Direct Link Between Cardiac Failure and Global Cerebral Atrophy in a Young Adult: A Case Report on Reduced Cerebral Artery Blood Flow.

BACKGROUND Heart failure is associated with structural brain abnormalities, including atrophy of multiple brain regions. Previous studies have reported brain atrophy in middle-aged patients with systolic heart failure. In this report, we present the case of a 21-year-old woman with idiopathic dilated cardiomyopathy, cardiac failure, and global cerebral atrophy due to reduced cerebral artery blood flow. We also discuss the impact of brain atrophy in this young adult patient with severe heart failure and no risk factors for atherosclerosis. CASE REPORT A 21-year-old woman with dyspnea and leg edema was admitted to our hospital. After several examinations, an endomyocardial biopsy led to a diagnosis of idiopathic dilated cardiomyopathy, and transthoracic ultrasound cardiography revealed that her left ventricular ejection fraction was 36%. One year after the first hospitalization, her heart failure was classified as New York Heart Association Class III. Magnetic resonance imaging showed severe global brain atrophy, and single-photon emission computed tomography combined with brain computed tomography showed reduced blood flow to the entire brain. She had no risk factors for atherosclerosis and no atherosclerotic changes to her brain or carotid arteries, but her neuropsychological and neurological findings indicated more pronounced brain and cognitive dysfunction. CONCLUSIONS This young adult patient with idiopathic dilated cardiomyopathy, cardiac failure, and global cerebral atrophy showed reduced cerebral artery blood flow and cognitive impairment. The findings of this report indicate that low cardiac output may directly cause brain atrophy in patients with systolic heart failure.

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.

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.

Effectiveness of individual nutrition counselling for the prevention of undernutrition among elderly people living in depopulated areas: secondary analysis of a model project in Tsu city.

Objectives: To examine the effectiveness of nutrition counselling (NC) in preventing undernutrition in elderly people living in depopulated areas. Design: Participants were elderly people aged at least 65 years living in a depopulated area. Participants completed self-administered questionnaires evaluating nutritional status, frailty and body composition at the start of the study, after a non-NC period (3-month control) and after an NC period (3-month intervention). During the NC period, participants attended monthly 1-hour NC sessions over 3 months. Sessions were conducted in three areas (A, B and C), and the schedule was staggered so that the NC period in one area was conducted simultaneously with the non-NC period of the next. All sessions within an area were attended by the same registered dietitian. Outcomes were assessed three times: before the non-NC period, after the non-NC period and after the NC period. The effects of NC were assessed by comparing the results between the non-NC and NC periods of all participants, using the Cochran-Mantel-Haenszel stratified test. Outcome measures: The primary outcome was undernutrition, as determined by the Mini Nutritional Assessment-Short Form. Secondary outcomes were Dietary Diversity Score (DVS), body weight and frailty. Body composition was also assessed. Results: Of 106 individuals who joined the project, 61 completed the project and were analysed. The NC in this study had no effect on the primary outcome. DVS in area A was significantly higher after the NC period than after the non-NC period (p=0.012). Frailty in area C was significantly lower after the NC period than after the non-NC period (p=0.025). NC had no significant effects on the other outcomes. Conclusions: NC improved food variety but did not improve nutritional status, frailty or body composition.

High-normal diastolic blood pressure as a risk factor for left ventricular diastolic dysfunction in healthy postmenopausal women.

Left ventricular (LV) diastolic dysfunction is associated with heart failure with preserved ejection fraction, and metabolic syndrome (MetS) is a risk factor. However, there is limited knowledge regarding the metabolic factors that contribute to LV dysfunction in postmenopausal women without comorbidities. This study aimed to analyze the relationship between LV diastolic dysfunction and MetS, as well as other cardiovascular risk factors, and to determine risks for LV diastolic dysfunction. Postmenopausal women without hypertension, diabetes mellitus, LV systolic dysfunction, or other heart diseases underwent physical examinations, including echocardiography. The study participants were diagnosed with LV diastolic dysfunction based on several echocardiographic parameters. Logistic regression analyses of LV diastolic dysfunction and cardiovascular risk factors were performed. Of the 269 postmenopausal women examined, 29 (10.7%) and 40 (14.9%) had MetS and LV diastolic dysfunction, respectively. Abnormal diastolic blood pressure (odds ratio, 3.6; 95% confidence interval, 1.16-10.9; P < 0.05) and age (odds ratio, 1.1; 95% confidence interval, 1.07-1.19; P < 0.01) were predictors of LV diastolic dysfunction. In healthy postmenopausal women, high-normal diastolic blood pressure was the only independent risk factor for LV diastolic dysfunction, and it thus may be a useful predictor of diastolic heart failure during routine physical examinations.

Translating and validating a Japanese version of the instrument for patient assessment of medical professionalism (J-IPAMP): a cross-sectional survey.

BACKGROUND: Although there are many tools to assess medical professionalism, they rarely address patients' perspectives. The instrument for patient assessment of medical professionalism (IPAMP) comprises 11 items and has been established and validated as a valuable tool for assessing trainees' professionalism from the patient's perspective. However, there is no instrument to assess professionalism from the patient's perspective in Japan. The purpose of the present study was to develop a Japanese version of the IPAMP (J-IPAMP) and test its validity and reliability. METHODS: We conducted a cross-sectional survey to examine the reliability and validity of the J-IPAMP in two hospitals (one each in an urban and rural area) in Japan. Receptionists or surveyors distributed the anonymous questionnaire to 276 inpatients; all participants were aged above 20 years and assigned to medical trainees. We evaluated its structural and criterion-related validity, as well as internal consistency reliability. RESULTS: Data of 235 (85.1%) patients were analyzed. Using the split-half validation technique, we performed an exploratory factor analysis (EFA) along with a confirmatory factor analysis (CFA). The EFA showed a one-factor solution. Then, to compare the model fitness between two models (the two-factor model from the original English version vs. unidimensional model suggested by the EFA), the CFA was performed. The CFA showed that almost all of the fit indices met their respective criteria and were approximately the same for the two models. Thus, we adopted a single-factor model. The Pearson correlation coefficients between the total J-IPAMP scores and the global ratings were 0.738, indicating adequate criterion-related validity. The Cronbach's alpha of the 11 items of the instrument was 0.96 (95% confidence interval: 0.96-0.97) and the omega value was 0.96, demonstrating acceptable internal consistency reliability. CONCLUSIONS: We developed the Japanese version of the IPAMP. Its validity and reliability were verified through analysis. This instrument can be utilized for professionalism education in the postgraduate training setting.

Effect of Daily Multidisciplinary Team Reflection in Ambulatory Care: A Qualitative Analysis.

PURPOSE: Research suggests that daily previsit team huddling leads to improved teamwork, however there are no reports on the effect and mechanism of daily team reflection in primary care practice. To help healthcare professionals to integrate fragmented information and to enhance continuity, we previously developed and implemented a daily multidisciplinary team reflection (DMDTR) approach. The present study aimed to construct a conceptual diagram illustrating how participation in DMDTR influence medical care in an ambulatory clinic. PARTICIPANTS AND METHODS: In this qualitative study, we analyzed data from semi-structured interviews (n = 12) conducted with physicians, nurses, and medical assistants who regularly participated in DMDTR. Modified grounded theory approach (M-GTA) was adopted as the analysis method, and structure-construction qualitative research method (SCQRM) was used as a meta-theory to determine the number of cases correlatively with the research objectives. RESULTS: Our conceptual diagram demonstrated that, through DMDTR, team members shared fragmented information to gain a more holistic view of the patient and discuss diverse points of view, a process that resulted in real-time problem solving through collaboration. This team approach showed benefit to each discipline and improves the care attributes of contextuality, coordination, accessibility, accountability, continuity, and comprehensiveness of care. CONCLUSION: We generated a conceptual diagram showing that DMDTR embodies a team approach that leads to improved care attributes, which results in enhanced quality of primary care.

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.

Translating and validating a Japanese version of the Patient Care Ownership Scale: a multicenter cross-sectional study.

BACKGROUND: Patient care ownership (PCO) is an essential component in medical professionalism and is crucial for delivering high-quality care. The 15-item PCO Scale (PCOS) is a validated questionnaire for quantifying PCO in residents; however, no corresponding tool for assessing PCO in Japan exists. This study aimed to develop a Japanese version of the PCOS (J-PCOS) and validate it among Japanese medical trainees. METHODS: We performed a multicenter cross-sectional survey to test the validity and reliability of the J-PCOS. The study sample was trainees of postgraduate years 1-5 in Japan. The participants completed the J-PCOS questionnaire. Construct validity was assessed through exploratory and confirmatory factor analyses. Internal consistency reliability was examined by calculating Cronbach's alpha coefficients and inter-item correlations. RESULTS: During the survey period, 437 trainees at 48 hospitals completed the questionnaire. Exploratory factor analysis of the J-PCOS extracted four factors: assertiveness, sense of ownership, diligence, and being the "go-to" person. The second factor had not been identified in the original PCOS, which may be related to a unique cultural feature of Japan, namely, a historical code of personal conduct. Confirmatory factor analysis supported this four-factor model, revealing good model fit indices. The analysis results of Cronbach's alpha coefficients and inter-item correlations indicated adequate internal consistency reliability. CONCLUSIONS: We developed the J-PCOS and examined its validity and reliability. This tool can be used in studies on postgraduate medical education. Further studies should confirm its robustness and usefulness for improving PCO.

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.

The "Healthy Akame!" community - government - university collaboration for health: a community-based participatory mixed-method approach to address health issue in rural Japan.

BACKGROUND: Although Japan has a decentralized public health system, local governments have considered expert opinions over those of the community in decisions about public health programs. Differences in communities' interests may create gaps between health program objectives and implementation. We hypothesized that community-based participatory research (CBPR), which involves the community at every step, promotes effective program implementation and community empowerment. This study addressed the first step of CBPR, assessing community needs and developing tailored health program for a rural community in Japan. METHODS: In this sequential exploratory mixed-method study (qualitative followed by quantitative), we first formed a community advisory board (CAB) representing community organizations, city officials, and university researchers. The CAB conducted group discussions with community residents to identify the community's health issues and strengths. These group discussions were analyzed using thematic analysis, and the results were used to develop a questionnaire, which was subsequently sent to all households in the community to obtain priority scores for health issues and proposed action and to assess willingness to participate in community health program. The CAB then designed a program using the overall study results. RESULTS: Ten group discussions with 68 participants identified the following health issues: 1) diseases; 2) unhealthy behaviors; and 3) unsupportive environment. Nature, vacant lots, and local farms were considered local strengths. Of a total of 1470 households in the community, questionnaires were collected from 773 households. Cancer, lifestyle-related diseases, and cerebrovascular diseases were ranked as the most important health problems. Improving services and access to medical checkups, use of public space for exercise, local farming, and collaboration with the community health office were considered necessary to address these health problems. Considering feasibility and the availability of resources in the community, the CAB decided to focus on lifestyle-related diseases and designed activities centered on health awareness, nutrition, and exercise. These activities drew on community's strengths and were adapted to Japanese culture. CONCLUSIONS: The community's priority health problem was closely related to the epidemiology of diseases. The CBPR approach was useful for identifying community's needs and for designing a unique community health program that made use of local strengths.

Developing and implementing a faculty development curriculum for Japanese family medicine residency faculty.

BACKGROUND: Despite the increase in family medicine residency in Japan, there are only a few structured faculty development (FD) programs. The objective of this project was to construct a consensus on core competencies of faculty to develop a faculty development curriculum in a Japanese family medicine context. METHODS: In 2015, a private FD initiative in the Mie University initiated a curriculum development in collaboration with FD fellowship at the University of Pittsburgh. A literature review and subsequent Delphi process were conducted for core competency development. Based on the core competency list, we designed and implemented a 2-year part-time FD curriculum from 2016. A course evaluation using pre-post confidence level was held during March 2017. RESULTS: Twenty-eight objectives were defined in five core domains: 1) care management/family medicine principle, 2) leadership/professional development, 3) administrative/management, 4) teaching, and 5) research/scholarly activity. A pre-post survey at the end of an academic year revealed a significant increase in learner confidence for "care management/family medicine principle" (P = .03), "teaching" (P < .01), and "research/scholarly activity" (P < .01), as well as the total score (P = .03). CONCLUSIONS: A family medicine FD curriculum based on a faculty core competency list was developed by consensus in a Japanese family medicine context. The core competency was strongly context-oriented, and the relevance of the FD topics and opportunities to apply to the participants' current positions may be inevitable for learner engagement. Further curriculum refinements will be required to see whether the curriculum could be used for faculty development in other family medicine residencies.

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.

Clinical impact of perinephric fat stranding detected on computed tomography in patients with acute pyelonephritis: a retrospective observational study.

Perinephric fat stranding (PFS) is often detected on computed tomography (CT) in patients with acute pyelonephritis (APN). However, its clinical impact remains unclear. This study aimed to evaluate the clinical impact of PFS detected on CT in patients with APN. This retrospective observational study included patients with APN who underwent CT (median age, 79.5 years). Patients were classified into PFS (patients with PFS observed on CT) and non-PFS (patients without PFS observed on CT) groups, which were further classified into bacteraemia and non-bacteraemia groups. Clinical findings between the groups were compared. Among 194 patients who underwent CT, 111 (57.2%) patients demonstrated PFS. The rate of bacteraemia was significantly higher in the PFS group than in the non-PFS group (55.2 vs. 23.1%, p < 0.001). CT findings other than PFS were not associated with bacteraemia. The median peak body temperature was significantly higher in the PFS group than in the non-PFS group (38.8 vs. 38.5 °C, p < 0.001); however, the duration of fever and in-hospital mortality rates were not significantly different between the groups. Concordance between blood and urine culture results was observed in 75.0% of the patients; the presence of PFS was not different between patients with concordant and discordant results, regardless of the pre-treatment antibiotic used. Our findings suggest that the presence of PFS in patients with APN predicts bacteraemia; thus, clinicians should consider obtaining blood cultures if PFS is found on CT in patients with APN, even if the patients had received antibiotics prior to admission.

Effectiveness of monthly and bimonthly follow-up of patients with well-controlled type 2 diabetes: a propensity score matched cohort study.

BACKGROUND: On average, patients in Japan with type 2 diabetes mellitus have a clinical consultation every month, although evidence for a favorable follow-up interval is lacking. This study investigated whether the follow-up interval can be extended by comparing the clinical outcomes and cost for monthly versus bimonthly follow-up of patients with well-controlled diabetes mellitus. METHODS: We combined administrative claims data from the National Health Insurance and the Health Checkups Program data of Tsu city, Japan between 2011 and 2014 to conduct a retrospective cohort study of patients with well-controlled type 2 diabetes mellitus. Propensity scores were used to assemble a matched-pairs cohort from patients who had monthly and bimonthly follow-up. Equivalence between two groups was assessed by designating the proportion of patients who maintained good control of their diabetes in the subsequent year as a primary outcome. The proportion achieving target blood pressure and lipid levels, favorable lifestyle, and annual cost were compared as secondary outcomes. RESULTS: Of 12,145 participants, 693 with monthly follow-up and 693 with bimonthly follow-up were matched using propensity scores. In the monthly follow-up group 654 (94.4%) remained under good diabetic control, versus 658 (95.0%) in the bimonthly group (difference: 0.6%; 95% confidence interval: - 1.8 to 2.9%). All secondary outcomes were equivalent for the monthly and bimonthly follow-up groups except the proportion achieving target blood pressure, the proportion engaging in regular exercise, and annual cost. CONCLUSIONS: For patients with well-controlled diabetes mellitus, although frequent follow-up by a physician does not affect the control of blood glucose level in the subsequent year, the annual treatment cost becomes much higher. We suggest that patients with well-controlled diabetes can be followed up less often.

Family Caregivers' Perspectives for the Effect of Social Support on their Care Burden and Quality of Life: A Mixed-Method Study in Rural and Sub-Urban Central Japan.

Japan has adopted community-based integrated long-term care, which has shifted the burden of care from institutions to the home. However, family caregivers have received less attention compared with care recipients. Many family caregivers are also older adults, and it is important that caregivers receive appropriate support to alleviate the burden of care. In rural and sub-urban area with limited resources compared to urban area, it is necessary to know which support to be prioritized. Therefore, this study aimed to understand family caregivers' perceptions of social support, the type and source of support which were considered important, and how it affected their caregiving burden and quality of life (QOL). We conducted a convergent mixed-method study with 174 primary family caregivers of older adults receiving home care in rural and suburb area of Central Japan. The mixed-method approach enabled qualitative data to complement quantitative results. Strong family support and higher education had positive effects on QOL, while higher caregiving burden and longer duration of care had negative effects on QOL. Provision of tangible support from family and healthcare professionals was central in reducing caregiving burden and improving caregivers' QOL. Support from distant relatives or neighbors, which was deemed inappropriate by caregivers, had a negative effect on caregivers' emotional status. In conclusion, family caregivers perceived support positively, but the effects depended on who provided support. While tangible support from close family and professionals was perceived positively, support from neighbors or distant relatives should consider caregivers' needs and condition to avoid a negative impact.

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.

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.