The Society of Associate and Assistant Professors, Shinshu University School of Medicine, voluntarily held a miniworkshop for medical education in December 2006.Subjects were students' motivation, integrated clinical lecture, early exposure and research experience program.Based on the proposals from this meeting, following changes/additions were made to the 2007 curriculum.
1) Clinical case presentation lectures for a combination of 5th and 6th grades students to raise the level of students' awareness and motivation.
2) Lectures on doctors'career development for women to nourish professionalism.
3) Doctors'office or hospital Visiting programs for freshmen to provide a chance to encounter the role model.

The importance of cooperation among the staffs of various medical specialties has been recognized.However, medical students have little chance to study with students of other specialties.We planned and held an interdisciplinary freshman seminar based on problem-based group learning for health science students.
1) All freshmen entering the Shinshu University School of Medicine were divided into 20 groups and participated in a group-learning program.
2) Students watched video material focusing on medical communication and were asked to investigate and discuss this issue in greater detail to deepen their understanding.
3) Questionnaires filled out by students after the course revealed that most students were satisfied with the program because they could deepen their partnership with students of other specialties but were unsatisfied with the program's tight schedule and the inefficiency of discussions.
4) Many instructors felt that the number of students in each group (12 or 13) was too large for effective group discussion.
5) This program helped students understand the importance of communication in medicine but did not encourage students to study for themselves.

  Pretests and posttests in the field of preventive medicine and public health were administered to third–year medical students of Shinshu University School of Medicine. This study aimed to determine whether pretest scores or posttest scores correlated with the term–end examination scores.
1）Pretests and posttests were administered 7 times to 112 third–year medical students, and the term–end examination was given in the first semester of the 2010 academic year.
2）Correlations were determined between pretest scores, posttest scores, the difference between pretest and posttest scores, and term–end examination scores. In addition, students were divided into quartiles in accordance with the pretest scores, and the posttest and term–end examination scores were compared among these quartiles.
3）The pretest scores significantly correlated with the posttest and term–end examination scores. The posttest and term–end examination scores were significantly higher in the fourth quartile（the highest pretest score quartile）than in the first quartile（the lowest pretest score quartile）.
4）The posttest scores did not correlate with the term–end examination scores.
5）Thus, we concluded that the pretest score rather than the posttest score is a useful predictor of the term–end examination score.

1) In 2004, Shinshu University School of Medicine started a program for third-year medical students to experience nursing services during both the day and night shifts. The program included lectures on nursing sciences before practice and debriefing sessions after practice.2) Most students viewed this program favorably and felt that the night-shift training was particular meaningful. They also had favorable opinions about the nurses who taught them.3) Some practical issues remain to be solved, such as security during the night shift and the possible excessive burden upon nurses.

Purpose: Does longer study time motivate students to learn and make them feel a sense of accomplishment? Whilst “Human Biology,” one of the required courses in the first year of the medical school, was in need of a total course design reformation to make a shift from teaching to learning, it was necessary to examine whether longer study time is effective for better learning outcomes.　Methods: To get students to learn outside of class, we flipped the course. Since the scores from weekly quizzes, which are held at the beginning of every class, and mid-term and final exams were returned to the students, fully calculated and strictly applied to their grades, students became motivated to study before class. During class time, lessons were taught in the active learning style. We used covariance structure analysis to examine the relationship between the out of class learning design, the syllabus reformation, students’ learning attitudes in the class, and their sense of accomplishment.　Results: Study time outside of class increased from 4 hours per week in 2013 to 10 hours per week in 2016, and the students became more satisfied with the course. Our analysis shows that this well-structured syllabus and designing of lessons made the students study more both inside and outside of class, and allowed students to achieve the higher goals of the course.　Conclusion: Designing out of class learning and incorporating it well with assessment resulted in longer study time and a stronger sense of accomplishment.

Endoscopic management of bile duct stones is now the standard of care, but challenges remain with difficult bile duct stones. There are some known factors associated with technically difficult bile duct stones, such as large size and surgically altered anatomy. Endoscopic mechanical lithotripsy is now the standard technique used to remove large bile duct stones, but the efficacy of endoscopic papillary large balloon dilatation (EPLBD) and cholangioscopy with intraductal lithotripsy has been increasingly reported. In patients with surgically altered anatomy, biliary access before stone removal can be technically difficult. Endotherapy using two new endoscopes is now utilized in clinical practice: enteroscopy-assisted endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided antegrade treatment. These new approaches can be combined with EPLBD and/or cholangioscopy to remove large bile duct stones from patients with surgically altered anatomy. Since various endoscopic procedures are now available, endoscopists should learn the indications, advantages and disadvantages of each technique for better management of bile duct stones.

BACKGROUND/AIMS: In distal malignant biliary obstruction, an antireflux metal stent (ARMS) with a funnel-shaped valve is effective as a reintervention for metal stent occlusion caused by reflux. This study sought to evaluate the feasibility of this ARMS as a first-line metal stent. METHODS: Patients with nonresectable distal malignant biliary obstruction were identified between April and December 2014 at three Japanese tertiary centers. We retrospectively evaluated recurrent biliary obstruction and adverse events after ARMS placement. RESULTS: In total, 20 consecutive patients were included. The most common cause of biliary obstruction was pancreatic cancer (75%). Overall, recurrent biliary obstruction was observed in seven patients (35%), with a median time to recurrent biliary obstruction of 246 days (range, 11 to 246 days). Stent occlusion occurred in five patients (25%), the causes of which were sludge and food impaction in three and two patients, respectively. Stent migration occurred in two patients (10%). The rate of adverse events associated with ARMS was 25%: pancreatitis occurred in three patients, cholecystitis in one and liver abscess in one. No patients experienced non-occlusion cholangitis. CONCLUSIONS: The ARMS as a first-line biliary drainage procedure was feasible. Because the ARMS did not fully prevent stent dysfunction due to reflux, further investigation is warranted.
Arm ; Asian Continental Ancestry Group ; Cholangiopancreatography, Endoscopic Retrograde ; Cholangitis ; Cholecystitis ; Drainage ; Humans ; Liver Abscess ; Pancreatic Neoplasms ; Pancreatitis ; Pilot Projects* ; Retrospective Studies ; Sewage ; Stents*

BACKGROUND/AIMS: To determine the nutritional markers important for assessing the degree of pancreatic insufficiency due to chronic pancreatitis in routine clinical practice. METHODS: A total of 137 patients with chronic pancreatitis were followed up for more than 1 year. They were divided into two groups: a pancreatic diabetes mellitus (DM) group, consisting of 47 patients undergoing medical treatment for DM of pancreatic origin, and a nonpancreatic DM group, consisting of 90 other patients (including 86 patients without DM). Serum albumin, prealbumin, total cholesterol, cholinesterase, magnesium, and hemoglobin were compared between the two groups. RESULTS: The total cholesterol was significantly lower in the pancreatic than the nonpancreatic DM group (164 mg/dL vs 183 mg/dL, respectively; p=0.0028). Cholinesterase was significantly lower in the former group (263 U/L vs 291 U/L, respectively; p=0.016). Among the 37 patients with nonalcoholic pancreatitis, there was no difference in the cholinesterase levels between the pancreatic and nonpancreatic (296 U/L vs 304 U/L, respectively; p=0.752) DM groups, although cholesterol levels remained lower in the former (165 mg/dL vs 187 mg/dL, respectively; p=0.052). CONCLUSIONS: Cholinesterase levels are possibly affected by concomitant alcoholic liver injury. The total cholesterol level should be considered when assessing pancreatic insufficiency due to chronic pancreatitis.
Adult ; Aged ; Aged, 80 and over ; Cholesterol/*blood ; Cholinesterases/blood ; Diabetes Mellitus, Type 2/complications ; Exocrine Pancreatic Insufficiency/*blood/etiology ; Female ; Follow-Up Studies ; Humans ; Liver Cirrhosis, Alcoholic/blood ; Male ; Middle Aged ; Nutritional Status ; Pancreas/enzymology ; Pancreatitis, Alcoholic/blood/complications ; Pancreatitis, Chronic/blood/*complications ; Serum Albumin/analysis

BACKGROUND/AIMS: Stent migration occurs frequently, but the prevention of complications resulting from covered self-expandable metal stents (C-SEMSs) remains unresolved. We prospectively assessed a newly developed C-SEMS, a modified covered Zeo stent (m-CZS), in terms of its antimigration effect. METHODS: Between February 2010 and January 2011, an m-CZS was inserted into 42 patients (31 initial drainage cases and 11 reintervention cases) at a tertiary referral center and three affiliated hospitals. The laser-cut stent was flared for 1.5 cm at both ends, with a 1 cm raised bank located 1 cm in from each flared end. The main outcome of this study was the rate of stent migration, and secondary outcomes were the rate of recurrent biliary obstruction (RBO), the time to RBO, the frequencies of complications, and overall survival. RESULTS: Of the 31 patients with initial drainage, stent migration occurred in four (12.9%, 95% confidence interval, 5.1% to 29.0%), with a mean time of 131 days. RBO occurred in 18 (58%), with a median time to RBO of 107 days. Following previous C-SEMS migration, seven of 10 patients (70%) did not experience m-CZS migration until death. CONCLUSIONS: m-CZSs with antimigration properties effectively, although not completely, prevented stent migration after stent insertion.
Aged ; Aged, 80 and over ; Alloys ; Carcinoma/*complications ; Cholestasis/etiology/*therapy ; Digestive System Neoplasms/*complications ; Drainage ; Equipment Design ; Feasibility Studies ; Female ; Humans ; Kaplan-Meier Estimate ; Lymphatic Metastasis ; Male ; Middle Aged ; *Prosthesis Failure ; Recurrence ; Reoperation ; *Stents/adverse effects ; Time Factors

Background/Aims: Recently, a three-plane symmetric nee-dle with Franseen geometry was developed for endoscopic ultrasound-guided fine needle biopsy (EUS-FNB). In this ret-rospective study, tissue acquisition per pass was compared between 22-gauge Franseen FNB and standard fine needle aspiration (FNA) needles in patients with solid pancreatic le-sions. Methods: Consecutive patients who underwent EUSFNA or EUS-FNB for solid pancreatic lesions between Octo-ber 2014 and March 2018 were retrospectively studied. The tissue acquisition rate and the diagnostic performance per session, per pass, and at first pass were compared. Results: A total of 663 passes (300 by the FNB needle and 363 by the standard FNA needle) were performed in 154 patients (71 FNB and 83 FNA). The tissue acquisition rate per session and at first pass in the FNB and FNA groups was 100% and 95% (p=0.13) and 87% and 69% (p=0.007), respectively. The multivariate analysis revealed that among the patients, EUS-FNB (odds ratio, 3.07; p=0.01) was associated with a higher first-pass tissue acquisition rate. While the tissue ac-quisition rate reached a plateau after the 4th pass with FNA, it reached a plateau after the 2nd pass with FNB. Among the 129 malignant cases, the histological tissue acquisition rate per session was similar (100% and 94%), but the sensitivity by histology alone per session was higher for FNB than for FNA (93% and 73%, p<0.01). Conclusions The results of our retrospective analysis indicated that compared with a standard FNA needle, a 22-gauge Franseen FNB needle was associated with a higher first-pass tissue acquisition rate.