Safety and feasibility of intravenous administration of a single dose of allogenic-Muse cells to treat human cervical traumatic spinal cord injury: a clinical trial.

INTRODUCTION: Spinal cord injury (SCI) is a devastating injury and remains one of the largest medical and social burdens because of its intractable nature. According to the recent advances in stem cell biology, the possibility of spinal cord regeneration and functional restoration has been suggested by introducing appropriate stem cells. Multilineage-differentiating stress enduring (Muse) cells are a type of nontumorigenic endogenous reparative stem cell. The positive results of Muse cell transplantation for SCI was shown previously. As a first step for clinical application in human SCI, we conducted a clinical trial aiming to confirm the safety and feasibility of intravenously injected donor-Muse cells. METHODS: The study design of the current trial was a prospective, multicenter, nonrandomized, nonblinded, single-arm study. The clinical trial registration number was JRCT1080224764. Patients with a cervical SCI with a neurological level of injury C4 to C7 with the severity of modified Frankel classification B1 and B2 were included. A primary endpoint was set for safety and feasibility. Our protocol was approved by the PMDA, and the trial was funded by the Life Science Institute, Tokyo, Japan. The present clinical trial recruited 10 participants (8 males and 2 females) with an average age of 49.3 ± 21.2 years old. All 10 participants received a single dose of allogenic CL2020 (a total of 15 × 106 cells, 2.1-2.7 × 105 cells/kg of body weight), which is a Muse cell-based product produced from human mesenchymal stem cells, by an intravenous drip. RESULTS: There were two reported severe adverse events, both of which were determined to have no causal relationship with Muse cell treatment. The change in the ISNCSCI motor score, the activity of daily living and quality of life scores showed statistically significant improvements compared to those data at the time of CL2020 administration. CONCLUSION: In the present trial, no safety concerns were identified, and Muse cell product transplantation demonstrated good tolerability. Future clinical trials with appropriate study designs incorporating a control arm will clarify the definitive efficacy of single-dose allogenic Muse cell treatment with intravenous administration to treat SCI. TRIAL REGISTRATION: jRCT, JRCT1080224764. Registered 03 July 2019, https://jrct.niph.go.jp/latest-detail/jRCT1080224764 .

Sensory profile of picky eaters among college female students.

Picky eaters are at risk of an unbalanced diet, which is critical for women of reproductive age. A sensory profile, which is a potential factor in picky eating, has not been well researched. This study assessed the differences in sensory profile and dietary intake according to the picky eating status among female Japanese undergraduate college students. Cross-sectional data were obtained from the Ochanomizu Health Study conducted in 2018. The questionnaire included items regarding demographic characteristics, picky eating status, sensory profile, and dietary intake. Sensory profile was assessed using the Adult/Adolescent Sensory Profile questionnaire, and dietary intakes were calculated using a brief-type self-administered diet history questionnaire. Among the 111 participants, 23% were picky eaters and 77% were non-picky eaters. The age, body mass index and household status did not differ between the picky eaters and non-picky eaters. Being a picky eater was associated with higher scores on sensory sensitivity and sensation avoiding, and lower thresholds for taste and smell, touch, and auditory stimuli than being a non-picky eater. Of the picky eaters, 58% and 100% were at a high risk for folate and iron deficiencies, respectively, compared to 35% and 81% of non-picky eaters. Nutrition education for picky eaters in reproductive age to increase vegetable dishes comfortably in their diet is suggested to prevent anemia during their future pregnancy.

Association of healthy eating literacy and resident status with energy, nutrients, and food consumption among lean and normal-weight female university students.

BACKGROUND & AIMS: This study aimed to describe the association of healthy eating literacy (HEL) with energy, nutrients, and food consumption in young women who had normal and lean weight at a Japanese university, considering their resident status. METHODS: Cross-sectional data from the Ochanomizu Health Study were used in this study. Participants answered a self-administered, two-part, anonymous survey in 2018 and 2019. A total of 203 female undergraduate students with lean and normal body mass index (BMI) were included in the analysis. Single and stepwise multiple linear regression analysis was used to examine the association of HEL and resident status with healthy food consumption, such as vegetables, fish, and shellfish. The dependent variables were HEL and resident status, and the covariates were age, BMI, and the total metabolic equivalents. RESULTS: The median (25th and 75th percentiles) age, BMI, and total HEL score were 20 (19, 21) years, 20.2 (18.9, 21.3) kg/m 2, and 18 (16, 20), respectively. Resident status and HEL were independently associated with vegetables, fish, and shellfish intake. Participants who had higher total HEL scores and lived in their family home consumed significantly more vegetables (ß = 0.17 and -0.34, p < 0.05) and fish and shellfish (ß = 0.24, -0.28, p < 0.001). CONCLUSION: This study provides an insight into the association between HEL and dietary consumption in young women with normal and lean BMI.

Changing genetic architecture of body mass index from infancy to early adulthood: an individual based pooled analysis of 25 twin cohorts.

BACKGROUND: Body mass index (BMI) shows strong continuity over childhood and adolescence and high childhood BMI is the strongest predictor of adult obesity. Genetic factors strongly contribute to this continuity, but it is still poorly known how their contribution changes over childhood and adolescence. Thus, we used the genetic twin design to estimate the genetic correlations of BMI from infancy to adulthood and compared them to the genetic correlations of height. METHODS: We pooled individual level data from 25 longitudinal twin cohorts including 38,530 complete twin pairs and having 283,766 longitudinal height and weight measures. The data were analyzed using Cholesky decomposition offering genetic and environmental correlations of BMI and height between all age combinations from 1 to 19 years of age. RESULTS: The genetic correlations of BMI and height were stronger than the trait correlations. For BMI, we found that genetic correlations decreased as the age between the assessments increased, a trend that was especially visible from early to middle childhood. In contrast, for height, the genetic correlations were strong between all ages. Age-to-age correlations between environmental factors shared by co-twins were found for BMI in early childhood but disappeared altogether by middle childhood. For height, shared environmental correlations persisted from infancy to adulthood. CONCLUSIONS: Our results suggest that the genes affecting BMI change over childhood and adolescence leading to decreasing age-to-age genetic correlations. This change is especially visible from early to middle childhood indicating that new genetic factors start to affect BMI in middle childhood. Identifying mediating pathways of these genetic factors can open possibilities for interventions, especially for those children with high genetic predisposition to adult obesity.

Mediating role of sensory differences in the relationship between autistic traits and internalizing problems.

BACKGROUND: Sensory differences are related to the autistic traits, and previous studies have shown a positive correlation between sensory differences and internalizing problems. In this study, we hypothesized that sensory differences and suffering due to sensory differences mediates the relationships between autistic traits and internalizing problems. METHODS: A total of 346 female Japanese university students completed questionnaires regarding their autistic traits, suffering due to sensory differences, and internalizing problems. Moreover, 114 participants completed a questionnaire related to sensory differences. RESULTS: Autistic traits were correlated with Low Registration and Sensation Avoiding. These sensory differences were also correlated with suffering due to sensory differences and internalizing problems. Moreover, path analysis indicated that the higher the suffering due to Low Registration and Sensation Avoiding was, the greater the internalizing problems in those who showed these sensory differences. CONCLUSIONS: Female university students with serious suffering due to sensory differences may need support in managing their suffering and internalizing problems. Further research will help suggest support that these people require, at school and elsewhere.

Rare case of real-time observation of paralytic deterioration after cervical dislocation in the hyperacute phase.

BACKGROUND: There have been no prior reports of real-time detailed records leading to complete quadriplegia immediately after fracture dislocation in high-energy trauma. Here, we report a case of cervical dislocation in which the deterioration to complete motor paralysis (modified Frankel B1) and complete recovery (Frankel E) could be monitored in real time after reduction in the hyperacute phase. CASE PRESENTATION: A 65-year-old man was involved in a car accident and sustained a dislocation at the C5/6 level (Allen-Ferguson classification: distractive flexion injury stage IV). His paralysis gradually deteriorated from Frankel D to C 2 hours after the injury and from Frankl C to B 5 hours after the injury. His final neurological status immediately before reduction was Frankel B1 (complete motor paralysis with sensation only in the perianal region). Reduction was completed within 6 h and 5 min after injury, and spinal fusion was subsequently performed. The patient exhibited rapid motor recovery immediately after surgery, and was able to walk independently on postoperative day 14. CONCLUSIONS: This case suggests that there is a mixture of cases in which the spinal cord has not been catastrophically damaged, even if the patient has complete motor paralysis. Prompt reduction has the potential to improve neurological function in such cases.

Relationship between parental autistic traits and parenting difficulties in a Japanese community sample.

BACKGROUND: Previous studies have suggested an association between higher levels of parental autistic traits and negative aspects of parenting; however, the domain of autistic traits specifically associated with parenting difficulties has not been investigated yet. Moreover, it remains to be determined whether this association exists even after controlling for children's characteristics. AIMS: This study examined the relationship between each domain of parental autistic traits and parenting difficulties after controlling for children's characteristics in a Japanese community sample. METHODS AND PROCEDURES: Surveys were administered to 1373 Japanese adults who were parents to children in kindergartens, nursery schools, and elementary schools. OUTCOMES AND RESULTS: The results showed that parents with higher levels of autistic traits had more parenting difficulties. Even after controlling for children's sex, age, and emotional/behavioral problems, paternal impaired communication and maternal poor attention switching, impaired communication, and lack of imagination were related to higher parenting difficulties, while a higher maternal level of attention to detail was associated with lower difficulties in parenting. CONCLUSIONS AND IMPLICATIONS: The findings of this study highlight the importance of focusing on parental autistic traits and providing appropriate parenting support considering these traits.

Later chronotype is associated with unhealthful plant-based diet quality in young Japanese women.

BACKGROUND: Having a late chronotype, that is, the tendency to go to sleep and wake up at later hours, influences an individual's physical and mental health. Despite a few studies noting the association of chronotype with healthy dietary patterns, this relationship remains unclear. PURPOSE: This study aimed to describe the association of chronotype with healthful and unhealthful plant-based diet quality in female Japanese undergraduate students. DESIGN: Cross-sectional. PARTICIPANTS AND SETTING: A total of 218 female university students in Tokyo, Japan. MAIN OUTCOME MEASURES: Healthful and unhealthful plant-based dietary index-Japanese version (hPDI-J and uPDI-J), calculated using the validated brief-type self-administered diet history questionnaire. STATISTICAL ANALYSES PERFORMED: A five-model stepwise multiple linear regression analysis was conducted. Independent variables were hPDI-J and uPDI-J scores, and dependent variables were various lifestyle habits related to the circadian rhythm and demographic characteristics. RESULTS: Mean (standard deviation) sleep duration, midpoint of sleep, sleep latency time, and social jetlag were 411 (60) min, 03:56 (00:57), 21 (27) min, and 50 (39) min, respectively. Chronotype and several variables, such as residential status, energy and alcohol intake, and nutritional knowledge, were associated with healthful and unhealthful plant-based diet quality. Individuals who had higher hPDI-J scores were more likely to have an earlier chronotype (ß = -0.168, P = 0.019) and better nutritional knowledge (ß = 0.164, P = 0.022) than those with lower hPDI-J scores. Individuals were more likely to have higher uPDI-J scores if they were living alone (ß = -0.301, P < 0.001), had a later chronotype (ß = 0.181, P = 0.001), higher frequency of snacking (ß = 0.164, P = 0.019), lower total energy (ß = -0.445, P < 0.001), and worse nutritional knowledge (ß = -0.172, P = 0.001). CONCLUSION: This study provided new evidence as to the relationship between sleep and dietary habits, the interaction of which may affect women's health.

Resilience building for mood disorders: Theoretical introduction and the achievements of the Re-Work program in Japan.

Mood disorders are common, tend to recur, cause sickness absence, and lead to economic loss. Since past experiences of mood disorder episodes often increase future vulnerability, it is imperative to assist those mood disorder patients who want to resume working to build resilience to prevent relapse. Paralleling efforts in the West, a resilience-building program utilizing the principles of the Illness Management and Recovery program was first developed in Japan in 1997. The purpose of this survey is to introduce the concept and theory behind the Re-Work program and to review studies that report on program assessment, content, effects and associated factors, and prognosis of participants. A literature search performed with PubMed and Igaku chuou zasshi (Ichushi) identified 30 relevant studies. One of these reported on a tool developed to assess readiness for returning to work. Concerning program content, a group therapy setting and cognitive behavioral therapy were found to be effective. Physical exercise and relaxation techniques may be useful as secondary program components. Several studies report on program effects, but there may be factors that limit these effects. The prognosis for relapse prevention after the resumption of work may be better for Re-Work program participants than for a control group. Further research in this area is needed to confirm program effectiveness and related factors.

Is mindful eating sustainable and healthy? A focus on nutritional intake, food consumption, and plant-based dietary patterns among lean and normal-weight female university students in Japan.

PURPOSE: This study aimed to investigate the correlation between mindful eating and nutritional intake, food consumption, and healthful and unhealthful plant-based dietary patterns in young Japanese women. METHODS: The sample comprised 215 female undergraduates who responded to a two-questionnaire anonymous survey conducted in Tokyo, Japan in 2018 and 2019 from November to December. We measured mindful eating status using the Expanded Mindful Eating Scale (EMES) and used Japanese plant-based dietary indices to determine plant-based dietary patterns. Partial correlation analyses were conducted to determine the correlation of mindful eating with energy and nutrient intake, food consumption, and plant-based dietary patterns, after adjusting for demographics and body mass index. RESULTS: Participants with higher sub-scores in "health of the planet" and "awareness and appreciation for food" ate higher quantities of several micronutrients and plant-based foods and were more likely to have a healthful plant-based dietary pattern. They were also less likely to have an unhealthful plant-based dietary pattern. In contrast, participants with higher scores in "non-judgmental awareness" ate less protein, whole grains, and vegetables, and were likely to have an unhealthful plant-based dietary pattern. CONCLUSION: This study is the first to show that young Japanese women with normal or lean body weight were more likely to consume healthful plant-based foods when they ate mindfully. LEVEL V: Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Assessing Knowledge-Based and Perceived Health Literacy Among Japanese Adolescents: A Cross-Sectional Study.

Health literacy assessment is a major aspect of planning health education for adolescents. We evaluated the health literacy of Japanese adolescents using both perceived and knowledge-based health literacy scales. Study questionnaires were administered to 773 junior and senior high school students aged 12 to 18 years. We tested a model describing the hierarchical relations between functional, communicative, critical, and knowledge-based health literacy using path analysis. Critical health literacy was found to be influenced by functional, communicative, and knowledge-based health literacy, while functional and knowledge-based health literacy were correlated. The model, with slight modification, was supported. The result indicates that perceived functional health literacy scores did not directly correlate with higher perceived critical health literacy; rather, they only informed critical health literacy when participants had high knowledge-based health literacy.

Development and validation of the Expanded Mindful Eating Scale.

PURPOSE: To develop and validate the Expanded Mindful Eating Scale (EMES), an expanded mindful eating model created for the promotion of health and sustainability. DESIGN/METHODOLOGY/APPROACH: A cross-sectional study using self-administered questionnaire surveys on Ochanomizu Health Study (OHS) was conducted. The survey was provided to 1,388 female university students in Tokyo, Japan. Exploratory factor analysis (EFA), confirmatory factor analysis (CFA) and a partial correlation analysis were used to confirm construct and criterion validity. Internal consistency of the EMES was confirmed to calculate Cronbach's alpha. FINDINGS: The response rate was 38.7 % (n = 537). Mean BMI was 20.21 ± 2.12, and 18.8% of them were classified as "lean" (BMI < 18.5). The authors listed 25 items and obtained a final factor structure of five factors and 20 items, as a result of EFA. Through CFA, the authors obtained the following fit indices for a final model: GFI = 0.914, AGFI = 0.890, CFI = 0.870 and RMSEA = 0.061. The total EMES score was significantly correlated with BMI, mindfulness, body dissatisfaction, drive for thinness and life satisfaction (r = -0.138, -0.315, -0.339, -0.281 and 0.149, p < 0.01, respectively). Cronbach's alpha for all items in this scale was 0.687. PRACTICAL IMPLICATIONS: The authors suggest the possibility that practitioners and researchers of mindful eating that includes this new concept can use authors' novel scale as an effective measurement tool. ORIGINALITY/VALUE: The EMES, which can multidimensionally measure the concept of the expanded model of mindful eating was first developed in this study.

Genetic and environmental influences on human height from infancy through adulthood at different levels of parental education.

Genetic factors explain a major proportion of human height variation, but differences in mean stature have also been found between socio-economic categories suggesting a possible effect of environment. By utilizing a classical twin design which allows decomposing the variation of height into genetic and environmental components, we tested the hypothesis that environmental variation in height is greater in offspring of lower educated parents. Twin data from 29 cohorts including 65,978 complete twin pairs with information on height at ages 1 to 69 years and on parental education were pooled allowing the analyses at different ages and in three geographic-cultural regions (Europe, North America and Australia, and East Asia). Parental education mostly showed a positive association with offspring height, with significant associations in mid-childhood and from adolescence onwards. In variance decomposition modeling, the genetic and environmental variance components of height did not show a consistent relation to parental education. A random-effects meta-regression analysis of the aggregate-level data showed a trend towards greater shared environmental variation of height in low parental education families. In conclusion, in our very large dataset from twin cohorts around the globe, these results provide only weak evidence for the study hypothesis.

Recent developments in undergraduate education in psychiatry in Japan.

The 2010 announcement by the Education Commission for Foreign Medical Graduates, related to accreditation by the World Federation for Medical Education, accelerated medical education reform in Japan. This article reviews reports on reforms undertaken in undergraduate medical education in psychiatry in Japan after 2010, and discusses resulting implications. While Japanese medical education has made significant progress, achieving global standards in less than a decade, there remain issues related to utilisation of active learning - inclusion of self-directed learning, problem-based learning, team-based and small group learning, and clinical training - as well as the provision of opportunities for students to be involved in certain medical procedures, and the integration of behavioural and social sciences, including communication skills, decision making, medical ethics, medical psychology, and general health promotion perspectives. These issues imply considerable paradigm shifts for psychiatry in Japan. It remains to be seen whether these progressive perspectives in undergraduate education can be effectively incorporated into postgraduate training, as well. There is also an issue of balance with specific important areas. The question of how undergraduate education in psychiatry in Japan can assimilate issues relevant to the practice of psychiatry in Japan, while ensuring conformity with high-level global standards, remains a serious challenge.

Time Course of Respiratory Dysfunction and Motor Paralysis for 12 Weeks in Cervical Spinal Cord Injury without Bone Injury.

INTRODUCTION: Cervical spinal cord injury without bone injury (SCIWOBI) is a common cervical injury in the elderly population and is most likely to occur at the C3/C4 level. Respiratory dysfunction (RD) related to the damage of the spinal respiratory center, which is close to the C4 segment, is one of the greatest obstacles in improving the activities of daily living of patients with severe paralysis. We evaluated the time course of RD and motor function in cervical SCIWOBI to identify effective medical strategies. METHODS: We followed 54 patients (49 men, 5 women; mean age: 65 years old) who were treated for SCIWOBI at our medical center from 2011 to 2014. The patients were evaluated within 72 hours of injury and were monitored for at least 12 weeks. All patients began respiratory-muscle training the day after admission regardless of whether they were treated conservatively or surgically. The percent vital capacity (%VC), forced expiratory volume (FEV) in one second/forced vital capacity ratio (FEV 1.0%), and American Spinal Injury Association motor score (MS) were recorded at admission and again at weeks 4 and 12. We calculated the %VC rate of change and the MS improvement rate over the entire period. RESULTS: Fifty patients (92.6%) had restrictive ventilatory impairment at admission. The %VC correlated with the upper- and lower-limb MSs at admission, and the %VC and upper- and lower-limb MSs had improved by weeks 4 and 12 after the injury. The %VC rate of change was significantly correlated with the rate of improvement in lower-limb MS throughout the entire period. CONCLUSIONS: Lung capacity decreased in SCIWOBI owing to respiratory-muscle paralysis and upper- and lower-limb motor paralyses. Lung capacity improved as the lower limbs recovered their motor function. Respiratory rehabilitation should be continued for at least 12 weeks after SCIWOBI.

Parental Education and Genetics of BMI from Infancy to Old Age: A Pooled Analysis of 29 Twin Cohorts.

OBJECTIVE: The objective of this study was to analyze how parental education modifies the genetic and environmental variances of BMI from infancy to old age in three geographic-cultural regions. METHODS: A pooled sample of 29 cohorts including 143,499 twin individuals with information on parental education and BMI from age 1 to 79 years (299,201 BMI measures) was analyzed by genetic twin modeling. RESULTS: Until 4 years of age, parental education was not consistently associated with BMI. Thereafter, higher parental education level was associated with lower BMI in males and females. Total and additive genetic variances of BMI were smaller in the offspring of highly educated parents than in those whose parents had low education levels. Especially in North American and Australian children, environmental factors shared by co-twins also contributed to the higher BMI variation in the low education level category. In Europe and East Asia, the associations of parental education with mean BMI and BMI variance were weaker than in North America and Australia. CONCLUSIONS: Lower parental education level is associated with higher mean BMI and larger genetic variance of BMI after early childhood, especially in the obesogenic macro-environment. The interplay among genetic predisposition, childhood social environment, and macro-social context is important for socioeconomic differences in BMI.

Quality of life in Japanese couples during the transition to parenthood.

OBJECTIVE: This study aimed to examine the quality of life (QOL) in Japanese couples during the transition to parenthood with their first child. BACKGROUND: Relevant literature suggests that the health status of women drop during pregnancy and the postpartum period. However, less is known about their partner's well-being during the transition to parenthood and little research has addressed the relationship between couples' QOL across multiple domains. METHOD: Participants included 9216 married Japanese men and women, including 3729 couples, who were expecting or raising their first child under the age of three. They independently completed questionnaires on baseline demographics and on WHOQOL-BREF. RESULTS: Men showed higher scores for psychological QOL, while women had higher scores for social and environment QOL. A significant interaction between gender and stage of transition to parenthood was found. The moderating effect of age between the stage and QOL was found for men on the physical and psychological domains. Couples' QOL scores were weakly to moderately correlated. CONCLUSION: Findings suggest that both men and women had lower QOL, with the exception of women's physical QOL, after childbirth, but they showed different trends during the transition to parenthood across different domains of QOL.

Two-stage corrective surgery for severe rigid cervical kyphotic deformity with unilateral vertebral artery occlusion after old blunt trauma: a case report.

INTRODUCTION: There are considerable risks for vertebral artery (VA) injury in case of corrective surgery for a severe and rigid cervical kyphotic deformity. This case report describes a rare case of surgical management for pre-existing traumatic rigid cervical kyphosis associated with unilateral VA occlusion. CASE PRESENTATION: A 73-year-old male fell down and injured his neck. He was referred to our hospital 10 months after injury because his degree of head drop progressed gradually to a chin-on-chest position such that he could not look straight forward. On plain X-ray, the C2-7 angles in the neutral, flexion, and extension positions were 61°, 71°, and 50°, respectively. CT revealed a collapse of the C5 vertebral body and bone fusion between C4 and C5 in the anterior vertebrae, and unilateral VA occlusion was confirmed by angiography. Two-stage surgery was planned to correct the kyphosis. In the first stage, anterior release of the C4/5 bone-spur fusion and dissection of the intervertebral disk were performed. After release, angiography confirmed neither occlusion nor rupture of the VA. In the second stage, anterior and posterior fixation was performed at correcting position while maintaining slight kyphosis in order to avoid excessive distortion of the VA. The postoperative C2-7 kyphosis angle improved to 16° without any VA injury, and the patient could look forward easily. DISCUSSION: The degree of correction as well as risk management of VAs should be considered carefully during corrective surgery for severe and rigid cervical kyphosis, especially with unilateral VA occlusion.

Factors Influencing Cancer Patients' Choice of End-of-Life Care Place.

BACKGROUND: It is important for cancer patients to receive end-of-life care at the desired place. OBJECTIVE: To identify issues in selection of place for end-of-life care of cancer patients to realize their optimal survivorship. DESIGN AND SETTING: Between September 2015 and January 2016, a questionnaire consisting of 33 items, including end-of-life care place preferences, was administered to cancer patients who attended three university hospitals in Japan. RESULTS: A total of 971 questionnaires were collected (response rate, 88.4%). Fifty-eight percent of patients preferred to stay at home to receive end-of-life care. In contrast, more than 80% of patients did not know the details of healthcare services. The factors significantly associated with patients' choice for place of end-of-life care at home were "male gender" (odds ratio [OR] = 1.43, p = 0.030), "living in a one-person household" (OR = 0.21, p < 0.001), "feeling close to friends" (OR = 0.94, p = 0.049), "thinking that the family is burdened" (OR = 0.55, p < 0.001), "thinking that pain is controllable at home" (OR = 1.39, p < 0.001), and "thinking that society should establish a system of home palliative care" (OR = 1.93, p < 0.001). CONCLUSIONS: This study identified six factors influencing the selection of a place for end-of-life care. Most patients have a desire for a social system that allows end-of-life care at home where they can live with their family, but have anxiety about treatment to deal with symptom change, with concern about burden on their family. These issues should be addressed in the future.

Awareness of traumatic occult lateral mass fracture of the cervical spine triggered by the presence of unilateral vertebral artery occlusion: a case report.

INTRODUCTION: We present an unusual case of traumatic occult lateral mass fracture of the cervical spine with unilateral occlusion of the vertebral artery (VA), that was missed by plain X-ray and magnetic resonance imaging (MRI), but identified by computed tomography (CT) after suspecting high-energy trauma as the underlying cause. CASE PRESENTATION: A 67-year-old male was injured in a car accident and came to our institute on foot 4 days after injury with complaints of neck pain and numbness in the right hand. Although, no specific bone injury was visible on plain X-ray, the absence of flow voids in the right VA was confirmed on axial T2-weighted MRI. We suspected high-energy trauma of the cervical spine at that point and performed CT for a more detailed assessment. Consequently, a fracture was detected in the right lateral mass of C6 and we speculated that spontaneous reduction of the fracture-dislocation had occurred. One-stage surgery with posterior fixation was subsequently performed for instability. The patient's preoperative symptoms were improved and neither recanalization of the occlusion nor another VA occlusion was observed after surgery. DISCUSSION: VA injury occurs frequently as a complication of blunt cervical spine trauma. In the present case, however, the lateral mass fracture was not seen on MRI and missed until the unilateral VA injury was detected. When high-energy trauma of the cervical spine is suspected, it is important to evaluate damage to the spinal cord, bone, soft-tissue, and VA by MRI and CT.