Anterior cutaneous nerve entrapment syndrome in children.

QUESTION: I frequently see adolescents with recurrent abdominal pain in my family medicine clinic. While the diagnosis frequently is a benign condition such as constipation, I recently heard that after 2 years of recurrent pain, an adolescent was diagnosed with anterior cutaneous nerve entrapment syndrome (ACNES). How is this condition diagnosed? What is the recommended treatment? ANSWER: Anterior cutaneous nerve entrapment syndrome, first described almost 100 years ago, is caused by entrapment of the anterior branch of the abdominal cutaneous nerve as it pierces the anterior rectus abdominis muscle fascia. The limited awareness of the condition in North America results in misdiagnosis and delayed diagnosis. Carnett sign-in which pain worsens when using a "hook-shaped" finger to palpate a purposefully tense abdominal wall-helps to confirm if pain originates from the abdominal viscera or from the abdominal wall. Acetaminophen and nonsteroidal anti-inflammatory drugs were not found to be effective, but ultrasound-guided local anesthetic injections seem to be an effective and safe treatment for ACNES, resulting in relief of pain in most adolescents. For those with ACNES and ongoing pain, surgical cutaneous neurectomy by a pediatric surgeon should be considered.

Children and adolescents in institutional care versus traditional families: a quality of life comparison in Japan.

BACKGROUND: A good quality of life (QOL) is important for the physical and mental well-being of all children. However, young people who live in an institutional setting may face different challenges than those who are raised in a traditional family. While a few quantitative studies of institutionalized children's QOL have been conducted, no research has investigated the QOL of young people living in Children's Homes (CHs) in Japan. This research compared the QOL of children and adolescents in Japan who live in CHs with that of children and adolescents living in traditional families. METHODS: A cross-sectional study was conducted in July 2016 with 204 students (grades three through nine), 47 of whom lived in a CH, and 157 of whom lived in a traditional family. Ages ranged from 8 to 15 years (CH: 55.8% Female, 44.2% Male; Traditional: 54.1% Female, 45.9% Male). Participants answered the kid-Kinder Lebensqualität Fragebogen (Translated from German: Children's quality of life questionnaire; KINDL®) Japanese Version, which covers six subscales of QOL; they filled in the questionnaires at home. Analysis of variance was used to compare QOL between the two samples. RESULTS: The total QOL score for all students (combined elementary school students and junior high school students) from CHs was statistically significantly lower than that for students from traditional families. Scores for the subscales, emotional well-being and family, were also significantly lower for CH young people than for those in traditional families. While elementary pupils in CHs reported lower QOL than those in traditional families, no significant differences in QOL were seen between junior high school students from CHs and their peers from traditional families. CONCLUSIONS: The findings presented support previous research showing that the QOL of elementary school students living in CHs is significantly lower than that of their peers in traditional families. However, this difference was not observed among junior high school students. This contrast suggests that QOL changes with age. Future research is needed to evaluate the determinants of QOL among all generations and family contexts.

Le syndrome de compression du nerf cutané antérieur chez l'enfant.

QUESTION: À ma clinique de médecine familiale, je vois souvent des adolescents souffrant de douleur abdominale récurrente. Le diagnostic est fréquemment un problème bénin comme la constipation, mais j'ai récemment entendu dire qu'un adolescent, après 2 ans de douleur récurrente, avait reçu un diagnostic de syndrome de compression du nerf cutané antérieur (ACNES). Comment ce problème est-il diagnostiqué, et quel est le traitement recommandé? RÉPONSE: Le syndrome de compression du nerf cutané antérieur, décrit initialement il y a près de 100 ans, est causé par la compression de la branche antérieure du nerf cutané abdominal qui empiète sur le fascia du muscle grand droit antérieur de l'abdomen. La connaissance limitée de ce problème en Amérique du Nord entraîne des diagnostics erronés et un retard dans le diagnostic réel. Le signe de Carnett, selon lequel la douleur s'aggrave lors de la palpation de la paroi abdominale intentionnellement tendue avec un doigt « en forme de crochet ¼, aide à confirmer si la douleur provient des viscères abdominaux ou de la paroi abdominale. L'acétaminophène et les anti-inflammatoires non stéroïdiens ne se sont pas révélés efficaces, mais des injections locales d'anesthésiques guidées par échographie semblent un traitement sûr et efficace pour l'ACNES, et elles entraînent un soulagement de la douleur chez la plupart des adolescents. Pour ceux dont l'ACNES et les douleurs persistent, il y a lieu d'envisager une neurectomie cutanée par un chirurgien pédiatrique.

Association between Excessive Alcohol Use and Alcohol-Related Injuries in College Students: A Multi-Center Cross-Sectional Study in Japan.

Alcohol-related injuries in college students are a major public health problem worldwide. We clarified the association between excessive drinking and alcohol-related injuries in Japanese college students. This was a cross-sectional study with a self-administered questionnaire. From January to March 2013, we sampled all college students and graduate students aged 20 years or older during annual health examinations at three colleges in Mie Prefecture in Japan. The questionnaire assessed the frequency of alcohol drinking, amount of alcohol consumed per day, binge drinking during the past year, alcohol-related injuries during the past year, and demographic data. Logistic regression analysis was conducted on the association between excessive alcohol use and alcohol-related injuries. A total of 2,842 students underwent health examinations, of whom 2,177 (76.6%) completed the questionnaire. Subjects included 1,219 men (56.0%) and 958 women (44.0%). Eighty-eight men (7.2%) and 93 women (9.7%) were classified as excessive weekly drinkers, while 693 men (56.8%) and 458 women (47.8%) were determined to be binge drinkers. Eighty-one men (6.6%) and 26 women (2.7%) had experienced alcohol-related injuries during the past year. In the logistic regression analysis, binge drinkers (odds ratio 25.6 [8.05-81.4]) and excessive weekly drinkers (odds ratio 3.83 [2.41-6.09]) had a history of significantly more alcohol-related injuries, even after adjusting for age and sex. In conclusion, alcohol-related injuries in college students in Japan were strongly associated with excessive drinking. As a strategy for preventing such injuries in this population, an interventional study is required to identify effective methods for reducing excessive alcohol use.

A comparison of the results of prospective and retrospective cohort studies in the field of digestive surgery.

PURPOSE: We compared the results of prospective and retrospective cohort studies in the field of digestive surgery to clarify whether the results of prospective cohort studies were more similar to those of randomized controlled trials (RCTs). METHODS: We conducted a secondary analysis of the results to compare the results of RCTs with those of cohort studies in meta-analyses of 18 digestive surgical topics. The data from the prospective and retrospective cohort studies were combined. The summary estimates of each design were compared with those of RCTs. We used the Z score to investigate discrepancies. RESULTS: Twenty-nine outcomes of 11 topics were investigated in 289 cohort studies (prospective, n = 69; retrospective, n = 220). These were compared with the outcomes of 123 RCTs. In comparison to retrospective studies, the summary estimates of the prospective cohort studies were more similar to those of the RCTs [19/29 (prospective) vs. 10/29 (retrospective), P = 0.035). Five of the 29 outcomes of prospective studies and 6 of 29 outcomes of retrospective studies (P = 0.99) showed significant discrepancies in comparison to RCTs. CONCLUSIONS: In the digestive surgical field, the results of prospective cohort studies tended to be more similar to those of RCTs than retrospective studies; however, there were no significant discrepancies between the two types of cohort study.

Evidence of surgical outcomes fluctuates over time: results from a cumulative meta-analysis of laparoscopic versus open appendectomy for acute appendicitis.

BACKGROUND: In surgical trials, complex variables such as equipment development and surgeons' learning curve are involved. The evidence obtained in these trials can thus fluctuate over time. We explored the stability of the evidence obtained during surgery by conducting a cumulative meta-analysis of randomized controlled trials for open and laparoscopic appendectomy. METHODS: We conducted a cumulative meta-analysis of randomized controlled trials comparing laparoscopic appendectomy with open appendectomy for acute appendicitis, a topic with the greatest number of trials in the gastroenterological surgical field. We searched the MEDLINE (PubMed), EMBASE, and CINAHL databases up to September 2014 and reviewed the bibliographies. Outcomes were the incidence of intra-abdominal abscess, incidence of wound infection, operative time, and length of hospital stay. We used the 95 % confidence interval (95 % CI) of effect size for the significance test. RESULTS: Sixty-four trials were included in this analysis. Of the 51 trials addressing intra-abdominal abscesses, our cumulative meta-analysis of trials published up to and including 2001 demonstrated statistical significance in favor of open appendectomy (cumulative odds ratio [OR] 2.35, 95 % CI 1.30-4.25). The effect size in favor of open procedures began to disappear after 2001, leading to an insignificant result with an overall cumulative OR of 1.32 (95 % CI 0.84-2.10) when laparoscopic appendectomy was compared with open appendectomy. CONCLUSIONS: The evidence regarding treatment effectiveness changed over time, after treatment effectiveness became significant in trials comparing laparoscopic and open appendectomy. Observing only the 95 % confidence interval of effect size from a meta-analysis may not provide conclusive results.

Development of a questionnaire to measure primary care physicians' scope of practice.

BACKGROUND: Despite an increase in research devoted to primary care attributes, the patient benefits and educational aspects of broad scope practice of primary care physicians (PCPs) have not been well studied, due to a lack of validated measurement in each country. The objective of this study was to develop and validate the Scope of Practice Inventory (SPI) to measure physicians' scope of practice within the Japanese primary care setting. METHODS: The questionnaire was developed in seven phases: 1) item generation, 2) consensus method for necessity of each item, 3) Delphi process for the importance of each item, 4) pilot tests to limit the number of items, 5) preliminary cross-sectional study to examine factor structure and to validate the construct validity, 6) evaluation of internal consistency and intra-class reliability, and 7) evaluation of external validity. To confirm the interpretability of the SPI, the determinants of the SPI using a generalized linear model were evaluated. RESULTS: Among 359 items generated by a focus group, 180 reached a defined consensus on face and content validity after the Delphi process. After deletion of items with Kappa values less than 0.6, 120 items were selected for the preliminary study. The principle component analysis using responses from 451 PCPs eliminated 52 items. The final 68-point SPI had three subdomains: Inpatient care, 25 items; Urgent care and minor procedures, 27 items; and Ambulatory care, 16 items. Internal consistency and test-retest reliability for total SPI and each subdomain revealed acceptable reliability. Male sex, less years since graduation, working in a hospital, sub-urban or rural setting, having remote experience, and having board certification as a PCP were positively associated with higher SPI. CONCLUSIONS: We developed a self-administered 68-point scale, the SPI, which had satisfactory validity and reliability. Primary care quality and educational research using SPI are expected to contribute to comprehensive and efficient health care systems in the future.

[Comparison between alcoholic patients and primary care patients for the use of the ambulance].

OBJECTIVE: Though heavy drinkers and patients with alcohol dependence make use of the ambulance more frequently as compared with the general population, there are few data on the alcohol-related use of the emergency department (ED) in Japan. METHOD: A cross sectional study was conducted. 170 patients with alcohol dependence in one clinic and 306 primary care patients across two clinics provided demographic data and answered some questions about the use of emergency ambulance services over the age of 20. The questions asked included whether use of the ambulance caused injuries, as well as AUDIT-C (primary care patients only). In this study, multiple logistic regression analysis was used. RESULT: The use of emergency ambulance services by patients with alcohol dependence was 4.68 times more than primary care patients, and the occurrence of ambulance-caused injuries was 6.03 times higher, as determined by multiple logistic regression. Among primary care patients, AUDIT-C positive patients (male; 5 points or more, female; 3 points or more) were 37 (12.2%), and the occurrence of ambulance-caused injuries was 3.32 times higher. CONCLUSION: Like with other countries, in Japan, heavy drinkers and patients with alcohol dependence lead to a significant increase in the use of emergency ambulance services as well as ambulance-caused injuries.

Perception and handling of breastmilk by childcare staff: A qualitative study of childcare facilities in Japan.

BACKGROUND: Breastfeeding in infancy has immunological and nutritional benefits. The actual status of breastfeeding in childcare facilities is unclear. However, it is expected to vary in every facility and region. This study aimed to explore what the staff of childcare facilities perceive of breastfeeding and how they feel about handling breast milk. METHODS: The study was conducted from May 2012 to September 2015. A list of childcare facilities in three cities in Japan was compiled. A questionnaire was sent to the facilities by mail asking whether or not they provided breastfeeding care and whether or not they would participate in the study. Semi-structured interviews were conducted with the staff members of childcare facilities that consented to the study. The transcribed text was analyzed by thematic analysis. RESULTS: Of the 211 facilities sent, 55 responded, and 21 of these facilities were implementing breastfeeding. Interviews were conducted at four facilities for those who agreed to be interviewed. The researchers extracted three categories of breastfeeding factors at childcare facilities: the value that caregivers see in breastfeeding, difficulties associated with breastfeeding in childcare facilities, and devices and elements for breastfeeding by childcare facilities. Although facility staff acknowledged the nutritional and psychosocial benefits of breast milk, they also felt the administrative difficulties and mental burden of handling expressed breast milk. CONCLUSION: This study revealed that for the childcare facility staff, breastfeeding was positioned as a means of communication and reassurance to the mother, and the immunological and nutritional benefits of breast milk.

Identifying the learning objectives of clinical clerkship in community health in Japan: Focus group.

BACKGROUND: The value of medical education in the community has been increasingly and globally recognized. In 2015, the World Federation for Medical Education emphasized the importance of medical education in various settings in their standard. Similarly, in Japan, the Model Core Curriculum for Medical Education in Japan (MCCMEJ) is revised in 2016. However, both the learning objectives of such clerkships and their concrete strategies in Japan are not clearly established. In this study, the authors identified the learning objectives of clinical clerkship in community health reflecting the perspectives of medical professionals and community inhabitants. METHODS: They held six focus groups that included physicians, other medical professionals, and inhabitants (n = 35) who were involved in a clinical clerkship in community health at three prefectures in Japan from 2017 to 2018. Further, they recorded, transcribed, and thematically analyzed the discussion using MCCMEJ as conceptual frameworks. RESULTS: The learning objectives comprised of 13 domains. The following four domains were not found in "Basic Qualities and Capacities for Physicians" in MCCMEJ: "future-oriented systematic view," "organic integration of knowledge/skill," "understanding of the community," and "awareness as an individual physician." CONCLUSION: With the community inhabitants' participation, the study results reflect the community needs in Japan. The authors hope that the outcome of this study will be useful to further improve clinical clerkship in community health.

Relationship between medical students' career priority and specialty choice: A nationwide multicenter survey.

BACKGROUND: The shortage of physicians in several specialties has been brought to public attention in several countries. However, little is known about factors affecting medical students' specialty choice. The objectives of our study were to illustrate medical students' career priority clusters and to assess their association with specialty preference. METHODS: We conducted a nationwide multicenter survey in 2015 at 17 medical schools. The study participants were asked their top three specialty preferences, demographic characteristics, and 14 career priority questions. Multilevel logistic regression models were used to determine the effect of each variable on student career choice. RESULTS: A total of 1264 responses were included in the analyses. The top five specialty choices were internal medicine: 833, general practice: 408, pediatrics: 372, surgery: 344, and emergency medicine: 244. An exploratory factor analysis mapped the 14 career priorities into 3-factor solution: "primary care orientation," "advanced and specific care," and "personal life orientation." Multilevel logistic regression models yielded satisfactory accuracy with the highest ROC curve (AUROC) noted in surgery (0.818), general practice (0.769), and emergency medicine (0.744). The career priorities under "primary care orientation" had positive association with choosing general practice, emergency medicine, internal medicine, and pediatrics. The "advanced and specific care" career priorities facilitated surgery and emergency medicine choice, while reducing the likelihood of choosing less procedure-oriented specialties, such as internal medicine, general practice, and pediatrics. CONCLUSIONS: Our results demonstrated medical students' career priorities and their association with specialty preference. Individualized career support may be beneficial for both medical students and each specialty fields.

Which medical interview behaviors are associated with patient satisfaction?

OBJECTIVE: The objective of this study was to investigate the association between several medical interview behaviors and patient satisfaction. METHODS: The subjects were 158 new patients who visited an outpatient facility of a university hospital in Japan. All medical interviews were videotaped and reviewed by a trained rater using a medical interview rating scale (Takemura Medical Interview Rating Scale) for evaluating medical interview behaviors. To measure patient satisfaction, a self-administered questionnaire was also developed. Both the rating scale and the questionnaire were assessed for validity and reliability beforehand. RESULTS: A significant positive association was found between the behaviors of reflection and legitimation on the one hand, and patient satisfaction on the other. The positive association between reflection and patient satisfaction existed after adjusting for both the duration of the interview and the other medical interview behaviors used. The association between legitimation and patient satisfaction also existed after adjusting for the duration of the medical interview but disappeared after adjusting for the other medical interview behaviors used. When we investigated the strength of the relationship between each medical interview behavior and patient satisfaction, reflection was found to be the strongest determinant of patient satisfaction. CONCLUSIONS: This research revealed a significant positive association between reflection or legitimation and patient satisfaction in an actual clinical practice setting.

Important Clinical Features of Japanese Spotted Fever.

Japanese spotted fever (JSF) is a zoonosis transmitted by ticks carrying the pathogen Rickettsia japonica. The classic triad of JSF symptoms is high fever, erythema, and tick bite eschar. About 200 people in Japan develop the disease every year. Japanese spotted fever is also a potentially fatal disease. At Minami-Ise Municipal Hospital in Japan, 55 patients were diagnosed with JSF from 2007 to 2015, which was equivalent to 4.3% of the total JSF cases in Japan. In this retrospective study, we examined the medical records of these 55 JSF cases. Fever, erythema, eschar, and elevated C-reactive protein (CRP) are characteristic clinical features of the disease. We confirmed four of these in the reviewed cases; however, eschar was not present in occasional cases. We confirmed that eosinopenia appeared in nearly all cases. Using fever, erythema, elevated CRP, and eosinopenia in diagnostic screening, our positivity rate was 90.9%. In our clinical practice, including eosinopenia improves the initial diagnosis of JSF.

What determines medical students' career preference for general practice residency training?: a multicenter survey in Japan.

BACKGROUND: Few studies have systematically explored factors affecting medical students' general practice career choice. We conducted a nationwide multicenter survey (Japan MEdical Career of Students: JMECS) to examine factors associated with students' general practice career aspirations in Japan, where it has been decided that general practice will be officially acknowledged as a new discipline. METHODS: From April to December 2015, we distributed a 21-item questionnaire to final year medical students in 17 medical schools. The survey asked students about their top three career preferences from 19 specialty fields, their demographics and their career priorities. Multivariable logistic regression was used to determine the effect of each item. RESULTS: A total of 1264 responses were included in the analyses. The top three specialty choice were internal medicine: 833 (65.9%), general practice: 408 (32.3%), and pediatrics: 372 (29.4%). Among demographic factors, "plan to inherit other's practice" positively associated with choosing general practice, whereas "having physician parent" had negative correlation. After controlling for potential confounders, students who ranked the following items as highly important were more likely to choose general practice: "clinical diagnostic reasoning (adjusted odds ratio (aOR): 1.65, 95% CI 1.40-1.94)", "community-oriented practice (aOR: 1.33, 95% CI 1.13-1.57)", and" involvement in preventive medicine (aOR: 1.18, 95% CI 1.01-1.38)". On the contrary, "acute care rather than chronic care", "mastering advanced procedures", and "depth rather than breadth of practice" were less likely to be associated with general practice aspiration. CONCLUSIONS: Our nationwide multicenter survey found several features associated with general practice career aspirations: clinical diagnostic reasoning; community-oriented practice; and preventive medicine. These results can be fundamental to future research and the development of recruitment strategies.

Which medical interview skills are associated with patients' verbal indications of undisclosed feelings of anxiety and depressive feelings?

BACKGROUND: In medical practice, obtaining information regarding patients' undisclosed "feelings of anxiety" or "depressive feelings" is important. The purpose of this study was to determine which interview skills are best suited for eliciting verbal indications of undisclosed feelings, for example anxiety or depressive feelings in patients. METHODS: Our group videotaped 159 medical interviews at an outpatient department of the Department of Family Medicine, Mie University Hospital (Mie, Japan). Physicians' medical interview skills were evaluated using a Medical Interview Evaluation System and Emotional Information Check Sheet for assessing indications of "feelings of anxiety" or "depressive feelings". We analyzed the relationship between the interview skills and patients' consequent emotional disclosure using generalized linear model (GLIM). RESULTS: The usage of interview skills such as "open-ended questions" "asking the patient's ideas about the meaning of illness" "reflection" and "legitimization" were positively associated with the number of anxiety disclosure, whereas "close-ended questions" and "focused question" were negatively associated. On the other hand, only "respect" was positively associated with the number of depressive disclosures, whereas "surveying question" was negatively associated. CONCLUSIONS: The results revealed that there are several interview skills that are effective in eliciting verbal indication of undisclosed "feelings of anxiety" or "depressive feelings".

Early prophylactic antibiotics administration for acute necrotizing pancreatitis: a meta-analysis of randomized controlled trials.

BACKGROUND: The effectiveness of prophylactic antibiotics use for acute necrotizing pancreatitis has been explored and a number of systematic reviews have been published with conflicting results. The timing of antibiotics administration can be fundamental to their effectiveness, but thus far no reviews have focused on the timing of administration. METHODS: A systematic review of randomized controlled trials (RCTs) of prophylactic antibiotics for acute necrotizing pancreatitis was conducted using MEDLINE (PubMed), CINAHL and Japana Centra Revuo Medicina. Trials in which antibiotics were administered within 72 h after onset of symptoms or 48 h after admission were included. Our primary outcomes were the mortality rate and the incidence of infected pancreatic necrosis, and secondary outcomes were the incidence of non-pancreatic infection and the incidence of surgical intervention. RESULTS: The search revealed six RCTs with a total of 397 patients. The mortality rates were significantly different for those taking antibiotics (7.4%), and controls (14.4%) (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.25-0.94). Also, early prophylactic antibiotics use was associated with reduced incidence of infected pancreatic necrosis (antibiotics 16.3%, controls 25.1%; OR, 0.55; 95% CI, 0.33-0.92). CONCLUSION: Early use of prophylactic antibiotics for acute necrotizing pancreatitis is associated with reduced mortality and lower incidence of infected pancreatic necrosis.