To evaluate the achievement of medical or dental education the criterion-referenced tests must be used. In this paper we proposed a new setting method of the difficulty level of the multiple-choice questions (MCQs) used in the National Board Examinations for Medical or Dental Practice. The difficulty levels should be determined by using the idea of the “Correct Terminal” which is consisting of the minimal sets of items to answer correctly. The difficulty level, the percentage of correct answer and the phi-coefficient of a question vary depending on the arrangement of the items in the question. Therefore, it is very difficult to get the real evaluation by the criterion-referenced measurement as far as we use MCQs. We should deepen our understanding of the limit of MCQ tests rather than we might expect the limitless possibility.

Background: Ischemic stroke can occur in patients with an underlying or undiagnosed malignancy. We aim to report the clinical features of ischemic stroke patients in whom a previously undiagnosed cancer was detected after stroke onset. Methods: Clinical and laboratory records of 28 consecutive ischemic stroke patients with cancer were reviewed retrospectively. The analysis was made focused on the differences between patients who were already diagnosed as having cancer before ischemic stroke (Group A) and those in whom a previously undiagnosed cancer was detected after ischemic stroke onset (Group B). Results: There were 18 patients in the Group A and 10 in the Group B. In Group B patients, the indicators that led to the detection of cancer were as follows: ascites (n=2), liver enzyme elevation (n=2), anemia (n=2), hematemesis (n=1), hematochezia (n=1), and sore throat (n=1), and autopsy (n=1). Nine of the 10 patients (90%) in Group B, and 6 of the 18 (33%) in Group A had a gastrointestinal cancer. In Group B, 8 of the 9 patients showed elevated serum carcinoembryonic antigen (CEA) and/or carbohydrate antigen 19-9 (CA19-9). Stroke relapse, prognosis, diffusion-weighted imaging patterns and laboratory fi ndings were not different between the 2 groups. Conclusions: Gastrointestinal cancer was frequent in ischemic stroke patients with newly diagnosed malignancy after stroke onset in this study among Japanese patients. Physicians should be aware that underlying cancer may be present particularly in ischemic stroke patients whose stroke etiology is unclear or who have anemia or liver dysfunction. In such cases, measurements of CEA and CA19-9 levels are easy and useful screening for the detection of occult malignancies.

Background/Aims: Difficult biliary cannulation is an important risk factor for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Therefore, this study aimed to identify the factors that predict difficult cannulation for common bile duct stones (CBDS) to reduce the risk for PEP. Methods: This multicenter retrospective study included 1,406 consecutive patients with native papillae who underwent ERCP for CBDS. Factors predicting difficult cannulation for CBDS were identified using univariate and multivariate analyses. Results: Univariate analysis showed that six factors significantly predicted difficult cannulation: ERCP performed by non-expert endoscopists, low-volume center, absence of acute cholangitis, normal serum bilirubin, intradiverticular papilla, and type of major duodenal papilla. Multivariate analysis identified ERCP performed by non-expert endoscopists (odds ratio [OR], 2.5; p<0.001), low-volume center (OR, 1.6; p<0.001), intradiverticular papilla (OR, 1.3; p=0.007), normal serum bilirubin (OR, 1.3; p=0.038), and absence of acute cholangitis (OR, 1.3; p=0.049) as factors significantly predicting difficult cannulation for CBDS. Conclusions Initial cannulation by an experienced endoscopist, early rescue cannulation, or early takeover by an experienced endoscopist should be considered when performing ERCP for CBDS in the presence of factors predicting difficult cannulation.

Background/Aims: This study aimed to examine the synergistic effect of independent risk factors on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Methods: This multicenter retrospective study included 1,273 patients with native papillae who underwent ERCP for bile duct stones in Japan. Independent PEP risk factors were identified using univariate and multivariate analyses. Significant risk factors for PEP in the multivariate analysis were included in the final analysis to examine the synergistic effect of independent risk factors for PEP. Results: PEP occurred in 45 of 1,273 patients (3.5%). Three factors including difficult cannulation ≥10 minutes, pancreatic injection, and normal serum bilirubin level were included in the final analysis. The incidences of PEP in patients with zero, one, two, and three factors were 0.5% (2/388), 1.9% (9/465), 6.0% (17/285), and 12.6% (17/135), respectively. With increasing risk factors for PEP, the incidence of PEP significantly increased (1 factor vs. 2 factors, p=0.006; 2 factors vs. 3 factors, p=0.033). Conclusions As the number of risk factors for PEP increases, the risk of PEP may not be additive; however, it may multiply. Thus, aggressive prophylaxis for PEP is strongly recommended in patients with multiple risk factors.

Osteoclasts are bone-specific multinucleated cells generated by the differentiation of monocyte/macrophage lineage precursors. Regulation of osteoclast differentiation is considered an effective therapeutic approach to the treatment of bone-lytic diseases. Periodontitis is an inflammatory disease characterized by extensive bone resorption. In this study, we investigated the effects of sodium fluoride (NaF) on osteoclastogenesis induced by Porphyromonas gingivalis, an important colonizer of the oral cavity that has been implicated in periodontitis. NaF strongly inhibited the P. gingivalis-induced alveolar bone loss. That effect was accompanied by decreased levels of cathepsin K, interleukin (IL)-1β, matrix metalloproteinase 9 (MMP9), and tartrate-resistant acid phosphatase, which were up-regulated during P. gingivalis-induced osteoclastogenesis. Consistent with the in vivo anti-osteoclastogenic effect, NaF inhibited osteoclast formation caused by the differentiation factor RANKL (receptor activator of nuclear factor κB ligand) and macrophage colony-stimulating factor (M-CSF). The RANKL-stimulated induction of the transcription factor nuclear factor of activated T cells (NFAT) c1 was also abrogated by NaF. Taken together, our data demonstrate that NaF inhibits RANKL-induced osteoclastogenesis by reducing the induction of NFATc1, ultimately leading to the suppressed expression of cathepsin K and MMP9. The in vivo effect of NaF on the inhibition of P. gingivalis-induced osteoclastogenesis strengthens the potential usefulness of NaF for treating periodontal diseases.
Acid Phosphatase ; drug effects ; Alveolar Bone Loss ; microbiology ; prevention & control ; Animals ; Anti-Bacterial Agents ; therapeutic use ; Anti-Inflammatory Agents ; therapeutic use ; Bacteroidaceae Infections ; microbiology ; prevention & control ; Bone Density Conservation Agents ; therapeutic use ; Cathepsin K ; drug effects ; Interleukin-1beta ; drug effects ; Interleukin-6 ; analysis ; Interleukin-8 ; drug effects ; Isoenzymes ; drug effects ; Macrophage Colony-Stimulating Factor ; drug effects ; Male ; Matrix Metalloproteinase 9 ; drug effects ; Osteoclasts ; drug effects ; Periodontitis ; microbiology ; prevention & control ; Porphyromonas gingivalis ; drug effects ; RANK Ligand ; drug effects ; Rats ; Rats, Sprague-Dawley ; Sodium Fluoride ; therapeutic use ; Tartrate-Resistant Acid Phosphatase ; Transcription Factors ; drug effects ; X-Ray Microtomography ; methods