Objective: To clarify the association between dementia knowledge and attitudes, lifestyle backgrounds, and practical training experiences of nursing students, and examine the basic nursing education for dementia.Participants and Methods: A total of 412 first-to-fourth-year students at Nursing College A participated in the study. A cross-sectional survey was conducted regarding knowledge (15 questions) and attitudes (15 questions) related to dementia.Results: Consent was obtained from 158 individuals (The response rate was 38.3%). Significant items regarding dementia attitudes and cohabitation experiences were identified. Additionally, significant items regarding attitude toward dementia and care providing experiences were identified.Conclusion: Associations among attitude toward dementia, cohabitation experiences, and care providing experiences were determined. Knowledge and attitudes regarding dementia improved with practical training experience.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is useful for diagnosing mediastinal lymph node lesions. Cell blocks prepared from the needle washing fluid and flow cytometry of tissue samples are helpful in making the diagnosis, but the combination of both examinations is not routinely performed. A 77-year-old woman with fever, dyspnea, and anorexia was admitted to our hospital. Computed tomography showed enlarged mediastinal lymph nodes with calcification and left ureteral calculus; however, no focus of infection was identified. We suspected lymph node tuberculosis or malignant lymphoma, and EBUS-TBNA was performed to evaluate the mediastinal lymph node lesions. Because a cell block prepared from the needle rinse fluid was suspicious for malignant lymphoma, we changed the puncture needle from 22 G to 19 G and performed a second EBUS-TBNA. Diffuse large B-cell lymphoma (DLBCL) was diagnosed based on the results of flow cytometry of the EBUS-TBNA samples. Here we report this case of DLBCL in which mediastinal lymph node tuberculosis was suspected and cell block preparation and flow cytometry using EBUS-TBNA specimens were useful for the diagnosis.

We reviewed 7 patients with unsuccessful endoscopic hemostasis using covered self-expandable metal stent (CSEMS) placement for post-endoscopic sphincterotomy (ES) bleeding. ES with a medium incision was performed in 6 and with a large incision in 1 patient. All but 1 of them (86%) showed delayed bleeding, warranting second endoscopic therapies followed by CSEMS placement 1–5 days after the initial ES. Subsequent CSEMS placement did not achieve complete hemostasis in any of the patients. Lateral-side incision lines (3 or 9 o’clock) had more frequent bleeding points (71%) than oral-side incision lines (11–12 o’clock; 29%). Additional endoscopic hemostatic procedures with hemostatic forceps, hypertonic saline epinephrine, or hemoclip achieved excellent hemostasis, resulting in complete hemostasis in all patients. These experiences provide an alert: CSEMS placement is not an ultimate treatment for post-ES bleeding, despite its effectiveness. The lateral-side of the incision line, as well as the oral-most side, should be carefully examined for bleeding points, even after the CSEMS placement.

Background/Aims: Although endoscopic transpapillary gallbladder drainage (ETGBD) has been reported as an alternative procedure for acute cholecystitis, it requires advanced endoscopic techniques. In terms of the certainty of achieving drainage, it remains a challenging procedure. The aim of the current study was to elucidate the practical efficacy of cholangioscopic assistance and to develop a new classification that could be used to evaluate the technical difficulty of ETGBD and provide a theoretical strategy to apply cholangioscopy appropriately for difficult ETGBD. Methods: A total of 101 patients undergoing ETGBD were retrospectively studied. The characteristics and technical outcomes of ETGBD with conventional ETGBD (C-ETGBD) and SpyGlass DS-assisted ETGBD (SG-ETGBD) were evaluated. The characteristics and technique-dependent factors of unsuccessful C-ETGBD/SG-ETGBD were evaluated using the classification based on the steps of the procedure. The predictive factors of successful C-ETGBD/SG-ETGBD were examined. Results: C-ETGBD was successful in 73 patients (72.3%). SG-ETGBD was successful in 11 of 13 patients (84.6%) who had C-ETGBD failure. Optional SG-ETGBD significantly increased the final success rate (94.1%) compared to C-ETGBD alone (p=0.003). ETGBD procedures could be classified into four steps. SG-assistance worked as an excellent troubleshooter in step 1 (failure to identify the cystic duct orifice) and step 2 (failure of guidewire advancement across the downturned angle of cystic duct takeoff). Magnetic resonance cholangiopancreatography could provide predictive information based on the classification. Conclusions Optional SG-ETGBD achieved a significantly higher success rate than C-ETGBD alone. Step classification is helpful for determining the technical difficulty of ETGBD and developing a theoretical strategy to apply cholangioscopy in a coordinated manner.

Background/Aims: Although endoscopic transpapillary gallbladder drainage (ETGBD) has been reported as an alternative procedure for acute cholecystitis, it requires advanced endoscopic techniques. In terms of the certainty of achieving drainage, it remains a challenging procedure. The aim of the current study was to elucidate the practical efficacy of cholangioscopic assistance and to develop a new classification that could be used to evaluate the technical difficulty of ETGBD and provide a theoretical strategy to apply cholangioscopy appropriately for difficult ETGBD. Methods: A total of 101 patients undergoing ETGBD were retrospectively studied. The characteristics and technical outcomes of ETGBD with conventional ETGBD (C-ETGBD) and SpyGlass DS-assisted ETGBD (SG-ETGBD) were evaluated. The characteristics and technique-dependent factors of unsuccessful C-ETGBD/SG-ETGBD were evaluated using the classification based on the steps of the procedure. The predictive factors of successful C-ETGBD/SG-ETGBD were examined. Results: C-ETGBD was successful in 73 patients (72.3%). SG-ETGBD was successful in 11 of 13 patients (84.6%) who had C-ETGBD failure. Optional SG-ETGBD significantly increased the final success rate (94.1%) compared to C-ETGBD alone (p=0.003). ETGBD procedures could be classified into four steps. SG-assistance worked as an excellent troubleshooter in step 1 (failure to identify the cystic duct orifice) and step 2 (failure of guidewire advancement across the downturned angle of cystic duct takeoff). Magnetic resonance cholangiopancreatography could provide predictive information based on the classification. Conclusions Optional SG-ETGBD achieved a significantly higher success rate than C-ETGBD alone. Step classification is helpful for determining the technical difficulty of ETGBD and developing a theoretical strategy to apply cholangioscopy in a coordinated manner.

A 70-year-old man with continuous diarrhea for over 1 month consulted a primary care doctor. He was treated with oral antibiotics and probiotics but his condition worsened. He developed generalized edema and was referred to our hospital. Abdominal ultrasound and computed tomography (CT) scan findings were suggestive of colon cancer with accompanying liver metastasis. Total colonoscopy and endoscopy for pathological diagnosis led to a diagnosis of cancer of the sigmoid colon accompanied with liver metastasis or liver abscess. We planned to perform sigmoidectomy with simultaneous resection of the liver lesion. However, we considered that he was not particularly fit to undergo two concurrent surgeries. Therefore, based on his physical condition, we planned to first do a sigmoidectomy. Before surgery, the fever persisted and a repeat CT scan showed deterioration of the liver lesion. We diagnosed the liver lesion as abscess and performed percutaneous transhepatic abscess drainage (PTAD). Three days after PTAD, we then performed sigmoidectomy. Subsequently, the liver abscess resolved and gradually disappeared. At 5 years after surgery, there has been no recurrence of the cancer or abscess.

Biliary drainage is required for the management of unresectable malignant hilar biliary obstruction (UMHBO), and endoscopic transpapillary drainage is the first-line therapy because it is less invasive. Self-expandable metallic stents (SEMSs) are superior to plastic stents because they have longer stent patency and are more cost-effective. Endoscopic bilateral SEMS placement is technically challenging compared to unilateral placement. However, recent developments in devices and techniques have facilitated bilateral SEMS placement. There are two methods for bilateral hilar SEMS placement for UMHBO: side-by-side (SBS) and stent-in-stent (SIS). Sequential SBS was commonly conducted for bilateral hilar SEMS placement. In a new and thinner delivery system that was developed for SEM placement, two SEMSs could be simultaneously inserted and deployed through the working channel. This new bilateral stenting method enabled us to accomplish simultaneous SBS placement, which increased the success rate of SBS. Insertion of the guidewire and delivery of the second SEMS through the mesh of the first SEMS is challenging in SIS. Newly designed or modified SEMSs that are suitable for SIS have been developed to overcome this challenge, and these SEMSs have facilitated SIS. Uncovered SEMS has been commonly used for hilar SEMS placement, but covered SEMS (CSEMS) is another option for hilar SEMS placement, because CSEMS prevents tumor ingrowth and allows for removal of the stent for re-intervention. Therefore, CSEMS can be used for bilateral SEMS placement in SBS. There are many methods and kinds of SEMS available for bilateral SEMS placement. However, due to lack of evidence, there is no consensus on whether SBS or SIS is optimal for bilateral hilar SEMS placement. In this review, we compared various outcomes between SBS and SIS from previous studies, to clarify which method is better for bilateral SEMS placement for UMHBO.
Cholangiopancreatography, Endoscopic Retrograde ; Cholestasis ; Consensus ; Drainage ; Klatskin Tumor ; Methods ; Plastics ; Self Expandable Metallic Stents ; Stents

BACKGROUND/AIMS: We aimed to evaluate whether the advanced techniques have influenced the minor papilla approach. METHODS: We studied the success rate of guide wire insertion by using ordinary techniques and advanced techniques (rendezvous method and precut method) in 30 patients via the minor papilla. We compared the selection of the access routes between before (52 patients) and after (28 patients) the introduction of the Soehendra stent retriever. RESULTS: In 19 out of 30 patients (63%), guide wire insertion via the minor papilla could be achieved by using ordinary techniques. In total, the guide wire could be inserted in 27 patients (90%) by using the advanced techniques. Before introduction of the Soehendra stent retriever, the major papilla approach was chosen in 38 cases (73%), and the minor papilla approach in 14 cases (27%). After introduction of the Soehendra stent retriever, the major papilla approach was used in 26 cases (93%) and the minor papilla in 2 cases (7%). The frequency of selecting the minor papilla approach has significantly decreased (p<0.05). CONCLUSIONS: The advanced techniques have contributed to the improvement of endoscopic approaches via the minor papilla, and decreased the frequency of selecting the minor papilla approach.
Humans ; Stents

The technique of intraductal ultrasonography (IDUS) of the bile duct with a thin-caliber probe and a ropeway system has provided excellent images of the bile duct and periductal structures and is an easy transpapillary approach. In addition, once the guide wire is inserted into the bile duct, IDUS and transpapillary biopsy after endoscopic retrograde cholangiopancreatography can be performed in a single session. Here, we review the usefulness of IDUS in the diagnosis of cholangiocarcinoma and IgG4-related sclerosing cholangitis.
Bile Ducts ; Biopsy ; Cholangiocarcinoma ; Cholangiopancreatography, Endoscopic Retrograde ; Cholangitis, Sclerosing

The shortage of physicians in Japan has been a social issue since the new postgraduate clinical training system started in 2004.The difficult working conditions of hospital physicians may influence this problem.We used a questionnaire to investigate the working hours, on-call frequency, work contents, and mental health of supervisors at various residency training hospitals in Japan.
1) We surveyed 479 physicians who worked at hospitals certified as residency-training facilities and who participated in a development workshop for supervisors or for residency training program managers held at 8 locations in 2004.
2) We found that supervisors worked, on average, more than 100 hours longer than statutory working hours per month and that more than one-fifth of supervisors worked more than 160 hours longer.
3) As for mental health, more than one-fifth of supervisors showed a depressive tendency.
4) These results suggest that the working conditions of supervisors at residency-training hospitals in Japan should be improved by reducing their clinical duties or managing their work content.