Feelings toward medicine in remote areas among medical students aiming to become generalists : A comparison with other specialists.

Geographic maldistribution of physicians is a serious problem in Japan, resulting in a few physicians in remote areas. We distributed questionnaires to 396 medical students at Tokushima University from 2013 to 2016. We examined the intensity of medical students toward medicine in remote areas by using a visual analog scale and investigated what medical specialty they chose after two years of clinical training. The intensity of interest in medicine and the intensity of willingness to contribute to it in remote areas were statistically higher among medical students who intended to choose general medicine. After graduation, only five participants chose to specialize in general medicine. Of the 14 medical students who originally chose general medicine, six chose internal medicine, three chose general medicine, and the others chose surgery, neurosurgery, anesthesiology, orthopedics, or emergency medicine. This study demonstrated that medical students who intend to choose general medicine have a higher intensity of willingness to contribute to medicine in remote areas, indicating that the support program for these students to become general practitioners after graduation increases the number of physicians in remote areas. J. Med. Invest. 70 : 129-134, February, 2023.

Clinical features and treatment outcomes of Fournier's gangrene in a single tertiary emergency hospital: Simplified Fournier's Gangrene Severity Index score is a predictor for death.

To assess the predictive reliability of the Simplified Fournier's Gangrene Severity Index Score (SFGSI) for mortality in Japanese patients with Fournier's gangrene (FG), we compared the clinical features and outcomes of a patient sample with the SFGSI. The medical records of 36 patients diagnosed with FG at our hospital between October 2007 and September 2022 were reviewed retrospectively. Clinical and laboratory variables, including SFGSI, were evaluated and predictive factors for fatality were investigated using multivariate logistic regression analysis. The median age and body mass index were 65 and 24.2, respectively. Eight patients had cooccurring chronic kidney disease and 23 had diabetes. None were taking sodium-glucose co-transporter-2 (SGLT-2) inhibitors. The causative organisms were diverse, and no specific trends in causative organisms were observed. 26 patients underwent debridement of necrotic tissue including eight colostomies, two orchiectomies, and one cystectomy. Multivariate logistic regression analysis revealed that SFGSI alone was an independent predictor of case fatality, with an odds ratio of 20.167 (95% CI: 1.66-245.53). In conclusion, the fatality rate was 19.4%, which was comparable to that reported in other studies. The SFGSI was an independent predictor of mortality in this study.

A Ca2+-binding motif underlies the unusual properties of certain photosynthetic bacterial core light-harvesting complexes.

The mildly thermophilic purple phototrophic bacterium Allochromatium tepidum provides a unique model for investigating various intermediate phenotypes observed between those of thermophilic and mesophilic counterparts. The core light-harvesting (LH1) complex from A. tepidum exhibits an absorption maximum at 890 nm and mildly enhanced thermostability, both of which are Ca2+-dependent. However, it is unknown what structural determinants might contribute to these properties. Here, we present a cryo-EM structure of the reaction center-associated LH1 complex at 2.81 Å resolution, in which we identify multiple pigment-binding α- and ß-polypeptides within an LH1 ring. Of the 16 α-polypeptides, we show that six (α1) bind Ca2+ along with ß1- or ß3-polypeptides to form the Ca2+-binding sites. This structure differs from that of fully Ca2+-bound LH1 from Thermochromatium tepidum, enabling determination of the minimum structural requirements for Ca2+-binding. We also identified three amino acids (Trp44, Asp47, and Ile49) in the C-terminal region of the A. tepidum α1-polypeptide that ligate each Ca ion, forming a Ca2+-binding WxxDxI motif that is conserved in all Ca2+-bound LH1 α-polypeptides from other species with reported structures. The partial Ca2+-bound structure further explains the unusual phenotypic properties observed for this bacterium in terms of its Ca2+-requirements for thermostability, spectroscopy, and phototrophic growth, and supports the hypothesis that A. tepidum may represent a "transitional" species between mesophilic and thermophilic purple sulfur bacteria. The characteristic arrangement of multiple αß-polypeptides also suggests a mechanism of molecular recognition in the expression and/or assembly of the LH1 complex that could be regulated through interactions with reaction center subunits.

Past infections are associated with low levels of anti-citrullinated protein autoantibodies in rheumatoid arthritis.

Background : Rheumatoid arthritis (RA), an autoimmune disease of unknown etiology, is believed to occur as the result of actions of genetic and environmental factors. In this study, we examined the relation of past histories about infectious diseases with the levels anti-citrullinated protein autoantibodies (ACPA) in RA. Methods : Results of a questionnaire about histories of infectious diseases were obtained from 85 patients with RA, and were analyzed. Results : Significantly lower level of ACPA was detected in patients with the history of tonsillitis, otitis media or urinary cystitis than in those without it. There was no difference in the level of ACPA in RA patients between with and without cold / influenza, rubella, chickenpox, herpes labialis or herpes zoster. When RA patients were divided into two groups, high-level and low-level ACPA, multiple logistic regression analysis revealed that the history of otitis media was a significantly independent factor for the low level of ACPA. There was no significant relation between the level of rheumatoid factor and histories of infectious diseases. Conclusion : This study clarified that the past history of otitis media is associated with the low level of ACPA in RA. J. Med. Invest. 67 : 182-188, February, 2020.

Epidemiological state, predictive model for mortality, and optimal management strategy for pancreatic injury: A multicentre nationwide cohort study.

BACKGROUND: Data for establishing the optimal management modalities for pancreatic injury are lacking. Herein, we aimed to describe the epidemiology, identify mortality predictors, and determine the optimal management strategy for pancreatic injury. METHODS: We identified patients with pancreatic injury between 2004 and 2017 recorded in the Japan Trauma Data Bank. The primary outcome was mortality. Multivariable logistic regression analyses were used to identify factors significantly associated with mortality and to develop a predictive model. Patients were also classified according to the Organ Injury Scaling of the American Association for the Surgery of Trauma (AAST grade I/II or III/IV). Outcomes were compared based on significant confounder-adjusted treatment strategy. RESULTS: Overall, 743 (0.25%) patients had pancreatic injury. Traffic accident was the most common aetiology. The overall mortality rate was 17.5%, while it was 4.7% for isolated pancreatic injury. AAST grade, Revised Trauma Scale score on arrival, age, and coexistence of severe abdominal injury aside from pancreatic injury were independently associated with mortality. A predictive model for mortality comprising these four variables showed excellent performance, with an area under the receiver operating characteristic curve of 0.89 (95% confidence interval [CI], 0.85-0.93). The in-hospital mortality was higher in patients who underwent celiotomy than in those who did not among those with AAST grade I/II (15.1% vs. 5.3%) and III/IV (13.8% vs. 12.3%). After adjusting for confounders, these differences were not significant with the adjusted odds ratios of 1.41 (95% CI, 0.55-3.60) and 0.54 (95% CI, 0.17-1.67) for AAST grade I/II and III/IV, respectively. CONCLUSIONS: AAST grade, Revised Trauma Scale score on arrival, age, and coexistence of severe abdominal injury aside from pancreatic injury were prognostic factors of mortality after pancreatic injury. Confounder-adjusted analysis did not show that operative management was superior to non-operative management for survival. Non-operative management may be a reasonable strategy for select pancreatic injury patients, especially in institutions where expertise in interventional endoscopy is available.

Can the shock index be a reliable predictor of early mortality after trauma in older patients? A retrospective cohort study.

AIM: Older patients have different physiological characteristics; thus, the reliability of the shock index (SI) to predict mortality could depend on age. We investigated whether the SI is a reliable predictor of early mortality in older patients and evaluated the clinical benefit of age in the interpretation of the SI. METHODS: Using data from the Japan Trauma Data Bank, we identified injured patients aged 20-84 years. Area under the receiver operating characteristic curve (AUC) was used to evaluate the discrimination ability of the SI to predict early mortality. A formula to determine the cut-off for each age was derived using linear regression analysis. Performance of the new method was compared with that of the traditional SI cut-off of ≥0.9 AUC. RESULTS: We analyzed data from 146,802 patients. Early mortality was observed in 4% of patients. The AUC showed a significant negative correlation with age (Spearman's ρ = -0.97, P < 0.001), and it decreased from 0.788 (95% confidence interval [CI], 0.761-0.815) in the 20-24 years age group to 0.660 (95% CI, 0.643-0.676) in those aged 80-84 years. By adjusting for age in the SI interpretation, AUC significantly improved from 0.681 (95% CI, 0.675-0.688) to 0.695 (95% CI, 0.688-0.701) (P < 0.001). CONCLUSIONS: The performance of the SI to predict mortality after trauma was significantly worse in older patients. Even if the SI cut-off value was adjusted based on age, the decrease in performance was not sufficiently prevented. Our results indicated that clinicians should be cautious when using the SI in older patients.

Effect of surgical rib fixation for rib fracture on mortality: A multicenter, propensity score matching analysis.

BACKGROUND: Rib fracture is a common injury and can be associated with complications and a high mortality rate. There has been growing interest in surgical rib fixation as a treatment for rib fracture. However, results from previous studies are conflicting, and conclusive results regarding the efficacy of surgical rib fixation for rib fracture are lacking. This study aimed to investigate if surgical rib fixation improves prognosis in patients with traumatic rib fractures. METHODS: Using the Japan Trauma Data Bank, a nationwide trauma registry, we identified patients 18 years or older with rib fracture between 2004 and 2015. The primary outcome was in-hospital mortality. Logistic regression analysis was used to estimate a propensity score to predict reception of surgical rib fixation. We used a 1:4 propensity score matching analysis to compare patients who underwent surgical rib fixation with those who did not. RESULTS: Overall, 236,698 patients were registered in the database, and 37,571 were eligible for propensity score matching analysis. This analysis included 147 patients who underwent surgical rib fixation and 588 as controls. The in-hospital mortality rate was significantly lower in patients who underwent surgical rib fixation than in those who did not (4.8% vs. 16.2%, respectively; absolute difference: -11.4%; 95% confidence interval: -14.8% to -8.0%). CONCLUSION: This study showed that surgical fixation may reduce in-hospital mortality in patients with rib fracture. Surgical rib fixation may offer a better modality for the management of selected patients with rib fracture. LEVEL OF EVIDENCE: Therapeutic, level III.

Emergency Trepanation as an Initial Treatment for Acute Subdural Hemorrhage: A Multicenter Retrospective Cohort Study.

BACKGROUND: Rapid decompression with trepanation and drainage in an emergency room has been proposed as a potentially effective initial intervention for early-stage acute subdural hemorrhage; however, the actual safety and efficacy of the procedure remain unclear. The aim of this study was to evaluate the feasibility of emergency trepanation as an initial treatment for acute subdural hemorrhage. METHODS: We investigated patients with thick subdural hemorrhages who had undergone craniotomy between 2004 and 2015 in Japan using a nationwide trauma registry (the Japan Trauma Data Bank). The endpoint was survival at discharge. We compared patients who underwent trepanation in an emergency room with those who did not undergo trepanation, and adjusted for potential confounders using a multivariate logistic regression model. RESULTS: During the study period, 236,698 patients were registered in the Japan Trauma Data Bank. Of the 1391 patients who were eligible for analysis, 305 had undergone trepanation in an emergency room. The survival rate was 37.7% in patients who had undergone emergency trepanation and 59.3% in those who had not. Performing emergency trepanation was significantly associated with decreased survival even after adjusting for possible confounders (adjusted odds ratio, 0.55; 95% confidence interval, 0.40-0.76; P < 0.001). CONCLUSIONS: Our results indicate that performing trepanation in an emergency room is associated with a decreased survival rate.

Evaluation of the outcome of traumatic thoracic aortic rupture in patients in a trauma and critical care center.

OBJECTIVES: Multiple injuries may lead to traumatic thoracic aortic rupture (TTAR), which can be fatal. We evaluated the relationship between the clinical findings and outcomes of 26 patients with TTAR who were treated at our institution. METHODS: A total of 26 patients (men, 21; women, 5; average age, 45.8 ± 19.6 years) with a diagnosis of TTAR received from 1999 to 2009 were studied. We categorized patients into groups based on the outcome (survival or death) and investigated the relationship between the outcome and the following factors: injury mechanism, vital signs, other combined injuries, injury severity score (ISS), revised trauma score, and probability of survival (Ps). RESULTS: Of the 26 TTAR patients, 7 underwent emergency operations, 5 underwent delayed operations, 1 received conservative treatment, and 13 suffered cardiopulmonary arrest immediately after consultation and died. Of the 13 patients who died, 11 died within 2 hours after injury because of bleeding. Two of the 7 patients who underwent emergency operations died within 1 day of consultation, whereas all those who underwent delayed operations survived. Patients who underwent TTAR repair had a relatively favorable outcome. Analysis of the relationship between the clinical data and outcome showed that a young age was significantly correlated with survival, and that the Glasgow coma scale (GCS), heart rate, respiratory rate, or occurrence of shock were not significantly related to the outcome. The abbreviated injury scale (AIS) was used to score the severity of multiple injuries, and ISS was calculated from the AIS score. ISS was significantly higher in the death group (P = 0.007). ISS did not significantly differ among body parts (P = 0.077), but ISS of the extremities was higher than those of other parts. Pelvic fractures were frequent in the death group. Our strategy, whereby the patient initially underwent pelvic external fixation followed by TTAR repair was found to be very effective. The P-values calculated by the trauma and injury severity score method were significantly higher in the survival group (both, P = 0.007). CONCLUSION: To treat TTAR, it is important to accurately evaluate the damage due to multiple injuries and apply an appropriate treatment strategy. Immediate repair of TTAR after bleeding due to combined injury improves the outcome. (English Translation of Jpn J Vasc Surg 2012; 21:5-9).