Perception of overseas experiences among medical students in Japan: a national online survey.

BACKGROUND: Data on the perceptions of medical students on international experience in non-English-speaking high-income countries (HICs) are very limited. This study aimed to assess the perceptions of medical students in Japan toward overseas experience while in school and post-graduation, as well as to characterize the support they require to pursue their profession in international settings. METHODS: A cross-sectional national survey was administered online between September 16, 2020, and October 8, 2020. Participants were recruited from 69 medical schools using snowball sampling through acquaintances and social media platforms. The survey results were analyzed by two researchers. RESULTS: A total of 548 students from 59 medical schools responded to the survey. Among them, 381 respondents (69%) expressed interest in working abroad, while only 40% seriously considered it. The majority of students responded that they would like to pursue clinical training abroad for a short term or while they were medical students (54%) or during a residency/fellowship (53%). The most popular regions among the respondents for future international experiences were North America and Europe. Finally, the most reported reasons for hesitation to work abroad were language barriers (70%), followed by lack of clarity regarding career options after working abroad (67%), difficulties obtaining medical licensure abroad (62%), and the lack of role models (42%). CONCLUSIONS: Although nearly 70% of participants reported a high interest in working overseas, various barriers to working abroad were identified. Our findings identified key problem areas that could be targeted when promoting international experiences for medical students in Japan.

Teaching "medical interview and physical examination" from the very beginning of medical school and using "escape rooms" during the final assessment: achievements and educational impact in Japan.

BACKGROUND: There is no consensus regarding the best time to teach two fundamental pillars of clinical medicine: medical interview and physical examination. We investigated the impacts of teaching the course "Medical Interview and Physical Examination" in Japan from the very beginning of medical school. In addition, we also evaluated the educational value of using "Escape Rooms", a series of timed, game-based scenarios using simulators, as a part of the final assessment of the course. METHODS: At the end of the course, the interview capabilities of 140 first year medical students at International University of Health and Welfare (Japan) were assessed by physicians who acted as simulated patients. Physical examination skills were assessed using the "Escape Room" team task method. Students also self-assessed their confidence in their physical examination skills pre and post "Escape Rooms." A day prior to the final assessment, students completed an anonymous course evaluation. RESULTS: The average global rating of the students' medical interview skills using a rating scale from 1 to 6 (1-fail 6-outstanding, no different from practicing junior physician's level) was 4.6. Twenty-two students scored the highest mark of 6. An average of 89% of "Escape Room" teams finished all the physical examination tasks correctly within the allotted time. All teams that could not finish in time completed all tasks correctly when given an additional 3 to 5 min. Students' self-assessed confidence in their physical examination skills increased from 49 to 73 (out of 100) pre and post "Escape Rooms." In the course evaluation questionnaire, 99% of students answered "this course enhanced their motivation" (response rate 89%) and 99% also answered "this course was interesting and useful" (response rate 86%). CONCLUSIONS: This descriptive study analyzing both quantitative and qualitative data showed that the course not only achieved the intended objectives of successfully conducting comprehensive medical interview and basic physical examination skills, but also enhanced student motivation. "Escape Rooms", used for the course assessment, in itself enhanced students' self-perceived physical examination skills and had an added educational value.

Hepatitis A in a human immunodeficiency virus-infected patient: Impending risk during the Tokyo Olympic Games in 2020.

Acute hepatitis A is caused by hepatitis A virus (HAV), which spreads through contaminated food or water or person-to-person contact, and has been epidemic among men who have sex with men (MSM) since 2018 in Tokyo. The majority of these patients have been found to be seropositive for human immunodeficiency virus (HIV) and contracted hepatitis A through sexual contact. We cared for an HIV-positive patient with fulminant hepatitis A while on antiretroviral therapy at our hospital. Hepatitis A vaccine should be aggressively promoted for HIV-positive MSM.

Human papillomavirus vaccination and postural tachycardia syndrome, deconditioning and exercise-induced hyperalgesia: An alternate interpretation of the reported adverse reactions.

Human papillomavirus vaccination (HPVV) was included in the national immunization program in 2013 in Japan. However, the Japanese government suspended proactive recommendations 2 months after this decision because various adverse events following the vaccination were reported by the media. More than 6 years have already passed since the suspension of proactive recommendations of all available vaccines in Japan. Although no causal relationship between the adverse effects and HPVV has been confirmed, the Japanese government has not withdrawn the suspension. Thus, it is important to show various possible causes of the adverse events other than HPVV. It is attempted to describe the possible contribution of the misunderstanding regarding the symptoms of postural tachycardia syndrome, deconditioning, and exercise-induced hyperalgesia as the adverse effects of HPVV in this review article.

Outbreak of Trichinella T9 Infections Associated with Consumption of Bear Meat, Japan.

An outbreak of trichinellosis occurred in Japan in December 2016. All case-patients had eaten undercooked bear meat, from which Trichinella larvae were subsequently isolated. DNA sequencing analysis of the mitochondrial genes cytochrome c-oxidase subunit 1 and internal transcribed spacer 2 confirmed that Trichinella T9 had caused the outbreak.

[A Patient with a Wedge-shaped Pulmonary Lesion Associated with Streptococcus parasanguinis].

An 84-year-old man was admitted to our hospital with bloody sputum. He was found to have a right lower lobe wedge-shaped nodular lesion with chest X-ray and computed tomography of the chest. Ceftriaxone and minocycline were started empirically based on a working diagnosis of community-acquired pneumonia. Streptococcus parasanguinis was isolated with sputum cultures obtained on three consecutive days and was identified based on its biochemical properties. S. parasanguinis is a member of the sanguinis group of viridans Streptococci. It is known as a causative pathogen for endocarditis. There are very few reports of S. parasanguinis associated with pulmonary infections. The present report describes the association of S. parasanguinis with a wedge-shaped nodular lesion in the lungs.

Routine blood cultures in the management of pyelonephritis in pregnancy for improving outcomes.

BACKGROUND: Pyelonephritis is a type of urinary tract infection (UTI) that affects the upper urinary tract and kidneys, and is one of the most common conditions for hospitalisation among pregnant women, aside from delivery. Samples of urine and blood are obtained and used for cultures as part of the diagnosis and management of the condition. Acute pyelonephritis requires hospitalisation with intravenous administration of antimicrobial agents. Several studies have questioned the necessity of obtaining blood cultures in addition to urine cultures, citing cost and questioning whether blood testing is superfluous. Pregnant women with bacteraemia require a change in the initial empirical treatment based on the blood culture. However, these cases are not common, and represent approximately 15% to 20% of cases. It is unclear whether blood cultures are essential for the effective management of the condition. OBJECTIVES: To assess the effectiveness of routine blood cultures to improve health outcomes in the management of pyelonephritis in pregnant women. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register without language or date restrictions (31 December 2014). SELECTION CRITERIA: Randomised controlled trials and quasi-randomised trials comparing outcomes among pregnant women with pyelonephritis who received initial management with or without blood cultures. Cluster-randomised trials were eligible for inclusion in this review but none were identified. Clinical trials using a cross-over design were not eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed one trial report for inclusion. MAIN RESULTS: We identified one trial report but this was excluded. No clinical trials met the inclusion criteria for this review. AUTHORS' CONCLUSIONS: There are no large-scale randomised controlled trials to assess outcomes in the management of pyelonephritis in pregnancy with or without blood cultures. Randomised controlled trials are needed to evaluate the effectiveness of managing pyelonephritis in pregnant women with or without blood cultures, and to assess any adverse outcomes as well as the cost-effectiveness of excluding blood cultures from treatment.

Strategies of testing for syphilis during pregnancy.

BACKGROUND: Each year about two million pregnant women are infected with preventable syphilis infection, mostly in developing countries. Despite the expansion of antenatal syphilis screening programmes over the past few decades, syphilis continues to be a major public health concern in developing countries. Point-of-care syphilis testing may be a useful strategy to substantially prevent syphilis-associated perinatal mortality and other negative consequences in resource-poor settings. However, the evidence on effectiveness has been generated mostly from observational study designs or has been reported as a mixed-intervention effect. OBJECTIVES: To assess the effectiveness of antenatal syphilis screening in improving the uptake of screening tests and treatment, and reducing perinatal mortality. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2014) and the reference lists of retrieved studies. SELECTION CRITERIA: Randomised (individual and cluster) controlled trials comparing different screening tests conducted during routine antenatal check-ups versus no screening test. Cross-over trials and quasi-randomised experimental study designs were not eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy. MAIN RESULTS: We included two cluster-randomised controlled trials (three reports). Both trials assessed point-of-care syphilis testing with conventional testing methods and together involved a total of 8493 pregnant women. Data from these trials were not amenable to meta-analysis as the measure of effectiveness was assessed in a non-comparable way.One trial randomised 14 antenatal clinics (including 7700 pregnant women) and was carried out at in Ulaanbaatar, Mongolia. The trial assessed one-stop syphilis testing using a rapid treponemal test, and was judged to have unclear methods of random sequence generation, allocation concealment, selective reporting, and other bias and low risk of bias for incomplete outcome data. Blinding was not reported and was assessed as high risk. The point-of-care testing provided screening, test results and treatment within the same day. The trial appears to have adjusted their results to account for clustering. We entered the data into RevMan using the generic inverse variance method. The incidence of congenital syphilis was lower in the clusters receiving on-site screening (adjusted odds ratio (AOR) 0.09, 95% confidence interval (CI) 0.01 to 0.71) and the proportion of women tested for syphilis was higher in the clusters receiving on-site screening at both the first antenatal visit and at the third trimester visit (OR 989.80, 95% CI 16.27 to 60233.05; OR 617.88, 95% CI 13.44 to 28399.01). Adequate treatment and partner treatment was higher with the on-site screening (AOR 10.44, 95% CI 1.00 to 108.99; AOR 18.17, 95% CI 3.23 to 101.20) and more syphilis cases were detected at first and third trimester visits with the on-site screening (AOR 2.45, 95% CI 1.44 to 4.18; AOR 6.27, 95% CI 1.47 to 26.69). Perinatal mortality, incidence of HIV/AIDS, obstacles in uptake of screening, any other adverse effects, or healthcare resource usage were not reported in this trial.The second trial divided clinics into seven matched pairs (including 7618 pregnant women, although results were only presented for the positive cases (793 women)), and within each pair one clinic was randomised to receive the on-site screening and the other to continue routine laboratory testing. The trial was conducted in primary healthcare clinics in KwaZulu-Natal, South Africa. Random sequence generation were judged to be at low risk of bias, but allocation concealment and incomplete outcome data were judged to be high risk. Other bias and selective reporting bias remain unclear. Blinding was not reported and was assessed as high risk of bias. This trial assessed the primary outcome of this review (perinatal mortality) and the secondary outcomes (adverse outcomes; adequate treatment; syphilis prevalence) in the subset of women (793 women) who tested positive for syphilis. Only one outcome, adequate treatment, was adjusted to account for cluster design. However, not enough information was provided to include this in an analysis using the generic inverse variance method. Where possible, results have therefore been presented in forest plots (perinatal mortality; adequate treatment), as if the data are from a parallel randomised controlled trial. These results should therefore be interpreted with caution.The trial reported on perinatal mortality in women with positive test results and showed that on-site screening using a rapid plasma reagin test had no clear evidence of an effect on perinatal mortality reduction (odds ratio (OR) 0.63; 95% CI 0.27 to 1.48; 18/549 (3.3%) versus 8/157 (5.1%)). After loss to follow up, 396/618 (64.1%) women with positive test results received adequate treatment (two or more doses of 2.4 mega units of benzathine penicillin) in the intervention cluster versus 120/175 (68.6%) in the control (OR 0.82; 95% CI 0.57 to 1.17). It was not possible to include any other data on reported outcomes in forest plots (adverse outcomes; syphilis prevalence). Incidence of congenital syphilis, proportion of women test for syphilis, incidence of HIV/AIDS, obstacles in uptake of screening, partner treatment, or healthcare resource usage were not reported in this trial. AUTHORS' CONCLUSIONS: This review included evidence from two cluster-randomised trials at high or unclear risk of bias for most of the 'Risk of bias' domains. Data were not combined in meta-analysis because the trials used non-comparable measures of effectiveness.Point-of-care syphilis testing showed some promising results for syphilis detection and treatment rates and for use in different settings. In Mongolia point-of-care testing was found to be effective in increasing the proportion of pregnant women tested for syphilis and treatment provided, reducing congenital syphilis, and improving access to treatment for both women and their partners. In contrast, in rural South Africa, among women with positive test results, there was no clear evidence of an effect of point-of-care syphilis testing in increasing adequate syphilis treatment rates, and reducing perinatal mortality, but point-of-care testing was found to reduce delay in seeking treatment.More trials are therefore warranted to determine the effectiveness of available testing strategies for improving syphilis-associated adverse outcomes in pregnant women and neonates, especially in high-risk regions.

Diagnostic challenges in a patient with dengue shock syndrome presenting with acute meningoencephalitis.

Dengue is a systemic viral infection, and clinical findings vary from asymptomatic to life-threatening, including shock and neurological complications. Despite efforts in vector control, the disease continues to spread worldwide, and the number of annual dengue infections is estimated to be 390 million. For patients with severe dengue, early diagnosis is important; however, owing to the wide range of symptoms and severity, diagnosis can be difficult. Herein, we report the case of a 24-year-old man from Vietnam who was found to have dengue shock syndrome complicated by meningoencephalitis, even though he did not show the typical clinical manifestations of dengue infection. He was transported to our hospital by ambulance because of fever and altered mental status. Brain magnetic resonance imaging revealed hyperintensities in the bilateral thalamus and brainstem on the T2 sequence. After hospitalization, polymerase chain reaction testing of cerebrospinal fluid, serum, and urine revealed the presence of dengue virus serotype 2. This confirmed the diagnosis of dengue encephalitis. The patient was discharged on day 49 with impaired abduction of the left eye and urinary retention. In this case, the initial differential diagnosis was broad because the patient was unable to provide any medical history owing to altered mental status. In addition, the fact that he did not show the characteristic symptoms of dengue infection initially made the diagnosis very difficult. In conclusion, dengue fever should always be considered as a part of the differential diagnosis when a patient from an endemic area presents with fever and impaired consciousness.

A multi-institutional study designed by members of Tokyo Guidelines (TG) Core Meeting to elucidate the clinical characteristics and pathogenesis of acute cholangitis after bilioenteric anastomosis and biliary stent insertion with a focus on biliary obstruction: Role of transient hepatic attenuation difference (THAD) and pneumobilia in improving TG diagnostic performance.

BACKGROUND/PURPOSE: The aim of this study was to clarify the clinical characteristics of acute cholangitis (AC) after bilioenteric anastomosis and stent-related AC in a multi-institutional retrospective study, and validate the TG18 diagnostic performance for various type of cholangitis. METHODS: We retrospectively reviewed 1079 AC patients during 2020, at 16 Tokyo Guidelines 18 (TG 18) Core Meeting institutions. Of these, the post-biliary reconstruction associated AC (PBR-AC), stent-associated AC (S-AC) and common AC (C-AC) were 228, 307, and 544, respectively. The characteristics of each AC were compared, and the TG18 diagnostic performance of each was evaluated. RESULTS: The PBR-AC group showed significantly milder biliary stasis compared to the C-AC group. Using TG18 criteria, definitive diagnosis rate in the PBR-AC group was significantly lower than that in the C-AC group (59.6% vs. 79.6%, p < .001) because of significantly lower prevalence of TG 18 imaging findings and milder bile stasis. In the S-AC group, the bile stasis was also milder, but definitive-diagnostic rate was significantly higher (95.1%) compared to the C-AC group. The incidence of transient hepatic attenuation difference (THAD) and pneumobilia were more frequent in PBR-AC than that in C-AC. The definitive-diagnostic rate of PBR-AC (59.6%-78.1%) and total cohort (79.6%-85.3%) were significantly improved when newly adding these items to TG18 diagnostic imaging findings. CONCLUSIONS: The diagnostic rate of PBR-AC using TG18 is low, but adding THAD and pneumobilia to TG imaging criteria may improve TG diagnostic performance.

Temporal Arteritis Caused by Tertiary Syphilis.

A 77-year-old man arrived at our hospital with bilateral shoulder pain persisting for several months and headache for 1 month. Giant cell arteritis with polymyalgia rheumatica was suspected. However, considering his medical history of testing positive for syphilis, we submitted a sample for a syphilis serology test, which yielded positive results. The Treponema pallidum hemagglutination assay of cerebrospinal fluid was positive, and a temporal artery biopsy revealed vasculitis, confirming the diagnosis of tertiary syphilis. He was successfully treated for two weeks with penicillin G infusions. Symptoms reminiscent of giant cell arteritis and polymyalgia rheumatica may reveal syphilis, which is called the "great imitator."

Gemella haemolysans as an emerging pathogen for bacteremia among the elderly.

We report a patient of an 82-year-old woman with occult Gemella haemolysans bacteremia without a clear entry site. Gemella haemolysans is part of the normal human flora but can cause severe systemic infections such as infective endocarditis on rare occasions. In this patient, physical examination showed no localized symptoms, and a transthoracic echocardiogram showed no vegetation on the heart valves. The entry site for this pathogen was unclear. As the number of the elderly with asymptomatic infections has been increasing, clinicians should be aware of that this microorganism can cause occult bacteremia and infective endocarditis.

Perspectives on Collaboration between Physicians and Nurse Practitioners in Japan: A Cross-Sectional Study.

BACKGROUND: Nurse practitioners (NPs) are known as effective healthcare providers worldwide. In Japan, nurse practitioner adoption is considered to be in a shaky period. Although nurse practitioners were introduced approximately 10 years ago at the initiative of educational institutions in Japan, the full extent of this trend is not known. Therefore, we have clarified the whole picture of nurse practitioners from two directions: the perception of nurse practitioners in Japan and the perception of physicians who work with nurse practitioners. This will inform discussions regarding the recruitment of nurse practitioners at the national level in Japan. METHODS: From 18 June to 24 July 2021, we administered a nationwide cross-sectional survey of NPs and physicians working in the same clinical settings as NPs in Japan. The domains of the survey included "scope and content of work", "perceptions of NPs' clinical practice", and "individual clinical practice characteristics". The survey was distributed and collected digitally. RESULTS: The total number of respondents to the survey was 281, including 169 NPs and 112 physicians; the percentage of NPs who responded was 50.5%. The number of valid responses was 164 NPs and 111 physicians, for a total of 275 respondents. Approximately 60% of NPs are concentrated in Tokyo, the capital of Japan, and the three prefectures adjacent to Tokyo. They also worked fewer hours per week, cared for fewer patients per day, and earned less money than physicians. More physicians than NPs indicated that "more NPs would improve the quality of care". A total of 90.1% of physicians and 82.3% of NPs agreed that "Nurse practitioners should practice to the full extent of their education and training," and 73.9% of physicians and 81.7% of NPs agreed that "Nurse practitioners' scope of practice should be uniformly defined at a national level". CONCLUSIONS: This study clarified the present working conditions of NPs from NPs' and physicians' perspectives in Japanese contexts. Japanese NPs may be able to work effectively in collaboration with physicians. Therefore, the implementation of NPs in Japanese medical conditions should be discussed further for better healthcare.

Modified Socratic Method (planned and executed by Takada) for medical education: Grade II Acute Cholecystitis of Tokyo Guidelines 2018 as an example case.

BACKGROUND: Socratic method, which is an educational method to promote critical thinking through a dialogue, has never been practiced in a large number of people at the academic societies. METHODS: Modified Socratic method was performed for the first time as an educational seminar using an example case of moderate acute cholecystitis based on the evidence described in Tokyo Guidelines 2018. We adopted a method that Takada had been modifying for many years: the instructor first knows the degree of recognition of the audience, then the instructor gives a lecture in an easy-to-understand manner and receives questions from the audience, followed by repeated questions and answers toward a common recognition. RESULTS: Using slides, video, and an answer pad, 281 participants including the audience, instructors and moderators came together to repeatedly ask and answer questions in the five sessions related to the case scenario. The recognition rate of the topic of Critical View of Safety increased significantly before vs after this method (53.0% vs 90.3%). The seminar had been successfully performed by receiving a lot of praise from the participants. CONCLUSION: This educational method is considered to be adopted by many academic societies in the future as an effective educational method.

[A case of disseminated gonococcal infection without typical skin rash].

Few case reports have been published on disseminated gonococcal infection in Japan. We report such a non-HIV case without typical skin rash. A 49-year-old Japanese man living in Thailand on business was seen for fever and multiple arthralgia after returning to Japan. Given the travel history, differential diagnoses included endemic viral infection such as human immunodeficiency virus (HIV), dengue fever, and chikungunya. Diagnosis was based on right-knee arthrocentesis, and synovial fluid culture followed by Neisseria gonorrhoeae polymerase chain reaction (PCR). The isolated strain was sensitive to penicillin. The man was treated with intravenous ceftriaxone and oral levofloxacin. Disseminated gonococcal infection should thus be considered when examining those with classical polyarthralgia symptoms even without a typical skin rash.

Exploring the Competencies of Japanese Expert Nurse Practitioners: A Thematic Analysis.

Nurse practitioners (NPs) provide medical care equivalent to that of physicians and facilitate access to healthcare. Although Japan's first NP graduated in 2010, how Japanese expert NPs work effectively in clinical contexts is yet to be investigated. We aimed to identify the competencies that make expert NPs in Japan effective. Twelve Japanese expert NPs were purposely selected. The average age of the participants was 44.8 years, average NP experience was 7.5 years, and eight participants were women. Semi-structured interviews were conducted online from March to May 2021. Interviews were recorded, transcribed verbatim, and analyzed using thematic analysis. Thematic analysis revealed five themes: working in physicians' contexts, interprofessional collaboration, involvement in nurses' work, contribution to healthcare, and personal qualities for effective working. Japanese expert NPs can function effectively in clinical settings by flexibly and humbly collaborating with other medical professionals who have autonomous positions. They can improve the quality of healthcare by proposing practical solutions to problems faced by patients and medical organizations. These explored competencies can be applied to other aging and more complex societal contexts, and in updating the required competencies of Japanese NPs.

Health Science Students' Perspective on Quality-of-Care-Relating Medical Professionalism.

PURPOSE: Health science students need to be professional to improve quality of care (QOC) in the current Vietnamese healthcare system. Therefore, we aim to evaluate medicine and traditional medicine (TM) students' perception of the professional attributes relating to QOC for improving inter-disciplined professionalism training that promotes QOC in Vietnam. METHODS: The cross-sectional study was carried on 2039 students of 6 years at the University of Medicine and Pharmacy at Ho Chi Minh City (HUMP) from the medical and TM faculty in March, 2021. The Vietnamese American Board of Internal Medicine (ABIM) questionnaire (2011) was used as the survey instrument. The confirmatory factor analysis (CFA) was performed to confirm the validity of the scale in TM students. Mean, Min-Max, standard deviation and sample paired t-test were performed for Likert scale. The one-way ANOVA was used for inferential statistics. RESULTS: The CFA demonstrated the validity of the Vietnamese questionnaire in measuring 4 QOC-relating professional attributes, previously found in medical students for TM students. In both faculties and across academic years, students perceived self-awareness and ensuring QOC as the leading important attribute, while social duty and professional habit as the least important attribute. Contrasting with preclinical phase, students' perception did not differ significantly between the two faculties in their clinical years (p > 0.05). CONCLUSION: TM students share universal QOC-relating professional traits with medical students. Moreover, exposure to clinical environment might increase inter-disciplined agreement on importance of these attributes. However, health sciences students' underestimation of social duty and professional habit persists throughout 6 academic years. Hidden curriculum in clinical training such as specialist-centeredness might hinder the students' improvement in perception of these traits. Therefore, these traits should strongly be emphasized in professionalism training to decrease the effects of hidden curriculum on them.