Conscientiousness Counts: How Personality Traits Impact Laparoscopic Surgical Skill Improvement in Medical Students.

OBJECTIVE: Studies have shown that personality traits affect cognitive performance; however, little is known about their influence on surgical performance. This study aimed to assess the impact of the Big Five personality traits on medical students' laparoscopic surgical skills. DESIGN: In this prospective study, medical students' laparoscopic surgical skills were assessed using the Hiroshima University Laparoscopic Surgical Assessment Device (HUESAD). The participants performed the HUESAD tasks 10 times before they underwent training. After completing the simulator training, they performed the tasks 10 times. Thereafter, they answered Big Five personality trait questionnaires (Extraversion, Neuroticism, Openness to experience, Conscientiousness, and Agreeableness). SETTING: Academic medical centers. PARTICIPANTS: Forty medical students (10 women) were recruited. The selection criterion was a lack of simulations or clinical experience in laparoscopic procedures. RESULTS: No significant correlations were found between personality traits and HUESAD assessment scores before training. Laparoscopic surgical skills improved significantly after the training (p < 0.001). The Big Five personality traits were correlated with improved laparoscopic surgical performance after training (r = -0.44, p < 0.05). Moreover, statistically significant positive correlations were observed between Conscientiousness and improvement rates (r = 0.36, p < 0.05). CONCLUSIONS: The results suggest that medical students scoring high on Conscientiousness were more likely to have improved laparoscopic surgical skills, regardless of their initial skills. The ability to predict laparoscopic surgical skills would be useful in designing tailor-made training programs for safe and high-quality operations.

Objective evaluation of tongue diagnosis ability using a tongue diagnosis e-learning/e-assessment system based on a standardized tongue image database.

Background: In Kampo medicine, tongue examination is used to diagnose the pathological condition "Sho," but an objective evaluation method for its diagnostic ability has not been established. We constructed a tongue diagnosis electronic learning and evaluation system based on a standardized tongue image database. Purpose: This study aims to verify the practicality of this assessment system by evaluating the tongue diagnosis ability of Kampo specialists (KSs), medical professionals, and students. Methods: In the first study, we analyzed the answer data of 15 KSs in an 80-question tongue diagnosis test that assesses eight aspects of tongue findings and evaluated the (i) test score, (ii) test difficulty and discrimination index, (iii) diagnostic consistency, and (iv) diagnostic match rate between KSs. In the second study, we administered a 20-question common Kampo test and analyzed the answer data of 107 medical professionals and 56 students that assessed the tongue color discrimination ability and evaluated the (v) correct answer rate, (vi) test difficulty, and (vii) factors related to the correct answer rate. Result: In the first study, the average test score was 62.2 ± 10.7 points. Twenty-eight questions were difficult (correct answer rate, <50%), 34 were moderate (50%-85%), and 18 were easy (≥85%). Regarding intrarater reliability, the average diagnostic match rate of five KSs involved in database construction was 0.66 ± 0.08, and as for interrater reliability, the diagnostic match rate between the 15 KSs was 0.52 (95% confidence interval, 0.38-0.65) for Gwet's agreement coefficient 1, and the degree of the match rate was moderate. In the second study, the difficulty level of questions was moderate, with a correct rate of 81.3% for medical professionals and 82.1% for students. The discrimination index was good for medical professionals (0.35) and poor for students (0.06). Among medical professionals, the correct answer group of this question had a significantly higher total score on the Kampo common test than the incorrect answer group (85.3 ± 8.4 points vs. 75.8 ± 11.8 points, p < 0.01). Conclusion: This system can objectively evaluate tongue diagnosis ability and has high practicality. Utilizing this system can be expected to contribute to improving learners' tongue diagnosis ability and standardization of tongue diagnosis.

Virtual reality as a learning tool for improving infection control procedures.

BACKGROUND: Hand hygiene and donning personal protective equipment (PPE) are essential techniques for infection control; however, low compliance is an issue. The effectiveness of virtual reality (VR) in learning infection control procedures is unknown. METHODS: To verify the effectiveness of VR, medical students were categorized into VR or lecture groups (n=21 each). Each group was given the same curricular content; one group received the training through VR learning using a fully-immersive 360-degree video and the other was conventional lecture-style learning. Before and after the training, they were evaluated for the implementation of hand hygiene and PPE using an Objective Structured Clinical Examination method. Post-test questionnaires were administered. RESULTS: The scores for hand hygiene, donning PPE, and the total score increased after learning in both groups. There was no difference between the pre-test total scores of the two groups (7 [5-9] vs 6 [5-7.5], P=.352); however, the VR group had significantly higher post-test total scores than the lecture group (12 [9.5-12] vs 9 [8-12], P=.024). More students in the VR group responded that they enjoyed the training and would like to use the same learning method next time. CONCLUSIONS: VR can be a useful tool for learning and practicing appropriate infection control procedures.

Symmetrical Skin Lesions on the Gluteal Region in a Patient with Anti-Laminin-332 Mucous Membrane Pemphigoid.

Mucous membrane pemphigoid (MMP), previously called cicatricial pemphigoid, is a rare subepidermal immunobullous disorder that primarily affects the mucous membranes (1,2). MMP is divided into two major subtypes, anti-BP180-type MMP and anti-laminin-332 (previously called laminin 5 or epiligrin) MMP. Anti-laminin-332 MMP is known to be associated with malignant tumors (3), which may cause overexpression of autoantibodies and induce autoimmunity to laminin-332 (4). MMP primarily affects the mucous membranes, and widespread skin lesions are rare. In MMP, circumscribed skin lesions have been previously reported as occurring on the head, neck, and upper trunk (5). We report a case of anti-laminin-332 MMP presenting with symmetrical skin lesions characteristic of MMP on the weight-bearing areas of the gluteal region. A 66-year-old Japanese man presented with a month-long history of multiple erosions and blisters on the mucous membranes and skin, with conjunctival hyperemia, nasal obstruction, oral pain, and hoarseness of voice. Three days before the first visit, he was diagnosed with gastric cancer with liver metastasis by gastrointestinal endoscopy and abdominal ultrasound examination for tarry stool. Physical examination demonstrated erosions and tense bullae on the conjunctivae, tongue, and lips (Figure 1, a,b), as well as erosive erythematous skin lesions on the nape, right index finger, both legs, and symmetric lesions on the gluteal region (Figure 1, c). His body weight was 86 kg. Laboratory examinations showed slight liver dysfunction and elevation of C-reactive protein levels. Histopathologic examination of the skin lesions demonstrated subepidermal blisters with lymphocytic and eosinophilic infiltrates (Figure 1, d,e). Direct immunofluorescence (IF) revealed linear deposits of IgG and C3, but not IgA, along the basement membrane zone (BMZ) (Figure 1, f,g). An IgG subclass study showed IgG1 and IgG4 deposits. Indirect IF on normal human skin revealed weak positivity for IgA anti-keratinocyte cell surface antibodies and IgG anti-BMZ antibodies, which were bound to the dermal side of 1 mol/L NaCl-split skin (Figure 1, h). IgG immunoblot analyses of both normal human epidermal and dermal extracts showed negative results (including BP230, BP180, 290 kDa type VII collagen, and 200 kDa laminin-γ1). Immunoprecipitation using radio-labeled cultured keratinocyte lysate demonstrated positive reactivity with laminin-332 (Figure 1, i). We established the diagnosis of anti-laminin-332 MMP. We started treatment with oral minocycline (200 mg/day) and niacinamide (900 mg/day) with topical corticosteroids without any effect after 2 weeks of therapy. Administration of oral prednisolone (40 mg/day) with topical corticosteroids and alprostadil ointment on the skin lesions, as well as beclometasone dipropionate powder on the oral lesions resulted in significant improvement of mucocutaneous lesions within 10 days. Although the gastric cancer and liver metastasis initially responded to chemotherapy with fluorouracil and cisplatin, the patient succumbed to multiple organ failure 9 months after the initial visit. Anti-laminin-332 antibodies were originally detected by immunoprecipitation, as in our case. Immunoblotting of purified human laminin-332 have been subsequently developed, which detects the 165/145 kDa α3, 140 kDa ß3, and 105 kDa γ2 subunits of laminin-332 in various patterns (6). Today, the ELISA system uses laminin-332 preparations as adjunct diagnostic tools in MMP (7). Occasionally, a wide spectrum of autoantibodies is detected in MMP, for example, MMP with IgG antibodies to both BP180 and laminin-332, which were considered to be developed via epitope spreading. Detection of circulating IgA autoantibodies against the skin have also been reported in MMP (8). However, the pathogenic significance and mechanisms of coexistence of IgG anti-laminin-332 antibodies and IgA anti-keratinocyte cell surface antibodies found in our case are currently unknown. It is generally considered that IgG1 antibodies activate complements and are pathogenic in MMP, while IgG4 antibodies behave as blocking antibodies and are protective. In our case, direct IF revealed IgG1 and IgG4 deposits; the same was reported in a previous case report (9). The pathogenic roles of autoantibodies with different IgG subclasses need to be analyzed in further studies. Conjunctival mucosal lesions in MMP may occur by rubbing of the eyes due to irritation. Blinking subjects the conjunctivae to repeated friction. Vocal cords vibrate during breathing and speaking. The tongue moves while eating and drinking; in particular, the tip of the tongue gets into frequent contact with the inner sides of the incisor teeth. In the present case, characteristic symmetrical skin lesions were seen on the weight-bearing areas of the gluteal region on bony prominences which receive mechanical stresses in the sitting position. These skin lesions were subjected to repeated stretch and pressure stresses, but no ischemic changes were observed, such as decubitus ulcers. Therefore, the symmetrical skin lesions in the gluteal region as well as the ocular and oral mucosal lesions seen in our patient might have resulted from the same mechanism of pathogenesis. We reported a case of anti-laminin-332 MMP presenting with symmetrical gluteal skin lesions, probably induced by mechanical stress. MMP primarily affects the mucous membranes, and widespread skin lesions are rare. Our case emphasizes that clinicians need to specifically check for the presence of skin lesions on weight-bearing parts of the body during examination of patients with suspected MMP.

Sox13 is a novel early marker for hair follicle development.

Sox13, a group D member of the Sry-related high-mobility group box (Sox) transcription factor family, is expressed in various tissues including the hair follicle. However, its spatiotemporal expression patterns in the hair follicle and its role in hair development remain to be elucidated. To address these questions, we generated Sox13-LacZ-knock-in mice (Sox13LacZ/+), in which the LacZ reporter gene was inserted in-frame into exon 2, which contains the translation initiation codon. X-gal staining in Sox13LacZ/+ embryos revealed that Sox13 is initially expressed in the epithelial portion of the placode, and subsequently in the hair germ and the hair peg during early hair follicle development. In postnatal catagen and anagen, Sox13 was detected in the epithelial sheath, whereas in telogen, Sox13 was localized in the bulge region, where hair follicle stem cells reside. Immunohistochemistry with an anti-ß-galactosidase antibody and anti-hair keratin antibodies that specifically mark the different layers of the hair follicle revealed that Sox13 was predominantly expressed in the outer root sheath in anagen. However, the integumentary structures of Sox13LacZ/LacZ mice were grossly and histologically indistinguishable from those of wild type mice. These results suggest that although Sox13 is dispensable for epidermal and adnexal development, Sox13 is a useful marker for early hair follicle development.

Incidence rate of cutaneous squamous cell carcinoma is rapidly increasing in Akita Prefecture: Urgent alert for super-aged society.

Incidence rates of cutaneous squamous cell carcinoma (SCC) are increasing in many countries. To estimate detailed trends of SCC incidence rates in the population of Akita Prefecture as the forerunner of super-aged societies, we conducted a retrospective analysis of patients diagnosed with SCC between 2007 and 2016 in Akita University Hospital. The crude SCC incidence rate increased rapidly between 2007 and 2016 from 2.5 to 10.0/100 000 people. Remarkably, the age-specific incidence rate of people aged 80 years or over increased between 2007 and 2016 from 14.7 to 51.6/100 000 people, suggesting that SCC incidence rates increase possibly due to not only the increased number of aged people but also because of unidentified cancer-prone environments. When the findings of the present study are generalized to other regions entering the era of super-aging, it is clear that we need to prepare for the economic disease burden together with careful monitoring to confirm future trends for SCC.

Topical 3-bromopyruvate is a novel targeted therapy for melanoma in a preclinical model.

BACKGROUND: Targeting cancer metabolism is a promising strategy in improving cancer treatment. OBJECTIVE: To introduce a targeted therapy with topical 3-bromopyruvate (3BP), aglycolytic inhibitor, into the clinic in the near future. METHOD: We investigated the anti-tumor efficacy of 3BP on melanoma cells in vitro and in a preclinical model. RESULTS: Our cell-based study demonstrated that 3BP showed cytotoxicity for melanoma cells under anchorage-dependent or independent cell growth via a reactive oxygen species-mediated and caspase-independent cell death pathway. Moreover, 3BP inhibited both self-renewal potential and growth of slow-cycling phenotype in melanoma cells. Remarkably, the preclinical mouse xenograft model shed light on topical application of 3BP, showing significant anti-tumor effects with no apparent toxicity in surrounding normal tissues. CONCLUSION: We have now proposed that a targeted therapy with topical 3BP is an innovative strategy for adjuvant chemotherapy of technically or medically unresectable melanoma and possibly other skin cancers.

[Checklist Development for Women-Doctor-Friendly Working Conditions in a Hospital Setting].

OBJECTIVES: This study aims to develop a scale of "women-doctor-friendly working conditions in a hospital setting". METHODS: A task team consisting of relevant people including a medical doctor and a hospital personnel identified 36 items related to women-doctor-friendly working conditions. From December in 2012 to January in 2013, we sent a self-administered questionnaire to 807 full-time employees including faculty members and medical doctors who worked for a university-affiliated hospital. We asked them to score the extent to which they think it is necessary for women doctors to balance between work and gender role responsibilities on the basis of the Likert scale. We carried out a factor analysis and computed Cronbach's alpha to develop a scale and investigated its construct validity and reliability. RESULTS: Of the 807 employees, 291 returned the questionnaires (response rate, 36.1%). The item-total correlation (between an individual item score and the total score) coefficient was in the range from 0.44 to 0.68. In factor analysis, we deleted six items, and five factors were extracted on the basis of the least likelihood method with the oblique Promax rotation. The factors were termed "gender equality action in an organization", "the compliance of care leave in both sexes and parental leave in men", "balance between life events and work", "childcare support at the workplace", and "flexible employment status". The Cronbach's alpha values of all the factors and the total items were 0.82-0.89 and 0.93, respectively, suggesting that the scale we developed has high reliability. CONCLUSIONS: The result indicated that the scale of women-doctor-friendly working conditions consisting of five factors with 30 items is highly validated and reliable.

Physician's Perceptions of Interprofessional Collaboration in Clinical Training Hospitals in Northeastern Japan.

BACKGROUND: Effective and efficient interprofessional collaboration (IPC) is needed between departments in a healthcare setting. Although Japanese physicians are expected to provide leadership in IPC, it has been suggested that their perception of IPC is more negative than among other healthcare professionals. The purpose of this study was to clarify Japanese physician's perceptions of IPC and what factors influenced their views. METHODS: This cross-sectional study surveyed 732 medical doctors at a university hospital and six foundation hospitals in a prefecture located in Tohoku district, northeastern Japan. Those hospitals were approved for delivery of postgraduate clinical training. Physician's perceptions of IPC were investigated for three items, namely providing patient-centered care, preventing medical accidents, and improving the quality of medical care. A total of 409 doctors who were engaged in clinical practice, responded adequately to the survey. Factors associated with negative perceptions towards IPC among physicians were analyzed using a logistic regression model. RESULTS: The proportion of negative perceptions of IPC for providing patient-centered care, preventing medical accidents, and improving the quality of medical care were 41.1%, 34.0% and 33.7%, respectively. Negative perceptions of IPC for providing patient-centered care were associated with older age (50 + years; odds ratio (OR): 2.73; 95% confidence interval (CI): 1.11 - 6.68) and a lower frequency of interprofessional meetings (no meetings; OR: 2.95; 95%CI: 1.43 - 6.08). Negative perceptions of IPC for preventing medical accidents were associated with a lower frequency of interprofessional meetings (no meetings, OR: 3.23; 95%CI: 1.58 - 6.62). Negative perceptions of IPC for improving the quality of medical care were associated with middle age (40 - 49 years, OR: 2.93; 95%CI: 1.20 - 7.12) and a lower frequency of interprofessional meetings (no meetings; OR: 2.75; 95%CI: 1.34 - 5.66). CONCLUSIONS: Physician's negative perceptions of IPC in our study were associated with age and a lower frequency of interprofessional meetings. Our findings suggest that effective regular interprofessional meetings serve to share information about patients, and to allow physicians to understand each other better, which should have a positive impact on the quality of patient-centered care.

Risk factors for sorafenib-induced high-grade skin rash in Japanese patients with advanced renal cell carcinoma.

The aim of this study was to evaluate the clinical factors, drug-related genetic polymorphisms, and human leukocyte antigen (HLA) types to determine the association with sorafenib-induced high-grade skin rash (HGSR) in Japanese patients with advanced renal cell carcinoma (RCC). A total of 55 patients with advanced RCC treated with sorafenib were analyzed retrospectively. Of these, 33 patients were subjected to HLA typing and polymorphism analyses of CYP3A5, ABCB1, ABCC2, and UGT1A1, which are involved in the metabolism and membrane transport of sorafenib. Grade 3 or higher SR developed in 12 (22%), and a higher incidence was observed in female patients than in male patients (40 vs. 15%, P=0.046). The initial dose, initial dose per body weight, and initial dose per body surface area in patients with HGSR were significantly higher than those in patients without HGSR. Patients with the ABCC2 -24CC genotype were at a significantly higher risk of SR than those with the CT genotype (35 vs. 0%, P=0.032). HLA-A*24 was significantly associated with the occurrence of HGSR (P=0.049). Our finding suggested that women, higher initial dose per body weight or body surface area, the ABCC2 -24CC genotype, and HLA-A*24 are associated with the risk of sorafenib-induced HGSR in Japanese RCC patients.