We performed a questionnaire survey of 199 graduates regarding surgical clerkships to help select future clinical trainingmethods for fifth-year medical students. Many of the graduates understood the significance of clerkships, and 70%were able to benefit from their participation in clinical training. They approved of clerkships, but 22% had critical opinions.Clinical instructors were asked to teach with greater enthusiasm, to be easier to talk with, and to have a deeperknowledge of diseases. Graduates who attended very few lectures in the fourth year were less likely to expect clinical instructorsto teach well. Most graduates believed that clinical instructors should have at least 5 years' clinical experience.These results suggest that all faculties should continue to place a greater emphasis on education and that faculty developmentshould be expanded.

BACKGROUND: Estrogens exert preferable effects on bone metabolism through two estrogen receptors (ERs), ER1 and ER2, which activate the transcription of a set of genes as ligand-dependent transcription factors. Thus, growth factors and hormones which modulate ER expression in the bone, if any, may possibly modulate the effect of estrogens on bone metabolism. However, research as to which of these molecules regulate the expression of ERs in osteoblasts has not been well documented. METHODS: A reporter assay system developed in this study was used to explore molecules that modulate ER1 expression in MC3T3-E1 osteoblastic cells. Gene expression was analyzed by reverse transcription-polymerase chain reaction. RESULTS: A pilot study using the reporter system revealed that bone morphogenetic protein (BMP)-2 negatively regulated ER1, but not ER2, expression in MC3T3-E1 cells. Consistently, estradiol-induced reporter activity via an estrogen responsive element was strongly suppressed in MC3T3-E1 cells pretreated with BMP-2. CONCLUSIONS: BMP-2 desensitizes osteoblastic cells to estrogen through downregulation of ER1 expression.
Bone Morphogenetic Proteins ; Down-Regulation* ; Estrogen Receptor alpha* ; Estrogens* ; Gene Expression ; Intercellular Signaling Peptides and Proteins ; Metabolism ; Osteoblasts* ; Pilot Projects ; Receptors, Estrogen ; Transcription Factors

Laparoscopy-assisted distal gastrectomy (LADG) has been advocated as a minimally invasive operation for early gastric cancer which needs regional lymph node resection. However, since it is technically too complicated and difficult to perform all laparoscopic procedures within the abdominal cavity, LADG has not become the standard surgical procedure for early gastric cancer. Moreover, a skin incision of approximately 5cm is required to allow the reconstruction of the digestive tract after gastrectomy. Therefore, we have developed an operative procedure which we call hand-assisted laparoscopic distal gastrectomy (HALDG). In this procedure we make a skin incision of 6cm, and the surgeon inserts his/her left hand into the abdomen to assist the laparoscopic procedure. The surgeon can move his/her left hand freely, to palpate and explore the organs, as in an open surgery. Therefore, the operation time can be shortened. Our results thus far obtained demonstrated that HALDG was as safe and effective as open distal gastrectomy. HALDG assures the patients a better quality of life, --less surgical trauma, less pain, speedy return to dialy life activities. Thus, it is beneficial to the patients with early gastric cancer. We, therefore, advocate the use of HALDG in such cases.
Gastrectomy ; Stomach Cancer ; Hand ; Procedures ; Pulmonary evaluation

Introduction：Intracranial hemorrhage after severe coronavirus disease 2019 (COVID-19) is associated with increased mortality and unfavorable patient outcomes.Case：A man in his 60s with independent activities of daily living (ADL) was diagnosed with COVID-19, and placed on a ventilator on Day (D)-3 and VV-ECMO on D-5. On D-23, an emergency craniotomy was performed for a left acute subdural hematoma. The patient was weaned from VV-ECMO on D-27. On D-33, sitting was initiated. On D-36, the patient was weaned from the ventilator and began exercise therapy. The Glasgow coma score (GCS) was E2V1TM4. Basic movement as assessed by the Functional Status Score for ICU (FSS-ICU) and Barthel Index (BI), was 3 and 0 points, respectively. On D-40, wheelchair use commenced. He began standing with a long leg orthosis on D-50, and began walking on D-53.On D-67, the patient transferred to a convalescent hospital. His GCS was E4V4M6. Generalized cognitive decline and motor paralysis were noted. The right upper limb, hand, and lower limb were assessed as Brunnstrom recovery stage IV, V, and V, respectively. The patient's grip strength was 11.9 kg [right] and 18.3 kg [left]. His knee extensor strength was 0.13 kgf/kg [right] and 0.19 kgf/kg [left]. The FSS-ICU, walking speed, and BI were 21 points, 0.17 m/sec, and 40 points, respectively. The patient was discharged on D-240.Discussion：The Early Mobilization and Rehabilitation Expert Consensus reports that early mobilization and active exercise can improve ADL at discharge. Our patient was weaned from VV-ECMO as soon as possible and practiced standing and walking with a long leg orthosis, resulting in a better outcome.

Objective：Independent walking is crucial for critically ill intensive care unit (ICU) patients to return home. We aimed to investigate the characteristics of patients with severe COVID-19 who could walk independently upon discharge.Methods：This study included 26 patients with severe COVID-19 who were admitted to our ICU between April 2020 and September 2023. Patient background, ICU progress, and outcome-related events were compared between the independent and dependent groups.Results：Compared to the dependent group, the independent group had a lower pre-admission clinical frailty scale score (2.0 [2.0-2.5] vs. 3.0 [2.5-3.0]) and shorter time to start standing (7 days [6-9] vs. 13 days [11-17]) and walking (10 days [8-11] vs. 20 days [13-50]). Functional status scores in the ICU (28±5. vs. 12±9) and ICU mobility scale (8 [8-10] vs. 4 [3-7]) were higher upon ICU discharge, while the duration of ventilator management (7 [4-9] vs. 9 [8-19] days) and ICU length of stay (10 [10-14] vs. 17 [15-23] days) were shorter. They had fewer complications (2 [18.2％] vs. 12 [80.0％]) and higher return-to-home rates (10 [90.9％] vs. 2 [13.3％]).Conclusion：Patients with severe COVID-19 who walked independently upon discharge had lower pre-admission frailty, fewer complications, shorter ventilator management duration, early mobilization, higher physical activity upon ICU discharge, shorter ICU stay, and higher return-to-home rates.

Introduction：Intracranial hemorrhage after severe coronavirus disease 2019 (COVID-19) is associated with increased mortality and unfavorable patient outcomes.Case：A man in his 60s with independent activities of daily living (ADL) was diagnosed with COVID-19, and placed on a ventilator on Day (D)-3 and VV-ECMO on D-5. On D-23, an emergency craniotomy was performed for a left acute subdural hematoma. The patient was weaned from VV-ECMO on D-27. On D-33, sitting was initiated. On D-36, the patient was weaned from the ventilator and began exercise therapy. The Glasgow coma score (GCS) was E2V1TM4. Basic movement as assessed by the Functional Status Score for ICU (FSS-ICU) and Barthel Index (BI), was 3 and 0 points, respectively. On D-40, wheelchair use commenced. He began standing with a long leg orthosis on D-50, and began walking on D-53.On D-67, the patient transferred to a convalescent hospital. His GCS was E4V4M6. Generalized cognitive decline and motor paralysis were noted. The right upper limb, hand, and lower limb were assessed as Brunnstrom recovery stage IV, V, and V, respectively. The patien's grip strength was 11.9 kg [right] and 18.3 kg [left]. His knee extensor strength was 0.13 kgf/kg [right] and 0.19 kgf/kg [left]. The FSS-ICU, walking speed, and BI were 21 points, 0.17 m/sec, and 40 points, respectively. The patient was discharged on D-240.Discussion：The Early Mobilization and Rehabilitation Expert Consensus reports that early mobilization and active exercise can improve ADL at discharge. Our patient was weaned from VV-ECMO as soon as possible and practiced standing and walking with a long leg orthosis, resulting in a better outcome.

Objective：Independent walking is crucial for critically ill intensive care unit (ICU) patients to return home. We aimed to investigate the characteristics of patients with severe COVID-19 who could walk independently upon discharge.Methods：This study included 26 patients with severe COVID-19 who were admitted to our ICU between April 2020 and September 2023. Patient background, ICU progress, and outcome-related events were compared between the independent and dependent groups.Results：Compared to the dependent group, the independent group had a lower pre-admission clinical frailty scale score (2.0 [2.0-2.5] vs. 3.0 [2.5-3.0]) and shorter time to start standing (seven days [6-9] vs. 13 days [11-17]) and walking (10 days [8-11] vs. 20 days [13-50]). Functional status scores in the ICU (28±5. vs. 12±9) and ICU mobility scale (8 [8-10] vs. 5 [3-7]) were higher upon ICU discharge, while the duration of ventilator management (seven [4-9] vs. nine [8-18] days) and ICU length of stay (10 [10-14] vs. 17 [15-23] days) were shorter. They had fewer complications (two [18.2％] vs. 12 [80.0％]) and higher return-to-home rates (10 [90.9％] vs. two [13.3％]).Conclusion：Patients with severe COVID-19 who walked independently upon discharge had lower pre-admission frailty, fewer complications, shorter ventilator management duration, early mobilization, higher physical activity upon ICU discharge, shorter ICU stay, and higher return-to-home rates.