose to undergo AS while the other 100 underwent PTMC surgery. Main outcomes were the adherence rate and loss‐to‐follow‐up rate of each group, factors influencing discontinuation, and safety considerations. The rate of AS adoption was substantial in the complete series of 327 low‐risk PTMC patients (69.4%). There was a significantly higher loss‐to‐follow‐up rate at 5 years in the AS group (28.6%) compared to the Surgery group (17.8%) (HR 1.62, 95% CI: 1.01–2.61; p = 0.046). Both univariate and multivariate analyses confirmed the significantly higher loss‐to‐follow‐up rate in the AS group as well as in older patients. No deaths due to PTMC progression were observed in the cases lost to follow‐up. Conclusion Despite concerns about loss to follow‐up, active surveillance remains a safe option for low‐risk PTMCs. Consistent follow‐up strategies are crucial, and further research is needed to enhance patient counseling and care for the management of patients with PTMC.

PURPOSETo investigate the discordance in sarcoma diagnoses between nonspecialized institutions following revision by dedicated sarcoma pathologists at a reference center in Brazil and the relevance of molecular pathology in this context.METHODSWe conducted a retrospective analysis of sarcoma samples initially analyzed at outside laboratories and subsequently reviewed by two specialized pathologists between January 2014 and December 2020. After obtaining demographic and tumor characteristics, pathology results were matched and classified as complete discordance (CD; benign v malignant, sarcoma v other malignancies), partial concordance (similar diagnosis of connective tumor, but different grade/histological subtype/differentiation), and complete concordance (CC). The concordance for histology or grade, and the role of molecular assessments supporting the diagnosis were also independently determined. Statistical analyses were conducted through the kappa coefficient of agreement and adherence by χ2 test, χ2 test by Person, and Fisher exact test.RESULTSIn total, 197 cases were included, with samples obtained predominately from male patients (57.9%) and localized/primary tumors (86.8%). Following revision, the most frequent final diagnoses were undifferentiated pleomorphic sarcoma (17.8%), well-differentiated/dedifferentiated liposarcoma (8.6%), and leiomyosarcoma (7.6%). CD was found in 13.2%, partial discordance in 45.2%, and CC in 41.6% of reviews (P < .001). We found a concordance for histology or grade of 53.5% (P < .001) and 51.8% (P < .001), respectively. Molecular assessments, comprising next-generation sequencing panels (79.5%) and fluorescent in situ hybridization (20.5%), were performed in 44 (22.3%) cases, with findings classified as of diagnostic relevance in 31.8%.CONCLUSIONIn nearly 60% of the cases, the initial sarcoma diagnosis was modified when revised by a reference center and dedicated pathologists, assisted by molecular pathology techniques. These results justify the assembly of referral networks in countries with limited health care resources.

Summary:. Accurate burn depth assessment is essential to decide an appropriate surgical procedure. However, most cases of burn depth are diagnosed with subjective judgment by an experienced plastic surgeon. There is a need for a simple, noninvasive, and accurate diagnostic method. Here, the authors present two burn cases in which burn depth was predicted using high-frequency power Doppler ultrasonography. In case 1, the patient showed partial deep burn area prediagnosed by clinical inspection in dorsal area. However, pulsatile microcirculation was detected in the deep dermal layer using high-frequency power Doppler ultrasonography, and we rediagnosed it as deep dermal burn. Tangential excision was performed to debride necrotic tissue, preventing excessive removal of viable dermal tissue. In case 2, the patient showed anterior chest burn covered eschar. Pulsatile microcirculation was detected in the dermis using high-frequency power Doppler ultrasonography. The authors diagnosed the area as superficial dermal burn and opted for conservative treatment. Dermal microvascular damage is a more sensitive indicator of tissue injury. Hence, the burn depth can be assessed using dermal microcirculation. To the best of the authors’ knowledge, there are no reports on the evaluation of blood flow in burn wounds using high-frequency power Doppler ultrasonography. In this case report, the authors introduce the possibility of using high-frequency ultrasonography to assess burn depth.

Purpose: Iliofemoral ligament (ILFL) is a capsular ligament located in the anterosuperior part of the hip joint capsule and contributes to hip joint stability. The purpose of this study was to compare the surgical outcomes of resection versus preservation procedure of the medial arm of the ILFL in total hip arthroplasty (THA) using the anterolateral approach. Methods: Perioperative outcomes, complication, implant placement and patient-reported outcome measures (PROMs) were evaluated in 42 patients in the resection group and 38 patients in the preservation group. As a PROM, the Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ), was administered at 6 months, 1 year and 2 years postoperatively. Results: There was no significant difference in perioperative outcomes, complication and implant placement between the two groups. Satisfaction for the hip joint condition (80.6 ​± ​22.4 vs 89.2 ​± ​20.1), JHEQ pain score (21.5 ​± ​4.5 vs 24.1 ​± ​5.2) at 6 months, and JHEQ pain score (21.6 ​± ​5.1 vs 23.5 ​± ​5.5) at 1 year were significantly better in the preservation group than in the resection group. At 2 years postoperatively, no significant difference was found in PROMs between the two groups. Conclusion: Our results indicate that preservation of the medial arm of the ILFL in THA improves pain during the first postoperative year without increased complications or disadvantages of implant placement. Preserving the medial arm of the ILFL may be a safe and effective option to improve the early clinical outcomes after THA using the anterolateral approach.

Abstract Hydrogen sulfide (H2S) and polysulfides (H2Sn, n ≥ 2) are signaling molecules produced by 3-mercaptopyruvate sulfurtransferase (3MST) that play various physiological roles, including the induction of hippocampal long-term potentiation (LTP), a synaptic model of memory formation, by enhancing N-methyl-d-aspartate (NMDA) receptor activity. However, the presynaptic action of H2S/H2Sn on neurotransmitter release, regulation of LTP induction, and animal behavior are poorly understood. Here, we showed that H2S/H2S2 applied to the rat hippocampus by in vivo microdialysis induces the release of GABA, glutamate, and d-serine, a co-agonist of NMDA receptors. Animals with genetically knocked-out 3MST and the target of H2S2, transient receptor potential ankyrin 1 (TRPA1) channels, revealed that H2S/H2S2, 3MST, and TRPA1 activation play a critical role in LTP induction, and the lack of 3MST causes behavioral hypersensitivity to NMDA receptor antagonism, as in schizophrenia. H2S/H2Sn, 3MST, and TRPA1 channels have therapeutic potential for psychiatric diseases and cognitive deficits.

Recognition of the molecular basis of gastrointestinal stromal tumors has paved the way for significant breakthroughs in the diagnosis and treatment of this disease as well as positioned gastrointestinal stromal tumors as a framework for the concept of precision oncology in solid tumors. The incorporation of novel targeted agents for molecularly defined subgroups has led to significant improvements in treatment outcomes; however, the characterization of heterogeneous KIT or PDGFRA mutations and the emergence of resistance mechanisms highlight the need for a broader use of comprehensive molecular profiling and emphasize the importance of molecularly driven adaptive treatment strategies. Such a molecular background is critical for developing personalized and effective interventions and optimizing outcomes. The present review summarizes key studies that provide the basis for standard-of-care management options as well as provides molecular insights into the management of gastrointestinal stromal tumors, with an emphasis on recent advances.

Abstract Aim Acute meningitis encompasses bacterial, viral (aseptic), fungal, tuberculous, and carcinomatous meningitis. The rate and risks of mortality in each type remain uncertain. This study aimed to elucidate these aspects in each type of meningitis. Methods This study utilized Japan's nationwide administrative Diagnosis Procedure Combination (DPC) database. Patients with acute meningitis, treated at 1132 DPC‐covered hospitals from 2016 to 2022, were enrolled. Results Among 47,366,222 cumulative hospitalized patients, 48,758 (0.10%) were hospitalized with acute meningitis. The types of meningitis were as follows: 10,338 with bacterial, 29,486 with viral/aseptic, 965 with fungal, 678 with tuberculous, and 3790 with carcinomatous meningitis. Bacterial and viral meningitis exhibited bimodal age distributions, with the first peak occurring at 0–9 years. The median onset age was below 50 years only in viral meningitis. The mortality rate was the highest in carcinomatous meningitis (39%), followed by fungal meningitis (21%), and the lowest in viral meningitis (0.61%). Mortality rates increased with age across all meningitis types, but this trend was less prominent in carcinomatous meningitis. The duration from admission to mortality was longer in fungal and tuberculous meningitis compared with other types. Staphylococcus aureus in bacterial meningitis (adjusted odds ratio 1.71; p = 0.0016) and herpes simplex virus in viral meningitis (adjusted odds ratio 1.53; p = 0.0467) exhibited elevated mortality rates. Conclusion Distinct demographic profiles and mortality rates were observed among different meningitis types. The high mortality rates in less common types of meningitis emphasize the necessity to further optimize the required diagnostic and treatment strategies.

Abstract The clinical utilities of paclitaxel in anaplastic thyroid carcinoma (ATC) have been reported. The current study investigated the outcomes in ATC patients treated by paclitaxel as neoadjuvant setting. Furthermore, the prognostic factor for overall survival (OS) and predictive marker for response to paclitaxel were investigated. Records of ATC patients treated by paclitaxel as neoadjuvant setting in our hospital were reviewed. The median OS for the patients with (n = 43) and without (n = 23) resection were 14.7 (95% CI, 11.0–21.7) and 4.2 (95% CI, 3.0–5.4) months, respectively (p

ABSTRACTIntroduction 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.

Summary:. We present a technique for treating orbital floor fractures using three-dimensional (3D) printing technology and a preoperative template based on the mirror image of the unaffected orbit. Our patient, a 56-year-old man, experienced persistent diplopia in the upward direction and left enophthalmos after previous open reduction internal fixation surgery. To address these complications, we used a simulation of the ideal orbital floor from computed tomography images and used a 3D printer to create a template. Subsequently, an absorbable plate was molded intraoperatively based on this template. Notably, the plate fit seamlessly into the fracture site without requiring any adjustment, reducing the operation time. Postoperative computed tomography scans confirmed successful reduction, improved visual function, and the absence of complications. Our method offers a precise and efficient approach to reconstructing fractured orbital floors. By leveraging 3D printing technology and preoperative templates, surgeons can enhance postoperative outcomes and minimize patient burden. Further investigations are warranted to assess the long-term effectiveness and cost-effectiveness of this technique. Our findings highlight the potential of this approach to improve treatment strategies for patients with orbital floor fractures.