Objective: Monitoring the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants is important due to concerns regarding infectivity, transmissibility, immune evasion and disease severity. We evaluated the temporal and regional replacement of previous SARS-CoV-2 variants by the emergent strains, Alpha and Delta. Methods: We obtained the results of polymerase chain reaction screening tests for variants conducted in multiple commercial laboratories. Assuming that all previous strains would be replaced by one variant, the new variant detection rate was estimated by fitting a logistic growth model. We estimated the transmission advantage of each new variant over the pre-existing virus strains. Results: The variant with the N501Y mutation was first identified in the Kinki region in early February 2021, and by early May, it had replaced more than 90% of the previous strains. The variant with the L452R mutation was first detected in the Kanto-Koshin region in mid-May, and by early August, it comprised more than 90% of the circulating strains. Compared with pre-existing strains, the variant with the N501Y mutation showed transmission advantages of 48.2% and 40.3% in the Kanto-Koshin and Kinki regions, respectively, while the variant with the L452R mutation showed transmission advantages of 60.1% and 71.9%, respectively. Discussion In Japan, Alpha and Delta variants displayed regional differences in the replacement timing and their relative transmission advantages. Our method is efficient in monitoring and estimating changes in the proportion of variant strains in a timely manner in each region.

A 43-year-old man with rheumatic arthritis was admitted to our hospital for symptoms of cough, left chest pain, and left elbow pain, and further examination revealed an elevated level of C-reactive protein. On day 2 after admission, he underwent esophagogastroduodenoscopy. On the morning of day 7, he developed a high fever of 39.7°C, several hours after bronchoscopy. On day 13, he underwent colonoscopy. Five minutes after the colonoscopy, he developed a high fever of 39.9°C, accompanied by stridor, indicating a decrease in arterial oxygen saturation level. An intradermal test for peracetic acid which was used for cleaning flexible endoscopy was positive. We suspect that he suffered from an allergic reaction to peracetic acid following the flexible endoscopy. This is the first case reported on suspicious allergic reaction to peracetic acid following a flexible endoscopy procedure.

BACKGROUND/AIMS: We recently identified recessive mutations in the solute carrier organic anion transporter family member 2A1 gene (SLCO2A1) as causative variants of chronic nonspecific multiple ulcers of the small intestine (chronic enteropathy associated with SLCO2A1, CEAS). The aim of this study was to investigate the gastroduodenal expression of the SLCO2A1 protein in patients with CEAS and Crohn’s disease (CD). METHODS: Immunohistochemical staining for SLCO2A1 was performed with a polyclonal antibody, HPA013742, on gastroduodenal tissues obtained by endoscopic biopsy from four patients with CEAS and 29 patients with CD. RESULTS: The expression of SLCO2A1 was observed in one of four patients (25%) with CEAS and in all 29 patients (100%) with CD (p < 0.001). The three patients with CEAS without SLCO2A1 expression had a homozygous splice-site mutation in SLCO2A1, c.1461+1G>C (exon 7) or c.940+1G>A (exon 10). The remaining one CEAS patient with positive expression of SLCO2A1 had compound heterozygous c.664G>A and c.1807C>T mutations. CONCLUSIONS: Immunohistochemical staining for SLCO2A1 in gastroduodenal tissues obtained by endoscopic biopsy is considered useful for the distinction of CEAS from CD.
Biopsy ; Crohn Disease* ; Humans ; Immunohistochemistry ; Intestine, Small ; Ulcer

Medical education towards a specialty is a core stage of training for medical doctors. The specialty training system in Japan was initially organized by various academic societies and was recently integrated under Japan Medical Specialty Board, which was established in 2014. From April 2018, a revised specialty training system will begin and be based on new program guidelines. Its main concepts are professional autonomy, quality assurance of the medical specialty board and trustworthy medical consultation. As with undergraduate education, global standards are recently required in postgraduate education. Consistent outcome policy throughout undergraduate and postgraduate education and workplace-based assessment can hopefully be established.

A community-based medicine program in the postgraduate clinical training system has been offered as a mandatory program since 2004. Training sites range from clinical attachments in rural/remote areas to public health centers in the city. The role of the program director is important for enhancing the community-based medical program and raising resident doctors. Unique training programs have been carried out, such as medical training in the afflicted area of the earthquake/Tsunami disaster area as well as an exchange program between Hokkaido and Kagoshima residents. The Japanese healthcare system is drawing global attention and local demand. Enrichment of the community-based medicine program is vital for the human resource development that makes the Japanese healthcare system innovative and sustainable.

"Quality of education" has various definitions, and the definitions are classified mainly into five categories. Introducing the definition categories of "quality of education" , we analyze what aspects of the postgraduate clinical training system for physicians as an educational program have been reconsidered and redesigned. According to the analysis, we propose to introduce a programmatic assessment, which compose of several assessment methods, for evaluation at each stage of medical education from undergraduate to continuous professional development. Realizing such evaluation, we also propose to introduce a student/trainee assessment from a patient's perspective.

"The Ordinance of Ministry of Health, Labor and Welfare on Japanese Postgraduate Medical Training System" from 2020 was announced to each prefectural governor on July 3rd, 2018. This Medical Training system has been reviewed once every five years, and has been strongly aware of the consistency between the model core curriculum of the undergraduate medical education and the continuing professional development of Japan Medical Association. In this journal, Postgraduate Education Committee in Japan Society for Medical Education has published six installments of a series entitled "Japanese Medical Training System and Medical Education" . We reviewed the series and discussed medical education trends surrounding the postgraduate medical training system and issues in the committee. We will be reporting the information as part of the seventh installment of the series.

SUMMARY OF EVENT: Bacterial, mycotic peritonitis and Candida fungemia developed in a patient with moderate ascites who had undergone endoscopic ultrasound-guided biliary drainage (EUS-BD). Antibiotics and antifungal agent were administered and ascites drainage was performed. Although the infection improved, the patient's general condition gradually deteriorated due to aggravation of the primary cancer and he died. TEACHING POINT: This is the first report to describe infectious peritonitis after EUS-BD. Ascites carries the potential risk of severe complications. As such, in patients with ascites, endoscopic retrograde cholangiopancreatography (ERCP) is typically preferred over EUS-BD or percutaneous drainage to prevent bile leakage. However, ERCP may not be possible in some patients with tumor invasion of the duodenum or with surgically altered anatomy. Thus, in patients with ascites who require EUS-BD, we recommend inserting the drainage tube percutaneously and draining the ascites before and after the intervention in order to prevent severe infection.
Anti-Bacterial Agents ; Ascites ; Bile ; Candida ; Cholangiopancreatography, Endoscopic Retrograde ; Drainage ; Duodenum ; Endosonography ; Fungemia ; Humans ; Peritonitis

Medical education towards a specialty is a core stage of training for medical doctors. The specialty training system in Japan was initially organized by various academic societies and was recently integrated under Japan Medical Specialty Board, which was established in 2014. From April 2018, a revised specialty training system will begin and be based on new program guidelines. Its main concepts are professional autonomy, quality assurance of the medical specialty board and trustworthy medical consultation. As with undergraduate education, global standards are recently required in postgraduate education. Consistent outcome policy throughout undergraduate and postgraduate education and workplace-based assessment can hopefully be established.

Under the current postgraduate clinical training system for physicians, three principles have been emphasized in its basic tenets; cultivation of character appropriate for physicians, generation of awareness to the societal role of medical science and healthcare, and mastery of basic clinical skills needed to respond appropriately to injuries and illnesses frequently encountered in general practice. In accordance with its quinquennial review rule, the Clinical Training Committee under the Medical Caucus of the Healthcare Professions Council released draft revisions of a notification published by the Director general of the Health Policy Bureau of the Ministry of Health, Labor and Welfare in March, 2018. The document is entitled "On the operation of the ordinance concerning the postgraduate clinical training prescribed in the paragraph (1) of Article 16-2, Medical Practitioners Act" .　A Key distinction of the revised draft is new learning outcomes featuring core values shared by physicians: commitment to physicians' societal mission of public health, altruistic behavior, respect for humanity, and maintaining one's own integrity. Another key distinction is securement of longitudinal consistency in the set of required faculties, from medical school curriculum to continuing professional development programs. Further improvements in systems and environments to enhance devotion to life-long learning are needed.