To teach is to learn twice, revisited: a qualitative study of how residents learn through teaching in clinical environments.

BACKGROUND: Teaching helps the teacher's own learning as a professional-as the saying goes, 'to teach is to learn twice'. Near-peer teaching in clinical practice has been shown to contribute to the development of both teaching skills and necessary competencies for doctors. Research on how near-peer teachers learn through their teaching roles has mainly focused on classroom learning. However, understanding how the phenomenon of 'teaching is learning twice' occurs in clinical settings and its influencing factors is important for the development of a quality workplace learning environment. Therefore, this study investigated how residents learn through teaching in clinical practice and the factors influencing this process. METHODS: This study's methodology is based on the constructivist grounded theory from a social constructivist perspective. Several teaching hospitals in Japan were included, and the study participants were post-graduate year 2 residents (PGY2s) from these hospitals. The interviews were recorded, transcribed into text, and analysed by the first author. RESULTS: From January 2016 to July 2022, 13 interviews were conducted with 11 PGY2s from nine educational hospitals. The PGY2s played diverse educational roles in clinical settings and learned competencies as physicians in almost all areas through such roles. We found that knowledge transfer and serving as role models stimulated PGY2s' intrinsic motivation, encouraged reflection on their own experiences, and promoted self-regulated learning. Further, educating about procedural skills and clinical reasoning prompted reflection on their own procedural skills and thought processes. Supporting post-graduate year 1 residents' reflections led to the refinement of PGY2s' knowledge and thought processes through the verbal expression of their learning experiences. Such processes required the formation of a community of practice. Thus, education promoted learning through reflection and clarified the expert images of themselves that PGY2s envisaged. CONCLUSIONS: The study found that residents acquire various physician competencies through multiple processes by teaching as near-peer teachers in clinical settings, that a community of practice must be formed for near-peer teaching to occur in a clinical setting, and that teaching brings learning to those who teach by promoting reflection and helping them envision the professionals they aim to be.

[Video-assisted Thoracoscopic Surgery for Mediastinal Tumor and Thoracic Wall Tumor].

"A final conceptual change concerns the appreciation that all major thymoma subtypes can behave in a clinically aggressive fashion and, therefore, should no longer be called benign tumors, irrespective tumor stage. Accordingly, their International Classification of Disease for Oncology( ICD)-O codes now have a /3 suffix, thymomas, for as malignant.1)" This manuscript indicated that almost all mediastinal tumors, which could not be easy to diagnose per-operatively, should be removed. There were two large problems for mediastinal tumors resection with video-assisted thoracoscopic surgery (VATS). First is management or approach for the thymic vein, which have a short distance but large diameter relatively, and individual variation about the position and the number. Some solutions were 1) performance of pre-operative enhanced computed tomograpy( CT) or magnetic resonance imaging( MRI), 2) transcervical approach with Kent retractor, 3) sternal-L shape approach. Second is for the patients, which have thymoma or thymic tumor with myasthenia gravis, to what extent should be removed anterior fatty tissue. For the moment including beneath the innominate vein it should be removed as extent as possible. Liga Sure Impact was useful to remove a large thoracic wall tumor with VATS for resection of thick muscle.

A 2-item version of the Japanese Consultation and Relational Empathy measure: a pilot study using secondary analysis of a cross-sectional survey in primary care.

BACKGROUND: The Consultation and Relational Empathy (CARE) measure is a patient-reported measure of physician empathy which is widely used internationally. The Japanese version of the CARE measure has very high internal reliability, suggesting that a shorter version may have adequate validity and reliability. OBJECTIVE: To investigate a valid shorter version of the Japanese CARE measure. METHODS: We conducted a pilot study using secondary analysis of previous data obtained from 9 general practitioners and 252 patients and used to develop the Japanese CARE measure. All 1,023 possible combinations of the Japanese CARE items (n = 1-10) were candidates for the short measure. The internal consistency (Cronbach's alpha) and the correlations between candidate short questionnaires and the original questionnaire were calculated. After selecting the most valid short questionnaire, inter-rater reliability was determined using generalizability theory, and construct validity (Spearman's rho) was determined using patient satisfaction. RESULTS: Two items were selected for a pilot shorter version: item 6 "Showing care and compassion" and item 9 "Helping you to take control." These showed high internal consistency and correlations with the 10-item measure (Cronbach's alpha = 0.920, correlation = 0.979). Forty-five questionnaires per doctor allowed us to reliably differentiate between practitioners. The construct validity for the pilot short measure was high (Spearman's rho 0.706, P < 0.001). CONCLUSION: We generated a pilot 2-item version of the Japanese CARE measure. This pilot 2-item version provides a basis for future validation studies of short CARE measures in other languages.

Development of an automatic multiplanar reconstruction processing method for head computed tomography.

BACKGROUND: Head computed tomography (CT) is a commonly used imaging modality in radiology facilities. Since multiplanar reconstruction (MPR) processing can produce different results depending on the medical staff in charge, there is a possibility that the antemortem and postmortem images of the same person could be assessed and identified differently. OBJECTIVE: To propose and test a new automatic MPR method in order to address and overcome this limitation. METHODS: Head CT images of 108 cases are used. We employ the standardized transformation of statistical parametric mapping 8. The affine transformation parameters are obtained by standardizing the captured CT images. Automatic MPR processing is performed by using this parameter. The sphenoidal sinus of the orbitomeatal cross section of the automatic MPR processing of this study and the conventional manual MPR processing are cropped with a matrix size of 128×128, and the value of zero mean normalized correlation coefficient is calculated. RESULTS: The computed zero mean normalized cross-correlation coefficient (Rzncc) of≥0.9, 0.8≤Rzncc < 0.9 and 0.7≤Rzncc < 0.8 are achieved in 105 cases (97.2%), 2 cases (1.9%), and 1 case (0.9%), respectively. The average Rzncc was 0.96±0.03. CONCLUSION: Using the proposed new method in this study, MPR processing with guaranteed accuracy is efficiently achieved.

Effect of physician attire on patient perceptions of empathy in Japan: a quasi-randomized controlled trial in primary care.

BACKGROUND: There is limited quantitative research on the effect of physician attire on patient-physician relationships. This study aimed to measure the influence of Japanese family physicians' attire on the "human" aspects of medical care in terms of patient-perceived relational empathy. METHODS: This was a multicenter, prospective, controlled trial conducted in primary clinics in Japan. We explored the effects of family physician attire (white coat vs. casual attire) on patient-perceived empathy. Family physicians were allocated to alternate weeks of wearing a white coat or casual attire during consultations. Patients' perceptions of physician empathy were evaluated using the self-rated Japanese Consultation and Relational Empathy (CARE) Measure. We used a linear mixed model to analyze the CARE Measure scores, adjusting for cluster effects of patients nested within doctor, age, and sex of patients, and doctors' sex and years of clinical experience. We used the same method with Bonferroni adjustment to analyze patient sex differences in perceived empathy. RESULTS: A total of 632 patients of seven family physicians were allocated to white coat-wearing consultations (n = 328), and casual attire-wearing consultations (n = 304). There was no difference in CARE Measure scores between white coat and casual primary care consultations overall (p = 0.162). Subgroup analysis of patient sex showed that CARE Measure scores of male patients were significantly higher in the Casual group than in the White coat group (adjusted p-value = 0.044). There was no difference in female patient scores between White coat and Casual groups (adjusted p-value = 1.000). CONCLUSIONS: This study demonstrated that physician attire (white coat or casual attire) in a primary care setting did not affect patient-perceived relational empathy overall. However, male patients of physicians wearing casual attire reported higher physician empathy. Although empathy cannot be reduced to simple variables such as attire, white coats may have a negative effect on patients, depending on the context. Family physicians should choose their attire carefully. TRIAL REGISTRATION: Japanese University Hospital Medical Information Network (UMIN-ICDR). Clinical Trial identifier number UMIN000037687 (Registered August 14, 2019, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000042749 ). The study was prospectively registered.

[Contrivance for Video-assisted Thoracic Surgery Lung Operation Especially Lobectomy with Adhesive and Fissureless Complications].

There were 74 cases (29.5%) with adhesive and fissureless complications in comparison with all 251 cases who had undergone video-assisted thoracic surgery (VATS) lung operations in author's hospital. On lobectomy and segmentectomy adhesive and fissureless effective factors were old age( p=0.012), the difference between %DLco to %DLco/VA( p<0.05), Brinkman index( p=0.043) compared with non-ad- hesive cases, therefore operation times of fissureless group prolonged (p=0.009). The point at issue was in what manner we should perform appropriate division of the bronchus, the pulmonary arteries and the veins on the fissureless lobectomy. Especially it is very important which the apicoposterior artery( rA2b:Asc) on right upper lobectomy and the lingular segmental artery( lA4+5) on left upper lobectomy branch from the major fissure or not. For that purpose the management procedure had been done pulmonary artery (primary upper division: A1+2+A3)→ pulmonary vein → bronchus → residual pulmonary artery (rA2b or lA4+5). On the very severe fissureless cases the management procedure had been done pulmonary vein → bronchus → pulmonary artery. Mobilization of "fissure first, hilum last" and/or "hilum first, fissure last" techniques should be performed for VATS fissureless lobectomy.

PARP1 V762A polymorphism affects the prognosis of myelodysplastic syndromes.

OBJECTIVE: Myelodysplastic syndromes (MDS), caused by various genetic mutations in hematopoietic stem cells, are associated with highly variable outcomes. Poly (ADP-ribose) polymerase-1 (PARP1) plays an important role in DNA damage repair and contributes to the progression of several types of cancer. Here, we investigated the impact of PARP1 V762A polymorphism on the susceptibility to and prognosis of MDS. METHODS: Samples collected from 105 MDS patients and 202 race-matched healthy controls were subjected to polymerase chain reaction-restriction fragment length polymorphism for genotyping. RESULTS: The allele and genotype frequencies of PARP1 V762A did not differ between MDS patients and the control group. However, MDS patients with the PARP1 V762A non-AA genotype, which is associated with high gene activity, had shorter overall survival rates (P = .01) than those with the AA genotype. Multivariate analysis of overall survival also revealed PARP1 V762A non-AA genotype as a poor prognostic factor (P = .02). When patients were analyzed according to treatment history, the PARP1 V762A non-AA genotype was only associated with poor survival in patients who had received treatment (P = .02). CONCLUSION: PARP1 V762A polymorphism may be an independent prognostic factor for MDS, and a predictive biomarker for MDS treatment.

Three Consecutive Cases of Familial Hemophagocytic Lymphohistiocytosis, Including a Case Due to Maternal Uniparental Disomy.

We have experienced 3 consecutive cases of familial hemophagocytic lymphohistiocytosis (FHL). All affected infants had mutations in exon 3 of the perforin gene. The first had a homozygous mutation, c.1168C>T (p.R390*), caused by maternal uniparental isodisomy. The second and third had compound heterozygous mutations: c.781G>A (p.E261K) and c.1491T>A (p.C497*); c.1724G>T (p.C242G) and p.R390*, respectively. FHL is very rare in Northern Japan but should be suspected if infants exhibit prolonged fever. This is the first report of a relationship of p.R390* with FHL caused by uniparental isodisomy, and the second reported case of FHL type 2 with this form of inheritance.

PDCD1 and CTLA4 polymorphisms affect the susceptibility to, and clinical features of, chronic immune thrombocytopenia.

Programmed death-1 (PD-1, PDCD1) and cytotoxic T lymphocyte-associated antigen-4 (CTLA-4, CTLA4) play central roles in immune checkpoint pathways. Single nucleotide polymorphisms (SNPs) of PDCD1 and CTLA4 have been reported to be associated with susceptibility to some autoimmune diseases. However, the potential association between SNPs in these immune checkpoint genes and risk of chronic immune thrombocytopenia (cITP) remain controversial and obscure. The aims of this study were to clarify the influence of PDCD1 and CTLA4 SNPs on the risk of developing cITP and its clinical features. We obtained genomic DNA from 119 patients with cITP and 223 healthy controls; their genotypes were determined by the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Patients with cITP had a significantly higher frequency of the PDCD1 +7209 TT genotype compared with healthy controls. The CTLA4 -1577 GG genotype and CT60 GG genotype showed higher frequencies of platelet count <5 × 109 /l at diagnosis, minimum platelet count <5 × 109 /l, and bleeding symptoms. Moreover, the PDCD1 -606 AA genotype and +63379 TT genotype were significantly associated with a lower number of patients who achieved a complete response to prednisolone treatment. Our results suggest that the immune checkpoint polymorphisms may affect the susceptibility to the clinical features of cITP, and treatment response of the affected patients.

IL17A and IL23R gene polymorphisms affect the clinical features and prognosis of patients with multiple myeloma.

Single nucleotide polymorphisms (SNPs) in interleukin 17 (IL17A) and IL-23 receptor (IL23R) are involved in the pathogenesis of many cancers and autoimmune diseases. We investigated the influence of IL17A and IL23R SNPs on the risk of developing multiple myeloma (MM) and its clinical features. We obtained genomic DNA from 120 patients with MM and 201 healthy controls and detected IL17A -197 G/A (rs2275913) and IL23R H3Q (rs1884444) genotypes using the polymerase chain reaction-restriction fragment length polymorphism method. There were no significant differences in the genotype and allele frequencies of IL17A -197 G/A and IL23R H3Q between the controls and patients with MM. Compared with the GG and GA genotypes, the IL17A AA genotype was significantly associated with lower hemoglobin levels. The IL23R HH genotype was significantly associated with higher frequency of bone lesions and plasmacytoma than the HQ and QQ genotypes. We observed significant differences in overall survival (OS) between patients treated with thalidomide and/or bortezomib and those treated conventionally. Therefore, we also examined the effect of IL17A and IL23R polymorphisms on the clinical variables and OS in patients treated with thalidomide and/or bortezomib. We observed that the IL23R HH genotype was significantly associated with poor survival compared with the QH and HH genotypes in these patients. Our findings indicate that IL17A -197 G/A and IL23R H3Q are not associated with susceptibility to MM. However, IL-17 and IL-23R polymorphisms may affect severity, bone lesions, and extra-medullary disease in patients with MM. Moreover, IL23R polymorphisms may contribute to poor prognosis in patients with MM treated with thalidomide and/or bortezomib.

How many patients are required to provide a high level of reliability in the Japanese version of the CARE Measure? A secondary analysis.

BACKGROUND: Empathy is widely regarded as being key to effective consultation in general practice. The Consultation and Relational Empathy (CARE) Measure is a widely used and well-validated patient-rated measure in English. A Japanese version of the CARE Measure has undergone preliminary validation, but its ability to differentiate between individual doctors has not been established. The current study sought to investigate the reliability of the Japanese version of the CARE Measure in terms of discrimination between doctors. METHODS: We conducted secondary analysis of a dataset involving 252 patients assessed by nine attending General Practitioners. The intra-cluster correlation coefficient was evaluated as an index of the reliability of the Japanese version of the CARE Measure for discriminating between doctors. With a criterion of intra-cluster correlation coefficient = 0.8, we conducted a decision (D) study using generalizability theory to determine the required number of patients for reliable CARE Measure estimates. RESULTS: The ability of the CARE Measure to discriminate between doctors increased with the number of patients assessed per doctor. A sample size of 38 or more patients provided an average intra-cluster correlation coefficient of 0.8. CONCLUSIONS: The Japanese CARE Measure appears to reliably discriminate between doctors with a feasible number of patient-ratings per doctor. Further studies involving larger numbers of doctors with a multicenter analysis are required to confirm the results of the current study, which was conducted at a single institution.

Identifying the social capital influencing diabetes control in Japan.

The number of patients with diabetes is increasing in Japan. Recently, Social capital (SC) has received increasing attention as a factor influencing health conditions. In the US, the relation between SC and diabetes control has been reported, but little attention has been paid to this connection in Japan. Three SC questionnaires, entitled "trust in people in a community," "social support," and "social relationships," were constructed. The subjects were adult patients with type 2 diabetes. Information on diabetic conditions, such as HbA1c, self-attainment of diet (SAD) and exercise (SAE), and complications were collected. The reliability coefficients for the SC questionnaire and factor analysis of SC were conducted. Multiple and logistic regressions were used to identify the influence of SC on diabetes control. Sixty-five patients participated in this study. The questionnaires "social support" and "social relationships" were adopted to measure Cronbach alpha coefficient. Factor analysis extracted the factors "hope to be helped (HH)," "participation in favorite events (PFE)," "sense of belonging (SB)," and "social movement (SM)." HbA1c was positively correlated with HH (P < 0.05). SAD and SAE were negatively correlated with HH (P < 0.05). SAE was positively correlated with PFE (P < 0.05). PFE reduced complication risks (P < 0.05). HH includes amae, which negatively affected self-efficacy that correlates with diabetes control. Therefore, higher HH might cause higher levels of HbA1c. PFE reduces distress and contributes to glucose control. Reduced distress through PFE might prevent complications. HH and PFE were identified as SC that influences diabetes control.

Listen to the outpatient: qualitative explanatory study on medical students' recognition of outpatients' narratives in combined ambulatory clerkship and peer role-play.

BACKGROUND: Understanding patients' narratives has been associated with methods of improving care that go beyond what may be regarded as a "narrow" view of scientific medicine. Medical interview training in which medical students develop understanding of the importance of patients' narratives is receiving increased attention. However, students generally receive education on patients' narratives that does not distinguish inpatients and outpatients. No studies exploring the characteristics of outpatients' narratives have been reported. We developed an educational program combining ambulatory clerkship and peer role-play using actual narratives from outpatients that students had encountered during their clerkship. These narratives were used as peer role-play scenarios in which the students acted as outpatients. This study explored what and how medical students learned about the characteristics of outpatients' narratives through this original educational program. METHODS: Participants were 70 fifth-year medical students from Nagoya University, Japan. We conducted 13 focus groups, based on a convenience sample of 11 groups in 2012, one group in 2013, and one group in 2017 (from 17 clinical groups in each year). Focus group transcripts were analyzed using the "Steps for Coding and Theorization" qualitative data analysis method. We assessed medical anthropological findings regarding narratives in a conceptual framework. RESULTS: Patients' narratives as perceived by medical students were divided into four quadrants by two axes: medical versus lived content, and objective versus subjective structure. Students recognized that outpatients' narratives mainly used a subjective structure, but were mixed and crossed each quadrant. This was described as "irreproducibility." Students also recognized that narratives of simulated patients and inpatients were mainly limited to a medical-lived content with an objective structure. These differences in narrative characteristics were recognized through students' previous interactions with simulated patients and inpatients. CONCLUSIONS: Despite some limitations, medical students learn about patients' narratives in our original educational program in a way that would be difficult to achieve through training using simulated patients or inpatients.

[One-stage Operation through the Same Skin Incision for Synchronous Double Primary Breast and Lung Cancer;Report of a Case].

A 75-year-old woman noticed a small mass in the right side breast and consulted our hospital. The results of the detailed examination indicated the synchronous double primary right breast cancer and the same side lung cancer (rS5). One-stage operation from the same skin incision was scheduled. Volume rendering (VR) of computed tomography (CT)-scan was very useful in deciding the position and the length of the skin incision. The breast tumor resection and the right middle lobe resection were successfully performed through 6.5 cm skin incision.

The cytokine polymorphisms affecting Th1/Th2 increase the susceptibility to, and severity of, chronic ITP.

BACKGROUND: T-helper cell type 1 (Th1) polarization in chronic immune thrombocytopenia (cITP) has been reported at the protein and mRNA levels. We evaluated the impact of Th1/Th2 cytokine and cytokine receptor functional polymorphisms on both susceptibility to, and severity of, cITP. We analysed IFN-γ + 874 T/A, IFN-γR -611G/A, IL-4 -590C/T, and IL-4Rα Q576R polymorphisms in 126 cITP patients (male/female: 34/92; median age: 47.7 years) and 202 healthy control donors. Genotyping was determined by PCR and direct sequencing. The Th1/Th2 ratio was detected in peripheral blood mononuclear cells via flow cytometry. RESULTS: cITP patients had a higher frequency of the IL-4Rα 576 non-QQ genotype compared to healthy subjects (P = 0.04). cITP patients with the IFN-γ +874 non-AA genotype (high expression type) showed more severe thrombocytopenia than those with the AA genotype (P < 0.05). cITP patients had a significantly higher Th1/Th2 ratio than control patients (P < 0.01); this ratio was inversely correlated with platelet counts. Furthermore, patients with both IFN-γ +874 non-AA genotype (high expression type) and IFN-γR -611 non-AA genotype (high-function type) had a significantly higher Th1/Th2 ratio (P < 0.05). CONCLUSIONS: The cytokine polymorphisms affecting Th1/Th2 increase the susceptibility to, and severity of, chronic ITP.

Cresyl Violet Stains Mast Cells Selectively: Its Application to Counterstaining in Immunohistochemistry.

The thiazine dye toluidine blue (TB) is well known to stain mast cells and hyaline cartilage metachromatically, and thus is mostly often used for their identification. However, TB is not suitable for counterstaining in immunohistochemistry, because of its high-background staining in the cytoplasm of other cell species and in extracellular structures. To expand the knowledge about dyestuffs staining mast cells in consideration with their usage in immunohistochemistry, we determined the stainability of several thiazines and oxazines, which are structurally related compounds to TB, using sections of mast cell-containing tissues. We found that all azine dyes used metachromatically stained mast cells and cartilage. Among these dyes, an oxazines cresyl violet (CV) stained mast cells with lower background, suggesting that those are useful for detecting mast cells and for counterstaining in immunohistochemistry. To ascertain its utility, CV was used in immunostaining of bHSDs in sections from adult rat ovary. Immunopositive signals reflected by DAB development in brown were clearly detected even after CV staining. We conclude that, similar to thiazines, oxazines stain mast cells metachromatically, and that of these, CV is more useful as a counterstain in immunohistochemistry than TB.

[Treatment Policy for Avoiding Pneumonectomy Regarding the Locally Advanced Lung Cancers].

The problem of pneumonectomy may result from an elimination of the extensive pulmonary vascular bed as a unit. Therefore this paper has indicated that 10 cases with the locally advanced lung cancers had been treated with some parenchymal sparing procedures including chemotherapy in order to avoid pneumonectomy. Six cases with preoperative chemotherapy were performed sleeve lobectomy in 3 cases, tangential pulmonary artery(PA) resection in 2, and left atrium partial resection in 1. One case with irradiation in vain was done sleeve LLL+lS4+5segmentectomy. Three cases without pre-treatment were done tangential PA resection in 2 cases, sleeve lobectomy in 1. Outcome was that there were no perioperative mortality and 7 cases achieved long-term survival, however, 2 cases died of relapse, and one died of pneumonia. On surgical technique U-shape mattress interrupted suture for bronchoplasty and tangential PA resection were proved very useful procedures.

[Novel Perfusion Evaluation Method Using Phase-ratio Image Map in Head 4D-CT].

PURPOSE: CT perfusion (CTP) is a powerful tool for the assessment of cerebrovascular disease. However, CTP maps are significantly different depending on CTP software and algorithm, even when using identical image data. We developed a phase-ratio image map (PI map), which was a novel perfusion map, without using CTP software. The purpose of this study was to investigate the usefulness of the PI map by comparing it with a positron emission tomography (PET) image. METHODS: Twenty patients (16 men, 4 women; mean age: 61.6 years) with unilateral cervical and intracranial steno-occlusive disease underwent CTP. CTP source images were obtained at 1-s intervals of 23 times and 5 intervals using dynamic multiphase imaging. An early-phase image was generated by computing the average of CT images for 5 s in the vicinity of the peak enhancement curve of a normal hemisphere. A delayed-phase image was generated by computing the average of CT images for 5 s immediately after the early phase. The PI map was created by dividing the delayed-phase image by the early-phase image. We investigated the validity of the PI map compared with PET-cerebral blood flow (CBF). Lesion-to-normal ratios between a PET-CBF and the PI map or two conventional CTP-CBFs were observed and compared, and the relative errors were also compared. RESULT: There was a strong correlation between the PET-CBF and the PI map (R=0.82). Correlations between the PET-CBF and two CTP-CBFs were weak (R=0.30) and middle (R=0.62), respectively. The relative error between the PI map and the PET-CBF was within 10% in most cases. CONCLUSION: The PI map was more similar to the PET-CBF on perfusion evaluation, and did not depend on CTP software. The robustness and simplicity of the PI mapping method would be advantageous compared with conventional CTP mapping methods.

Identification of novel ALK rearrangement A2M-ALK in a neonate with fetal lung interstitial tumor.

Fetal lung interstitial tumor (FLIT) is a recently reported type of congenital lung lesion comprising solid and cystic components. The pathological features include unique interstitial mesenchyme-based cell proliferation, and differ from other neoplasms represented by pleuropulmonary blastoma or congenital peribronchial myofibroblastic tumor. FLIT is extremely rare and its gene expression profile has not yet been reported. We provide the first report of a novel chromosomal rearrangement resulting in α-2-macroglobulin (A2M) and anaplastic lymphoma kinase (ALK) gene fusion in a patient with FLIT. The tumor cells contained a t(2;12)(p23;p13) and were mesenchymal in origin (e.g., inflammatory myofibroblastic tumors), suggesting the involvement of ALK in this case of FLIT. Break apart fluorescence in situ hybridization demonstrated chromosomal rearrangement at ALK 2p23. Using 5'-rapid amplification of cDNA ends, we further identified a novel transcript fusing exon 22 of A2M to exon 19 of ALK, which was confirmed by reverse-transcription polymerase chain reaction. The corresponding chimeric gene was subsequently confirmed by sequencing, including the genomic break point between intron 22 and 18 of A2M and ALK, respectively. Discovery of A2M as a novel ALK fusion partner, together with the involvement of ALK, provides new insights into the pathogenesis of FLIT, and suggests the potential for new therapeutic strategies based on ALK inhibitors.

[Examination of Visual Effect in Low-dose Cerebral CT Perfusion Phantom Image Using Iterative Reconstruction].

CT perfusion (CTP) is obtained cerebrovascular circulation image for assessment of stroke patients; however, at the expense of increased radiation dose by dynamic scan. Iterative reconstruction (IR) method is possible to decrease image noise, it has the potential to reduce radiation dose. The purpose of this study is to assess the visual effect of IR method by using a digital perfusion phantom. The digital perfusion phantom was created by reconstructed filtered back projection (FBP) method and IR method CT images that had five exposure doses. Various exposure dose cerebral blood flow (CBF) images were derived from deconvolution algorithm. Contrast-to-noise ratio (CNR) and visual assessment were compared among the various exposure dose and each reconstructions. Result of low exposure dose with IR method showed, compared with FBP method, high CNR in severe ischemic area, and visual assessment was significantly improvement. IR method is useful for improving image quality of low-dose CTP.