The mRNA vaccine, which was expected to be the trump card to converge the pandemic of COVID-19, has been shown high efficacy comparable to natural immunity by inducing humoral and cellular immunity.ｍ-RNA vaccination has shown strong efficacy in preventing exacerbation.

However, in the early stages of the COVID-19 epidemic, severe respiratory failure was seen in unvaccinated groups of 40s and 50s, and sometimes even in the group of 30s, severe pathology requiring intensive care management and high-level ventilator management had been essential for the treatments.

However, as the rate of severe illness and mortality declines, a shift to category 5 infectious diseases is being discussed. The three important items to prevent COVID-19 infection are : ⑴ how to detect symptomatic patients as soon as possible, ⑵ wearing N95 mask during aerosol-generating techniques, and ⑶ thorough health observation before and during hospitalization. Patients with adaptions for hospitalization should be accepted by many medical institutions as class 5 infectious diseases. And then the situation should be landed back to normal as soon as possible. It must be important to fully share practical knowledge and infection control techniques that have been cultivated through know-how among administrative agencies, health centers, and medical facilities.

Since the first positive case of COVID-19 in Tokushima Prefecture was confirmed on February 25, 2020, a total of more than 160，000 positive cases have been reported in the past three years.　Tokushima prefectural government established the “Tokushima Prefecture COVID-19 Hospitalization Coordination Headquarters” on April 1, 2020.　Coordination of hospitalization at priority medical institutions that respond to hospitalization, admission to accommodation treatment facilities, home treatment, etc., and with the cooperation of related organizations including Tokushima Prefectural Medical Association, Tokushima Prefectural Nursing Association, Tokushima Prefectural Pharmacists Association, etc., we have been responding with “All Tokushima” for more than three years.　We report on the outline presented at the 266th Tokushima Medical Society

“Joint Symposium “Current Status and Countermeasures for COVID-19”” on February 12, 2023.

At the end of 2019, a novel coronavirus was identified as the cause of a cluster of pneumonia cases in Wuhan, a city in the Hubei Province of China.　It rapidly spread, resulting in an epidemic throughout China, followed by an increasing number of cases in other countries throughout the world.　Coronavirus disease 2019 （COVID-19） can progress in a subset of patients to acute respiratory distress syndrome （ARDS） and has had a catastrophic effect on the world’s demographics resulting in more than 6 million deaths worldwide.

The major morbidity and mortality from COVID-19 is largely due to acute viral pneumonia that evolves to ARDS.　Most patients who are mechanically ventilated due to COVID-19-related ARDS should be managed in accordance with evidence-based ARDS strategies, including low tidal volume ventilation with permissive hypercapnia, prone positioning or extracorporeal membrane oxygenation （ECMO）.　In recent years, it has revealed that excessive respiratory effort exacerbates lung injury, which called patient self-inflicted lung injury （P-SILI）, and the importance of controlling excessive respiratory effort has been recognized.

Although infection with the SARS-CoV2 Omicron variant is associated with less severe disease compared with the Alpha and Delta variants, Omicron is spreading faster than any previous variant.　The overall risk related to this variant remains very high because its infection also extends to the patients with severe underlying disease or immune-compromised host including patients with chemotherapy or organ transplant recipients.　COVID-19 survivor, especially with ARDS, are at high risk for long term physical and mental impairments, and a multidisciplinary approach is essential for critical illness recovery.

Patients often report various symptoms after recovery from acute COVID-19.　These symptoms are called Long COVID.　Although coronaviruses have been mutated and changes in infectivity have been noted, there have been no reports of differences in symptoms of Long COVID between strains of coronaviruses.　In order to examine the differences in sequelae caused by different viral strains, we examined the age, sex, and symptoms of patients who visited the outpatient clinic of Hakuai Memorial Hospital from July 2021 to October 2022, and classified these patients into three periods （Period I : July to December, Period II : January to May, and Period III : June to October）. month） Period I corresponded to the pre-Delta strain, Period II to the Omicron strain, and Period III to the subtype.

There were 401 patients, 45 in stage I （21 males, 24 females, average age of 41 years）, 178 in stage II （70 males, 108 females, average age 42.7 years）, and 178 in stage III （74 males, 104 females, average age 42.8 years）.　Women tended to be more numerous than men.　Most of the patients had been vaccinated, and 22 had not been vaccinated.　The place of care after the diagnosis of COVID infection was examined, and 42％ of the inpatients were hospitalized in Period I, while most patients in Periods II and III recuperated at home or in hotels.　The age distribution of the patients showed that most of them were between 30 and 70 years old, indicating a trend toward middle-aged and older persons.　This trend was the same for all stages from stage I to stage III.　Their symptoms are very varied.　Patients with cough, phlegm, and pharyngeal discomfort being more common in stage II and stage III.　while olfactory and respiratory disturbances were more common in stage I.　Long-term patients were mostly malaise and memory impairment, and many of them were mild cases at the onset of the disease.

Symptoms of the patients were often related to various medical departments, and it was considered important to collaborate with them.　It is also important to avoid infection because sequelae can develop even in those with mild symptoms.

Coronavirus disease 2019 （COVID-19） is an infectious disease caused by the new coronavirus （SARS-CoV-2） that originated in China in December 2019, and it has been reported that it mainly causes respiratory symptoms but also exhibits various skin symptoms associated.

The skin lesions are classified into six patterns represented by the acronym “GROUCH” : Generalized maculo- popular.　Grover’s disease and other papulo-vesicular eruptions, livedo Reticularis, Other eruptions, Urticarial, and CHilblain-like.　Patients with chilblain-like lesions were younger and had a lower incidence of systemic symptoms.　Purpuric and livedoid lesions have been suggested to occur more frequently in elderly patients with severe COVID-19.

COVID-19 often leaves sequelae that last weeks to months after initial recovery.　It was estimated that 80％ of the infected patients developed one or more long-term symptoms.　The five most common symptoms were fatigue （58％）, headache （44％）, attention disorder （27％）, hair loss （25％）, and dyspnea （24％）.　A major cause of hair loss after COVID-19 is considered as telogen effluvium, defined by diffuse hair loss after the systemic stress or infections.　Most patients with hair loss recovers within 6 months.

Skin reactions have been reported after COVID-19 vaccination as well.　The most reported cutaneous finding was a delayed large local reaction “COVID-arm” a median of 7 days after vaccine.　The pathophysiological mechanism is still unknown, but it is overwhelmingly common in women, suggesting a cross-reaction between polyethylene glycol, a component of cosmetics, and injection components.　In additions, there have been reports of skin rashes similar to those after COVID-19 infection and the aggravation of psoriasis or other skin conditions.

The mechanism of the cutaneous manifestations is still unclear.　We must remember to ask about a history of COVID-19 infection and vaccination status at the time of consultation.

Coronavirus disease-2019 （COVID-19） induces of multi-organs damage including heart, vessels, and lung neurological systems in addition to respiratory disorders, causing subsequent complications.　Patients with cardiovascular damage induced by COVID-19 show ischemic heart disease, arrhythmias, and venous thromboembolism, resulting in death.　Patients with a medical history of hypertension, diabetes, and coronary artery disease are associated with an increased rate of aggravation and mortality.　It is very important to prevent the onset of cardiovascular complications caused by COVID-19, however, there are no therapeutics for them and new treatments and therapeutic agents need to be developed.　Kampo medicine is a traditional Japanese herbal medicine and has been attracting attention in the treatment of COVID-19.　This article outlines the pathophysiological findings of COVID-19-related cardiovascular complications and the potential effect of Kampo as supportive care against it.

Atrial fibrillation （AF） is one of the most common arrhythmia.　Various tools such as portable electrocardiogram （ECG） and implantable cardiac monitor have been available for diagnosis of AF.　In addition, the treatment for AF has progressed remarkably in accompany with the development of anticoagulant therapy and catheter ablation.　However, it remains unknown about the pathophysiology of AF such as inflammation.　In this regard, there is still room for the further progress in diagnostic and therapeutic methods for AF.　We reported previously that local production of pentraxin （PTX） 3 in the left atrium might reflect the local inflammation of AF.　In addition, we also reported that local production of microRNA （miR）-328 in the left atrium might be involved in the process of atrial remodeling in patients with AF.　Based on these results, it is suggested that plasma concentrations of PTX3 or miR-328 might be used as a new biomarker for AF.　For the development of preventive strategies, the ability to identify risk markers for new-onset AF is critical.　We have shown that a new combined score including age, premature atrial contraction count, maximum RR interval, and left atrial diameter could help characterize the risk of new-onset AF.　Activated factor X （FXa）, which contributes to chronic inflammation via protease-activated receptor 2 （PAR-2）, might play an important role in AF arrhythmogenesis.　We have recently shown that angiotensin II-treated PAR-2 deficient mice had a lower incidence of AF and less atrial fibrosis compared to wild-type mice treated with angiotensin II.　We also have shown that rivaroxaban, but not warfarin, reduced AF inducibility and collagen volume fraction in the atrium.　These findings suggested the possibility of Xa inhibitors as therapeutic agents for the onset and progression of AF through the new mechanism.　I would like to continue working on the development of new diagnostic and therapeutic methods for arrhythmia including AF.

Gastroesophageal reflux disease （GERD）, classified into reflux esophagitis （RE） and nonerosive reflux disease, is one of the most common upper gastrointestinal disorders worldwide and may decrease quality of life.　Recently, the prevalence of GERD, including RE, has been increasing and was approximately 8-30% in the world, and there may be approximately 10-15 million patients with RE in Japan.　RE is a major risk factor for Barrett’s esophagus, which is the precursor to esophageal adenocarcinoma.　Therefore, prevention of RE is important for the prevention of esophageal adenocarcinoma.　Additionally, the effective countermeasure of RE is essential for the prevention of RE because there are many high-risk patients for RE, such as those with obesity, metabolic syndrome, metabolic dysfunction, and unfavorable lifestyle habits.　We herein introduced our several research about the extraction of high-risk patients for the development RE.　From our research, in addition to conventional reported risk factors related with RE, distinction of individuals based on the severity of metabolic syndrome, qualitative assessment of visceral fat, and several metabolites related with RE maybe important for the prevention of RE.　As regards alcohol intake, although the influence of alcohol consumption on RE was different between men and women, age and drinking status such as quantity and frequency should be assessed when considering the prevention of RE.　We want to contribute to a decrease of patients with esophageal adenocarcinoma by continuing study for RE.

The presence of metastasis to lymph node and distant organ before lung cancer treatment has a great impact on the selection of an appropriate treatment strategy and on the prognosis.　FDG-PET has been developed as a diagnostic imaging modality that can sensitively detect malignant lesions with accelerated glucose metabolism, and is now widely used not only for the stage diagnosis of lung cancer but also for the diagnosis of recurrence and evaluation of therapeutic effects.　Chest CT is a common diagnostic imaging method for N-factor diagnosis, which is important in the diagnosis of lung cancer, but there are many false negatives.　FDG-PET is considered to have a better ability to diagnose lymph nodes than CT, but nonspecific FDG accumulation of lymph nodes due to chronic inflammation of the hilum and mediastinum is often observed.　Moreover, the presence of micro lymph node metastasis could reduce the ability of diagnosing lymph node metastasis.　With the findings on FDG-PET, unexpected lymph node metastasis or distant metastasis may be found in clinical practices, and treatment plan may be changed.　In recent years, the development and progress of PET devices such as total-body PET scanner have progressed, and dynamic imaging after FDG administration are in the spotlight.　In this review article, I make an introduction for the research and future prospects aimed at clinical practical application, including my experiments.

Diabetic nephropathy （DN） has been a leading cause of the initiation of dialysis in Japan.　We have concentrated on the research on the pathogenesis of DN and focused on the relevant role of proximal tubular （PT） cells based on the concept that DN is a metabolic disease on the kidney.　We have identified Sirtuin molecule that was shown to be related to the lifespan of various organisms as a player in the initiation of DN in the early stage before the onset albuminuria.　We have established the working hypothesis “Tubular-glomerular interaction”.　Another important molecule which draws an attention in this field is sodium-coupled glucose co-transporter 2 （SGLT2） which is expressed in PT and reabsorbs glucose from primary filtrate from the glomerulus.　The recent clinical trials using SGLT2 inhibitor demonstrated the renoprotective effects on the DN as well as non-DN chronic kidney disease （CKD）.　At present, SGLT2 inhibitor can be prescribed for the treatment to DN as well as non-DN CKD.　Finally, mineralocorticoid receptor （MR） antagonist （MRA） is another reagent for the treatment of DN.　Non-epithelial cells in the kidney expresses MR such as mesangial dells, podocytes, or glomerular endothelial cells.　Last year it was published that MRA can retard the progression of DN and reduced the renal specific outcomes.　MRA, finerenone, became available for the treatment of DN.　Before that we have reported that the high serum aldosterone levels are an independent risk factors for the progression of CKD and MRA can reduce eGFR decline of CKD patients.　The future picture of kidney disease will change profoundly owing to the newly developed drug, such as SGLT2 inhibitor or MRA.　I have now challenged to develop new health-care system for the identification of CKD patients at the early stage.

The purpose of this study was to clarify the current status of nursing practice for elderly cancer patients with dementia receiving treatment in acute care hospitals and related factors.　An anonymous， self-administered questionnaire survey was conducted from May to July 2021， involving 400 people with experience of providing nursing care for elderly cancer patients with dementia.　Factor analysis identified <considering situations where patients have difficulty in managing their own safety> and <making arrangements to help patients maintain ordinariness> as factors of self-evaluation of nursing practice for elderly cancer patients with dementia receiving treatment in acute care hospitals.　Such evaluation was influenced by <years of nursing experience>， <years of providing nursing care for elderly cancer patients with dementia>， <participation in study groups/training seminars on dementia>， <knowledge of dementia>， <status of nursing practice for dementia>， and <ethical behavior>.

Background :

Retinoblastoma （RB） occurs at a very young age.　Since the disease is diagnosed at an early age, the family is responsible for the care of the childʼs disease acceptance.

Objective : This study aims to explore the parenting process of children with RB toward disease acceptance.

Methods : Parents of eleven children with RB living in Japan were interviewed, and the data were analyzed using the Modified Grounded Theory Approach of Kinoshita （M-GTA）.

Results : There were twenty-one concepts representing the process of parenting a child with RB while guiding him or her toward disease acceptance, and nineteen of them were classified into

ten categories based on semantic similarities.　The two other concepts showed similar interpretability to categories.　These categories and concepts were summarized into two core categories :

“Helping the child develop a positive mindset to define the disease as a part of him/herself” and

“Paving the way in advance for the child to live comfortably when his or her living space expands”.

Conclusions : In a cyclical framework of parenting, consisting of two core categories described

in Results, the parents coordinated these two approaches while maintaining balance by “Avoiding saying anything that does not need to be said” and established their process of parenting a child

with RB while guiding him or her toward disease acceptance, according to their household situation.　The results suggest the necessity of recognizing that in childhood-onset cancers, such as RB,

and diseases involving genetic issues, problems tend to occur not only during the treatment period but also at the time of life events and providing support from a comprehensive perspective.

The COVID-19 pandemic has profoundly changed medical student clinical practice and limited hospital clinical practice.　In order to make student training more meaningful, we have introduced medical education using a laparoscopic simulator.　We conducted a student questionnaire on the usefulness of this training and evaluated the degree of understanding.　For students who were able to practice at the hospital, they practiced using a laparoscopic simulator （Lap Mentor™）.　A questionnaire survey was conducted on the presence or absence of interest in surgery.　Student understanding of laparoscopic surgery improved 100％.　91％ understood the surgical procedure, 91％ improved technique and 97％ understood pelvic anatomy.　In the training at Lap Mentor™, medical students were able to experience surgery while viewing images of the inside of the pelvis, which served as a means to increase their interest in surgery and obstetrics and gynecology.

A female patient in her 60s visited her previous doctor because of a right cervical mass that exist for 7 years and gradually increased in size.　As she was suspected of cervical lymph node metastasis of thyroid cancer, she was referred to our hospital.　At the initial visit, a 5-cm right cervical mass and enlargement of the right lobe of the thyroid gland were observed.　Fine needle aspiration cytology was performed on both, but no malignant findings were observed.　To confirm the diagnosis and improve the patient’s appearance, a right lobectomy of the thyroid gland and resection of the right cervical mass were performed.　A rapid intraoperative histological examination of the cervical mass revealed a schwannoma.　The right thyroid tumor was diagnosed as follicular adenoma.　Her postoperative course was good, and after several years of follow-up, patient consultation was terminated.

Neurolemmoma is a benign tumor arising from Schwann cells in the nerve sheath, and it occurs frequently throughout the head and neck region, with 25%-45% of cases occurring in this region.　Cervical schwannomas are characterized by irritation of the vagus nerve, brachial plexus, and sympathetic nerves.　However, many patients present with only a painless neck mass, as in this case.　Although the mass can be diagnosed by puncture aspiration cytology in some cases, sufficient specimens are often unavailable, and the diagnosis is made preoperatively in about half of all cases.

Differential diagnoses of an anterior cervical mass include malignant lymphoma, cervical lymph node metastases of malignant tumors, submandibular gland tumors, and tuberculous lymph node metastases.　In this patient, we also considered lymph node metastasis of thyroid cancer.　However, a histological examination did not detect malignancy in either the thyroid gland or neck mass, and we considered that the thyroid follicular adenoma and the cervical schwannoma occurred independently.

We report our experience of cervical schwannoma combined with thyroid tumor which was suspected of lymph node metastasis of thyroid cancer.

A woman in her 80s who was diagnosed with multiple thyroid tumors and subclinical hyperthyroidism 1 year previously was referred to our outpatient clinic due to deteriorated hyperthyroidism.　She was diagnosed with dilated cardiomyopathy 4 years ago.　Her cardiac function has been stabilized with medical conservative treatment.　Blood autoantibody levels, including TSAb and TRAb, were within normal ranges.　Ultrasonography and computed tomography revealed multiple tumor lesions in both thyroid lobes.　Tc-99m scintigraphy showed multiple hot nodules in both thyroid lobes.　Because the patient’s thyroid function had deteriorated, we selected surgical total thyroidectomy rather than radioisotope treatment as the most appropriate treatment.　Histopathological examination of the resected specimen demonstrated multiple nodular lesions with a maximum size of 23 mm and a microlesion of papillary carcinoma 2 mm in diameter in the thyroid.　A few days after surgery, thyroid function blood levels declined to the normal range.

As a second-year resident at the University of Tokushima Hospital, I report on my experience of overseas training in the Philippines under the training program of the National Institute of Health Sciences.　The National Institute of Health Sciences is an institution that conducts education, investigation, and research related to health, medical care, and welfare, and I trained for two months in the Department of Clinical Training in Community Health, Specialty Course III.　In addition to the out-of-hospital training at the Ministry of Health, Labour and Welfare, Chiba

Prefectural Government, and National Institute of Infectious Diseases, the one-week overseas training in the Philippines （Manila） consisted mainly of lectures and training on mosquito-borne infectious diseases, zoonosis, and parasites at the University of the Philippines, Philippine General Hospital, Suburban Health Center, and WHO Western Pacific Office.　Infectious diseases are very different from those in Japan.　The actual observation made us understand that rabies and parasitic infections are raging in the Philippines due to the sanitary conditions of the living environment, which is very different from that of Japan.　By learning about the medical system at overseas medical facilities, we were able to rethink deeply about the merits of the Japanese medical system and the direction it should take in the future from various perspectives.