Objective: To evaluate whether multiple-answer multiple-choice questions are more effective than single-answer questions in measuring the academic abilities of students, taking into account test-taking strategies used by students.

Methods and Materials: We conducted surveys using three subjects (i.e., Mathematics, English, and Japanese), with both multiple-answer and single-answer questions. We asked eight medical students to solve these questions and to select primarily used test-taking strategies after solving each question.

Results: We found that multiple-answer questions generally had a low percentage of correct answers. The use of a particular test-taking strategy primarily depended on the individual. Students evaluated all choices when solving multiple-answer questions.

Conclusions: Although various strategies are used by different participants for different subjects, multiple-answer questions are generally more effective than single-answer questions in having test takers examine all choices, and prodding them to think more deeply.

Objective: To identify the characteristics of the motivation of medical students and their relationships with entrance selection systems in Japan and the U.S.

Methods and Materials: We had two types of participants: medical students and teachers at medical schools in Japan and the U.S. The students and teachers responded to a survey that included 11 and 3 questions, respectively.

Results: It was found that although students in Japan enter medical schools with high motivation─similar to students in the U.S.─, after some time, medical students in Japan are considerably less motivated than students in the U.S.

Conclusions: Based on the results, we conclude that the selection system of medical schools, including general education, is one of the reasons why motivation decreases drastically in Japan. We propose two potential changes to the selection system for medical schools in Japan.

　I performed basic research at the University of Connecticut, New England, USA from October 2016 to June 2018. I worked in the Human Soft Tissue Research Laboratory, which is part of the Department of Orthopedic Surgery at the University of Connecticut. I performed basic research to develop new treatments for shoulder joint disease with Prof. Augustus D. Mazzocca, who has done extensive work in biological and biomechanical orthopedics, especially for shoulder disease. I was fortunate to be able to work alongside seven highly motivated German orthopedic surgeons from the Department of Orthopaedic Sports Medicine, Technical University of Munich. During my 2 years at the University of Connecticut, I performed biological, biomechanical, and clinical studies of shoulder surgery and observed the medical and cultural differences between Japan, the USA, and Germany. In this review, I summarize the biological and biomechanical studies that I performed at the University of Connecticut.

　Treatment of chronic total coronary occlusions (CTOs) is the most challenging field of percutaneous coronary intervention (PCI) because of the historically low procedural success and high recurrence rate. The success of CTO-PCI depends mainly on operator experience. Therefore I studied abroad at Darmstadt Hospital in Germany, which is a high volume center in Europe for CTO-PCI, to acquire the theory and skill of CTO-PCI. Another experiment is to struggle to get the German doctor’s license. Foreign physicians who want to train or work in Germany need a permanent medical license (Approbation) or a temporary medical license (Berufserlaubnis). In this report we will describe the CTO PCI, my experiences in the heart catheter laboratory at Darmstadt Hospital, and how to get the German doctor’s license.

　Maternal stress during pregnancy has been linked to chronic disease and cancer in offspring. We used prenatal stress animal models to study maternal stress during pregnancy at Johns Hopkins University from December 2017 to February 2019. This is the review article about prenatal stress and animal models.

　Previous epidemiology reports have shown that maternal stress could cause cancer, cardiovascular, neuropsychiatric illness or immune dysfunction in human populations. Furthermore, stress during pregnancy has also been linked specifically to colon cancer and leukemia in adult offspring.

　We have developed three animal models of prenatal stress, 1. A/J mouse for lung cancer, 2. ApoE (Apolipoprotein E) knockout mouse for atherosclerosis, 3. mogp-TAg mouse for ovarian cancer. In our first publication, the effect prenatal stress on carcinogenesis through changing the tumor environment was suggested in our studies with A/J mice who develop lung cancer.

　There were no animal models to study the role of prenatal stress and future carcinogenesis in the offspring exposed to stress as a fetus. We set up a study to test the hypothesis that prenatal stress would make the progeny more sensitive to carcinogens. Animal model of prenatal stress is necessary to understand the stress hormonal effect between mother and fetus, and the role of stress on carcinogenesis.

　Cancer is the leading cause of death in Japan. Cancer is treated by multidisciplinary therapy such as surgery, chemotherapy, molecular target therapy and radiotherapy. However, almost of advanced cancer relapse after treatment. The relapsed cancer acquires resistance to the therapeutic agents we already used. The prognosis of relapsed cancer is very poor. Therefore, new treatment agents are needed urgently. In recent years metabolites derived from natural foods are focused as new therapeutic agents of cancer diseases. The metabolites are expected to cause less side effect than chemotherapy and have same effect as chemotherapy to cancer. Furthermore therapeutic agents from natural foods are Ellagic acid is metabolite derived from nuts, berries, and pomegranates. Ellagic acid is known to have anticancer effects, due to affecting apoptosis, cell proliferation and cell cycle regulation. Some of metabolites from ellagic acid also have anticancer effect. Urolithins are gut derived bacterial metabolites from ellagic acid. Many articles reported that Urolithin-A has anticancer effect for many cancers. Urolithin-A was reported to regulate p53 protein, caspase 3, caspase 7, AKT, aromatase and PARP in some cancers. Actin polymerization is regulated via Rac1 pathway by Urolithin-A in endometrial cancer. Furthermore, proliferation of many cancer cell lines is suppressed by UA. Safety of UA was investigated by using Rat model. The article suggested Urolithin-A has less genotoxicity compared with cyclophosphamide. Thus, Urolithin-A might be able to have a role as new treatment agent to cancer.

　Among the various coagulation-related factors, fibrinogen levels are the first to decrease below critical levels during massive hemorrhage. Therefore, in obstetric hemorrhage, the lost fibrinogen should be replaced at an early stage to restore hemostatic blood levels. Recently, the use of fibrinogen concentrates for critical obstetric hemorrhage has been increasing in Japan, and its efficacy in Japanese patients is similar to that reported in patients from other countries. According to the survey conducted by the Japanese Society of Obstetrics and Gynecology on the use of fibrinogen concentrates, a median dose of 3 g is generally administered, and if the effect is inadequate, additional doses are administered. The Japanese Clinical Practice Guide for Critical Obstetrical Hemorrhage (2017 revision) states that blood transfusion should be initiated as soon as possible and recommends the prompt administration of fresh-frozen plasma and red blood cells because obstetric hemorrhage can easily result in disseminated intravascular coagulation. Moreover, the use of fibrinogens is also recommended for severe hemorrhage cases.

　Evaluation of the efficacy of fibrinogen concentrates in severe cases, such as a placebo-controlled, randomized and double blind study, cannot be carried out because it is unethical. However, since it is clear that fibrinogen concentrates have a high potential for reducing maternal mortality, there is an urgent need to expand the indications for fibrinogen concentrate administration.

　This digest of reports was prepared as part of an academic encouragement award from the Juntendo Alumni Association. Ten published reports covering five different topics focusing on technical innovations and approaches to management for enhancing long-term outcomes of pediatric minimally invasive surgery (MIS) through the application of currently available technology will contribute to exposing surgical residents to sustainable training and learning opportunities that they can use to enhance their expertise and skills.

　While MIS has many advantages compared with conventional open surgery, many are somewhat subjective and difficult to assess objectively. Thus, new MIS procedures require motivation, creativity, and skill to develop but are only of practical value if they can be performed safely and effectively with acceptable cost performance ratios.

　Pediatric surgical patients have a much longer postoperative period than adult patients and coupled with decreased mortality and increased longevity, postoperative quality of life (QOL) is a long-term factor that pediatric surgeons are in a position to control. Because pediatric MIS requires more specific skills because of size limitations that are associated with longer learning curves, the chosen reports reflect how balancing surgical/anatomic challenges, maximizing postoperative QOL, and maintaining teaching and skill acquisition at a high standard of excellence are crucial for managing pediatric patients successfully.

Objective: As gastrointestinal tract perforation frequently causes severe sepsis, it is associated with a poor prognosis. We investigated the usefulness of measuring blood interleukin-6 (IL-6) levels using a simple semi-quantitative analysis kit to predict the severity of perforative peritonitis.

Materials and Methods: Nineteen patients with generalized peritonitis due to gastrointestinal tract perforation who had undergone surgery in our department were eligible for this study. Preoperative blood IL-6 levels were measured using a semi-quantitative analysis kit and classified into two groups according to the color code: a dark-colored group (IL-6 ≥5,000 pg/ml) and a light-colored group (IL-6 <5,000 pg/ml). The two groups were then compared in terms of preoperative inflammatory markers, severity scores (Mannheim Peritonitis Index (MPI), Acute Physiology and Chronic Health Evaluation (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score), postoperative factors, and outcome (survive/death).

Results: The median age of the patients was 70 years. The median interval between the onset of symptoms and surgery was 13 hours. Seventeen patients survived, and 2 patients died. Compared with the light-colored group, the preoperative white blood cell count was significantly lower; however, the MPI, postoperative SOFA score, and number of patients requiring vasopressors and hemoperfusion using polymyxin B-immobilized fiber column after surgery were significantly higher in the dark-colored group. Perforative peritonitis in the dark-colored group was more often associated with a fatal outcome (p=0.04).

Conclusion: The results suggest that the semi-quantification of blood IL-6 levels is useful for predicting the outcome of patients with generalized peritonitis due to gastrointestinal tract perforation.

Objective: Anastomotic leakage (AL) is one of the most serious postoperative complications in colorectal surgery. AL reportedly occurs in 5-10% of cases following colorectal surgery. Poor colonic perfusion is proceeded to be AL during mesenteric resection. The purpose of this study was to evaluate the clinical utility of assessing colonic perfusion with indocyanine green (ICG) fluorescence imaging.

Materials and Methods: The subjects comprised 47 patients who underwent colorectal surgery with double-stapling technique anastomosis between March 2015 and September 2016. We measured the time fluorescence first appeared after the ICG injection and the time until maximum fluorescence was measured. These were compared with other clinical findings that correlated with AL.

Results: The median first fluorescence time was 43 sec, and the median maximum fluorescence time was 92 sec. Based on the fluorescence imaging, the surgical team judged the proximal colon to be anastomosed insufficiently in 10 patients (21.2%). The median proximal change distance of the transection line was 12.5 mm (5-70). In all 47 patients, AL occurred in 6 patients (12.8%). Maximum fluorescence time (over 98 sec) was significantly longer in the AL group (p=0.025).

Conclusions: The results of this study suggested that assessing colonic perfusion using ICG fluorescence imaging during colorectal surgery was clinical useful. It was considered that patients with elongation of fluorescence time should be careful of AL.

Objective: Although epidural anesthesia and paravertebral blocks are routinely administered to achieve postoperative analgesia after trunk surgery, the use of anticoagulant therapy has increased the number of cases in which these procedures are contraindicated. The efficacy of erector spinae plane block (ESPB), an alternative method of postoperative analgesia, has been reported following trunk surgery. This study aimed to determine the analgesic effect of this procedure over a 48-h period following abdominal, breast, and spinal surgery.

Methods: This stratified randomized, observer-blinded comparative study enrolled patients aged ≥20 years who underwent abdominal, breast, or spinal surgery at Juntendo University Shizuoka Hospital between June 20, 2018 and February 7, 2019. Patients were divided into the ESPB and non-ESPB groups. Numerical rating scale (NRS) scores, which were used to assess pain 0, 3, 6, 12, 24, and 48 h after surgery, were compared between both groups. The occurrence of adverse events was recorded.

Results: The analysis included 51 and 59 patients from the ESPB and non-ESPB groups, respectively. NRS scores were significantly lower in the ESPB group than in the non-ESPB group during the 48-h postoperative period. One patient in each group complained of nausea. Numbness of the extremities or an itching sensation of the skin were not observed in any patient.

Conclusions: ESPB significantly reduced NRS scores during the initial 48-h postoperative period without major complications. Our findings indicate the utility of the ESPB for postoperative analgesia after trunk surgery.

　Fungi are usually identified by evaluating morphological characteristics. As fungi are rarely encountered in routine microbiology, it is important to have a suitable guide for the accurate identification of medically important fungi. This study was designed to improve identification of medically important fungi. A total of 20 clinical and reference fungal isolates, were used in this study. The examinations were conducted during the training period in the departments of clinical laboratory and dermatology at Juntendo University Hospital. For the identification of filamentous fungi, conventional culture, colony characteristics, and microscopic findings were collected via photographs. The macroscopic and microscopic morphologies of filamentous fungi showed similar characteristics to those of references. The chromogenic differential media, CHROMagar, was used for the identification of Candida spp. and Malassezia spp. Matrix-assisted laser desorption ionization-time of flight mass spectroscopy was used to rapidly and accurately identify Candida at the species level. Fourteen filamentous fungi and six yeasts were identified in this study using general resources such as Sabouraud dextrose agar (SDA), potato dextrose agar (PDA), and lactophenol cotton blue. The 14 fungi exhibited colony characteristics and microscopic findings on SDA and PDA at 30℃ for 2-14 d. In conclusion, using appropriate guides as tools for identification and implementing new testing technologies will enable the accurate identification of fungi. CHROMagar is extremely useful in rapid identification of common yeast species, improving and streamlining the work flow in clinical microbiology laboratories in the Kingdom of Thailand.

　The head and neck have important functions, including speech, articulation, swallowing, mastication, and cosmesis. The treatment of head and neck cancer (HNC) results in the impairment of these functions. Therefore, it is necessary to consider the balance between curability and post-treatment quality of life in the treatment of HNC. Current knowledge about the treatment of HNC is necessary for head and neck surgeons. This study focuses on new topics in HNC treatment, including radiotherapy and concomitant intra-arterial cisplatin, perforator skin flap, human papilloma virus, transoral robotic surgery, narrow band imaging, transoral surgery, voice prosthesis, active surveillance for micropapillary carcinoma, particle beam radiotherapy, and drug development: immune checkpoint inhibitors, molecular target drugs, and photoimmunotherapy.