Four successive cases of human fasciolosis in Japan.

Fasciolosis is a food-borne parasitic disease, caused by the large liver fluke, Fasciola. Humans acquire infection by ingesting fresh or undercooked water plants, on which infective metacercaria encyst. In spite of the rarity of the disease in Japan, we encountered four successive fasciolosis patients within a short period, who were all living in the same area. The patients were 70-82 years old, three females and the husband of one of the female patients. They started complaining of non-specific symptoms, such as fever, general fatigue, appetite loss, and abdominal pain, almost at the same time. All patients showed prominent peripheral blood eosinophilia, and the medical imaging indicated multiple hepatic lesions. No parasite eggs or worms were detected in any of the patients. Diagnosis was made serologically and they were treated with praziquantel and/or triclabendazole. No cattle or sheep were farmed in the area, but the wild sika deer, Cervus nippon, inhabited adjacent to the residential area. The intermediate host snail, Austropeplea ollula, were found near the residence of the patients, and one of the collected snails was positive for F. hepatica/gigantica hybrid type rediae. Our report should alarm the medical professionals for this rare and unfamiliar parasitic disease.

Epstein-Barr virus-associated infectious mononucleosis with acute epididymitis: a case report.

BACKGROUND: Infectious mononucleosis due to the Epstein-Barr virus is an infectious disease that causes the appearance of atypical lymphocytes in the peripheral blood; it mainly presents with fever, tonsillar pharyngitis, and lymphadenopathy. In addition to hepatitis, splenomegaly, and rashes, it can involve different organs. Here, a case of epididymitis as a rare complication in a patient with Epstein-Barr virus-associated infectious mononucleosis was reported. CASE PRESENTATION: A healthy 23-year-old man visited an outpatient clinic with fever and pharyngitis. Tonsillar pharyngitis, lymphadenopathy, atypical lymphocytes in the peripheral blood, liver dysfunction, and splenomegaly were observed. The patient was diagnosed with infectious mononucleosis based on clinical signs. The next day, the patient developed left testicular pain and was immediately transferred to the emergency outpatient ward. Pain, redness, and swelling were observed in the left scrotum. Ultrasonography revealed swelling of the epididymis and increased blood flow, and the patient was hospitalized with a diagnosis of left epididymitis. The patient's symptoms improved with symptomatic treatment and was discharged on day 16 after admission. Changes in antibody titers established a definitive diagnosis of infectious mononucleosis caused by the Epstein-Barr virus. Based on the disease course, the patient was also diagnosed with infectious mononucleosis associated with unilateral epididymitis. CONCLUSIONS: This is the first case report of Epstein-Barr virus-associated infectious mononucleosis complicated with acute epididymitis. Infectious mononucleosis can cause numerous organ-related complications; thus, physicians and healthcare workers should remain cognizant of Epstein-Barr virus-associated complications throughout the body and not just in the primary organs affected by infectious mononucleosis.

Loss of PRMT1 in the central nervous system (CNS) induces reactive astrocytes and microglia during postnatal brain development.

PRMT1, a major arginine methyltransferase, plays critical roles in transcription, DNA damage response, and cell proliferation. Although we have previously discovered the crucial roles of PRMT1 for oligodendrocyte lineage progression in the central nervous system of neural stem cell-specific PRMT1 conditional knockout (PRMT1-CKO) mice, the context of other glial cell states that may cause the hypomyelination phenotype in PRMT1-CKO mice has not been explored so far. Here, we performed RNA-seq of the neonatal cortices of PRMT1-CKO mice to reveal overall gene expression changes and show the up-regulation of inflammatory signaling which is generally mediated by astrocytes and microglia in advance of the myelination defects. In particular, qRT-PCR analyses revealed Interleukin-6 (Il-6), a major central nervous system cytokine, was dramatically increased in the PRMT1-CKO brains. The gene expression changes led to augmentation of glial fibrillary acidic protein and Vimentin protein levels in PRMT1-CKO mice, showing severe reactive astrogliosis after birth. We further show that IBA1-positive and CD68-positive activated microglia were increased in PRMT1-CKO mice, in spite of intact Prmt1 gene expression in purified microglia from the mutant mice. Our results indicate that PRMT1 loss in the neural stem cell lineage causes disruptive changes in all glial types perturbing postnatal brain development and myelination.

Meningitis retention syndrome caused by varicella zoster virus in a patient without a rash: a case report.

BACKGROUND: Meningitis retention syndrome (MRS) is a rare condition that presents with acute urinary retention as a complication of aseptic meningitis. Cases of MRS due to varicella zoster virus (VZV) infection without a rash are rare. We report the case of a patient who had no signs of meningitis or VZV infection, including a rash. CASE PRESENTATION: A 58-year-old man presented with dysesthesia of the lower limbs and acute urinary retention. He had fever but no rash and no signs of meningitis. He was diagnosed to have VZV infection based on the detection of VZV DNA in the cerebrospinal fluid. He responded satisfactorily to a course of intravenous acyclovir and experienced no sequelae during a 2-year follow-up period. CONCLUSION: MRS due to aseptic meningitis of viral origin should be considered in the differential diagnosis of acute urinary retention even in the absence of specific signs and symptoms of meningitis or a suggestive rash.

Multiple thrombosis associated with Cytomegalovirus enterocolitis in an immunocompetent patient: a case report.

BACKGROUND: Cytomegalovirus (CMV) is reported to have thrombogenic characteristics that activate factor X in vitro and stimulate the production of factor VIII and von Willebrand factor (vWF). Thrombosis associated with CMV infection is prevalent among immunocompromised patients and predominantly presents as a solitary large thrombus in the deep vein, pulmonary artery, splanchnic arteriovenous ducts, or other similar sites. Multiple thrombi, however, are rarely observed in such cases. Here, we report about an immunocompetent man with multiple microthrombi associated with CMV infection. CASE PRESENTATION: A 72-year-old Japanese man who complained of abdominal pain was hospitalized with multiple colonic stenosis. He was later diagnosed with CMV enterocolitis and treated with ganciclover from Day 27 post-admission. During hospitalization, the patient developed thrombi in his fingers. He was initially treated with anticoagulant therapy (rivaroxaban); however, the therapy was discontinued owing to a prolonged activated thromboplastin time and an elevated international normalized ratio of prothrombin time. Instead, vitamin K and fresh-frozen plasma were administered. Nevertheless, his coagulation profile remained abnormal. Eventually, he developed colonic perforation and had to undergo emergency surgery. An intraoperative specimen showed several microthrombi in the middle and small arteriovenous ducts of his small and large intestines. The patient's coagulopathy improved preoperatively, and his overall condition improved postoperatively. Since the activation of ADAMTS13 was reduced remarkably, the thrombotic tendency was determined to be a thrombotic microangiopathy-like condition owing to increased vWF. We could not attribute the coagulopathy to any other cause except CMV infection; therefore, we concluded that this was a case of multiple thrombosis associated with CMV. CONCLUSIONS: We present an extremely rare case of a patient with multiple thrombotic microangiopathy-like microthrombosis caused by CMV infection. Our findings suggest that CMV infection may be considered as a differential diagnosis for immunocompetent individuals who present with thrombosis of unspecified cause.

Utility of Ascitic Fluid Adenosine Deaminase Levels in the Diagnosis of Tuberculous Peritonitis in General Medical Practice.

BACKGROUND: Tuberculous peritonitis is difficult to diagnose due to its varying clinical features, in addition to the low yield on bacterial culture or polymerase chain reaction using ascitic fluid samples. This study aimed to investigate the sensitivity and specificity of elevated adenosine deaminase (ADA) levels as a diagnostic marker for tuberculous peritonitis. METHODS: A retrospective cohort of 181 adult patients who underwent ascitic fluid ADA level examination at Jichi Medical University Hospital between January 2006 and December 2015 were included. We collected data regarding ascitic fluid analyses including ADA levels, bacteriology and cytology, final diagnosis (cause of ascites), basis of the diagnosis, duration to diagnosis, and disease outcome. RESULTS: Among 181 patients, elevated ascitic ADA levels (≥40 IU/L) were observed in 15 patients (median, 87.2 IU/L; range, 44.0-176.1 IU/L); 8 patients had tuberculous peritonitis, 4 had lymphoma-related ascites, and 2,had peritoneal carcinomatosis with bacterial coinfection, and 1 had chlamydial pelvic inflammatory disease. Among 166 patients without ascitic ADA level elevation (median, 7.3 IU/L; range, <2.0-39.1 IU/L), none had tuberculosis, 4 had lymphoma-related ascites, 28 had cancer/mesothelioma-related ascites, and 134 had ascites due to other causes. In our cohort, elevated ascitic fluid ADA levels (≥40 IU/L) showed 100% sensitivity, 96.0% specificity, 53.3% positive predictive value (PPV), and 100% negative predictive value for the diagnosis of peritoneal tuberculosis. CONCLUSIONS: Ascitic fluid ADA levels ≥40 IU/L showed excellent sensitivity, despite a low PPV, for the diagnosis of tuberculous peritonitis. Lymphoma-related ascites is an important mimic of tuberculous peritonitis that can result in high ascitic fluid ADA levels with similar clinical manifestations.

The Difference between Ideal and Actual Fasting Duration in the Treatment of Patients with Aspiration Pneumonia: A Nationwide Survey of Clinicians in Japan.

In Japan, aspiration pneumonia is common among the elderly and patients are often treated by temporary discontinuation of meals. However, there are few published studies on the fasting duration for aspiration pneumonia treatment. Therefore, we conducted the present study to assess the opinions of clinicians regarding the fasting duration for the treatment of patients with aspiration pneumonia and the actual medical practice with regard to oral ingestion in hospitalized patients with aspiration pneumonia. We targeted hospitals with internal medicine and respiratory medicine departments across Japan. A questionnaire regarding the fasting duration for aspiration pneumonia treatment and oral ingestion in hospitalized patients with aspiration pneumonia was mailed to physicians treating patients with pneumonia at 2,490 hospitals. We received appropriate responses from 350 facilities (response rate, 14.1%). Most clinicians (78.3%) responded that it best to keep the fasting duration for treatment as short as possible and considered that fasting is absolutely unnecessary. Regarding oral ingestion in hospitalized patients, more than 25% of clinicians restricted oral intake for a certain number of days. The majority of these clinicians (53.3%) preferred prolonged fasting for 3 to 7 days. Although most physicians preferred the fasting duration to be as short as possible, there was a difference between the ideal and actual scenarios in reintroducing oral intake early in patients with aspiration pneumonia. Improving physicians' knowledge and experience will bridge the gap between the ideal situation and what currently occurs. Further studies should investigate the acceptable fasting duration for the treatment of aspiration pneumonia.

A rare case of anasarca caused by infiltration of the pituitary gland by diffuse large B-cell lymphoma.

BACKGROUND: Anasarca in patients with lymphoma is a rare symptom. We report a patient with DLBCL associated with pituitary gland infiltration that was diagnosed based on significant anasarca. CASE PRESENTATION: A 72-year-old woman with a 10-year history of hypertension visited a local hospital presenting with anasarca and 15-kg weight gain in the past 3 months. we clinically diagnosed central hypothyroidism caused by pituitary gland infiltration of diffuse large B-cell lymphoma (DLBCL) (clinical stage IV in the Ann Arbor staging classification). The first course of chemotherapy improved anasarca remarkably and the patient's body weight returned to what it was 3 months before. CONCLUSIONS: We experienced a patient with remarkable anasarca caused by DLBCL infiltration of the pituitary gland. A pituitary gland lesion with central hypothyroidism should be considered as one of the differential diagnoses of edema. This case was very valuable because we could assess it by following the time course of symptoms (edema and delayed relaxation time of the Achilles tendon reflex), laboratory data, and imaging findings (swelling anterior pituitary lobe).

A case of subacute infective endocarditis and blood access infection caused by Enterococcus durans.

BACKGROUND: Infection by Enterococcus durans (E. durans) is very rare; reported cases are often preceded by therapy or an immunosuppressed state, including infective endocarditis, urinary tract infection, or wound infection. A few reported cases of infective endocarditis exist, with no reports describing involvement of blood access infection. CASE PRESENTATION: The patient is an 83-year-old man who had been undergoing hemodialysis for 8 years due to renal failure caused by diabetic nephropathy. He developed infective endocarditis and blood access infection/infective aneurysm due to Enterococcus durans; these conditions were treated with the antibiotic regimen of ampicillin + gentamicin. There have been only a few reported cases of infective endocarditis caused by E. durans, and to our knowledge, this is the first report of blood access infection. CONCLUSIONS: We have experienced a case of concurrent infective endocarditis and blood access infection/infective aneurysm caused by E. durans. This is the world's first reported case of blood access infection/infective aneurysm by E. durans.

Training items for trainee residents in community medicine in rural areas.

OBJECTIVE: To examine the significant events experienced by initial trainees during community medicine training, evaluate their impact on community medicine practice, and support improvements in rural community medicine training. RESULTS: Three faculty teachers independently evaluated the reports of 25 residents who had completed a four-week community medicine training in a rural area to analyze major events. The reports were analyzed using topics from the Model Core Curriculum for Medical Education that relate to rural medicine. The most frequently reported items were identified as follows: Primary care: 9 (36.0%); integrated community care systems: 8 (32.0%); medical care in the local community: 7 (28.0%); home health care and systems, patient-physician relationship, and end-of-life medical treatment and care: 6 each (24.0%). Reports from residents describing events related to home health care and systems and end-of-life medical treatment and care were related to more than one item.

A Comparison of the Learning Effects of Face-to-Face Versus Online Formats of a Clinical Reasoning Lecture.

Objective This study investigated the different learning effects achieved through a clinical reasoning lecture that was simultaneously conducted via two formats: one format involved in-person face-to-face instruction, whereas the other provided remotely conducted online instruction. The lecture was based on a case presentation held at a participating university in 2015. Methods We compared the learning outcomes between the abovementioned formats based on participants' responses. Data were obtained using questionnaires distributed to eligible lecture attendees, including medical students and physicians who had graduated during the preceding 10 years. The questions were about the following aspects: the time duration of the lecture, degree of satisfaction with the online system (online attendees), and degree of satisfaction with the lecture content. The participants then completed a five-question mini-test related to the disease from the presented lecture case to assess their overall degree of understanding. Results Online participants gave significantly higher scores for images in the online system (degrees of satisfaction: online 72.7 ± 18.0 vs. in-person 55.6 ± 24.9), audio in the online system (66.1 ± 20.5 vs. 57.5 ± 25.8), the usefulness of multiple venues (82.1 ± 19.3 vs. 60.5 ± 25.0), intention to attend the next lecture (82.3 ± 19.0 vs. 65.8 ± 21.4), and overall meaningfulness of the lecture in the online interactive format (83.6 ± 16.3 vs. 72.6 ± 19.6) compared with the in-person group. However, similar mini-test scores were documented between the two groups (4.2 ± 0.7 for the in-person group and 4.3 ± 0.7 for the online group; no significant differences were noted). Conclusions The results show similar learning effects, degrees of satisfaction, and degrees of comprehension between online and in-person lecture attendees. Our findings demonstrate that the online format is a suitable pedagogical intervention in the study context. Continued implementation and further studies are thus warranted to gain deeper insights into the topic.

Evaluation of Adverse Reactions to Influenza Vaccination: A Prospective Cohort Study.

This study aimed to investigate the influence of sex, age, and quadrivalent vaccination history on adverse reactions (ARs) to influenza vaccines and the relationship between the occurrence of ARs and the risk of influenza infection. Study participants were employees of three hospitals in the Hyogo Prefecture, Japan, who received the influenza vaccine in 2019. Data were collected using questionnaires. The main factors were age, sex, and history of influenza vaccination as a control. The primary outcomes were the incidence of local and systemic ARs attributable to the vaccine and positive influenza cases among the participants during the influenza season. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (CI). Among the 1493 participants, 80% experienced either local or systemic ARs. ARs were less common among men than among women (OR: 0.28, 95% CI: 0.21-0.37) and less common among those aged ≥60 years (OR: 0.48, 95% CI: 0.26-0.89). ARs were significantly more likely to occur in those with a history of influenza vaccination (OR: 1.96, 95% CI: 1.15-3.33). Those who had ARs, notably localized ones, were significantly more likely to incur influenza infection. Individuals who report ARs to influenza vaccination should strictly adopt non-pharmaceutical preventive measures in the hospital, community settings, and at home.

Varicella-zoster virus-associated meningitis, encephalitis, and myelitis with sporadic skin blisters: A case report.

BACKGROUND: Varicella-zoster virus (VZV) generally causes chickenpox at first infection in childhood and then establishes latent infection in the dorsal root ganglia of the spinal cord or other nerves. Virus reactivation owing to an impaired immune system causes inflammation along spinal nerves from the affected spinal segment, leading to skin manifestations (herpes zoster). Viremia and subsequent hematogenous transmission and nerve axonal transport of the virus may lead to meningitis, encephalitis, and myelitis. One such case is described in this study. CASE SUMMARY: A 64-year-old man presented with dysuria, pyrexia, and progressive disturbance in consciousness. He had signs of meningeal irritation, and cerebrospinal fluid (CSF) analysis revealed marked pleocytosis with mononuclear predominance and a CSF/serum glucose ratio of 0.64. Head magnetic resonance imaging revealed hyperintense areas in the frontal lobes. He had four isolated blisters with papules and halos on his right chest, right lumbar region, and left scapular region. Infected giant cells were detected using the Tzanck test. Degenerated epidermal cells with intranuclear inclusion bodies and ballooning degeneration were present on skin biopsy. Serum VZV antibody titers suggested previous infection, and the CSF tested positive for VZV-DNA. He developed paraplegia, decreased temperature perception in the legs, urinary retention, and fecal incontinence. The patient was diagnosed with meningitis, encephalitis, and myelitis and was treated with acyclovir for 23 days and prednisolone for 14 days. Despite gradual improvement, the urinary retention and gait disturbances persisted as sequelae. CONCLUSION: VZV reactivation should be considered in differential diagnoses of patients with sporadic blisters and unexplained central nervous system symptoms.

Efficient open recruitment and perspectives of host families on medical student homestays in rural Japan.

We devised and assessed open recruitment of host families for medical student homestays in a rural area of Hyogo Prefecture, Japan, so that program organizers would not have to depend on professional and personal connections. The duration of the homestays was one night and two days, and they were conducted in August 2016, 2017, and 2018. The purpose of this community-based medical education program was to promote interactions between medical students and residents of Tamba area. The study asked one family member from each host family to complete a questionnaire after the homestay, and their experiences were evaluated in the study. The questionnaire results were analyzed using a visual analog scale (VAS; 0-100 mm). Thirty-three host families participated in the homestay program over three years. Results showed that VAS scores were high for enjoyment of homestays (VAS; 92.4 ± 13.0), continuation of the homestay program (91.7 ± 12.7), continuation of participation in the homestay program (89.2 ± 16.2), and desire for the homestay students to work in the area in the future (95.4 ± 6.3). The recruitment of host families through advertising was an efficient method for this community-based medical education homestay program. The results indicate that it is possible to attract more host families through open recruitment, which will contribute to the sustainability of the homestay program. Further research, including a follow-up of the students who participated and whether they chose a rural area or Tamba to practice is needed in the future. Since this is an ongoing program, further research in a similar format can be conducted in the future.

Breast tuberculosis presenting with intractable mastitis: a case report.

BACKGROUND: Breast tuberculosis, also known as tuberculous mastitis, is an extremely rare form of tuberculosis. It accounts for <0.1% of all breast diseases and <2% of all cases of tuberculosis. It is often misdiagnosed as breast cancer, which can potentially lead to a delayed diagnosis. CASE PRESENTATION: A 69-year-old Japanese woman presented with a tumor-mimicking lesion in her right breast, followed by intractable mastitis with a fistula formation. The time until the correct diagnosis of tuberculosis of the breast and sternal bone was 14 months. CONCLUSIONS: Although rare, it is important to recognize that tuberculous mastitis can present as refractory abscesses/mastitis or mass lesions that mimic carcinomas in women of reproductive age and elderly people. Breast tuberculosis should always be considered in the differential diagnoses, particularly in patients with a history of tuberculosis and those living in areas where tuberculosis is endemic.

Concerns and Anxieties of Patients During Hospitalization for COVID-19.

Objective The objective of this study was to evaluate the concerns and anxieties of hospitalized coronavirus disease (COVID-19) patients. Methods A questionnaire was distributed to patients on discharge. The responses were analyzed once they were returned by mail. Results Responses were received from 27 of 39 patients (average age, 50 ± 17 years). Among the participants, 16 were male (59.3%), 19 were symptomatic (70.4%), and two required a ventilator (7.4%). Anxiety about symptom exacerbation was reported by 36.0% of participants. Quarantine-associated stress was experienced by 60.0% of participants, and 72.0% of participants supported the change in federal policy that allows asymptomatic patients and patients with mild conditions to isolate themselves at a hotel or their home. Following discharge, 44.0% of participants experienced anxieties regarding their lives after discharge, and 56.0% were anxious regarding discrimination and rumors. During hospitalization, 68.0% of participants re-evaluated their attitude toward health, 44.0% regretted the preventative measures they took before contracting COVID-19, and 44.0% felt guilty for becoming infected. Conclusions Participants experienced various kinds of stress related to hospitalization for COVID-19. There was a trend of people being more concerned about their relationships than their own health. Therefore, as asymptomatic participants and participants with mild symptoms also experienced psychological stresses, it is also necessary to consider the psychological and social effects of the disease.

Changes in patients' outlook, behaviors, and attitudes toward COVID-19 after hospitalization and their experiences of discrimination and harassment.

OBJECTIVE: This study aims to examine changes in patients' perspectives and outlooks regarding the disease and their health after hospitalization for COVID-19 and investigate their discrimination and harassment experiences. This prospective observational study surveyed discharged patients who had been admitted to Hyogo Prefectural Tamba Medical Center in Japan for COVID-19. Patient characteristics, changes in outlook and behaviors after discharge, and incidents of discrimination and harassment were examined. The study was conducted in two waves: March-June 2020 and July-September 2020. RESULTS: Responses were obtained from 27 patients aged 50 ± 17 years, including 16 men (59.3%). We found most patients feared infection before hospitalization (88.5%) and had taken some preventive measures (96.3%), however after discharge, all (100%) practiced social distancing and infection prevention. Twenty patients (80%) considered changing their lifestyles, and 19 (79.2%) decided to use sick leave when they felt ill; these trends were more prominent during the second wave. Six patients (23.1%) reported experiencing discrimination or harassment after discharge. While most patients with COVID-19 had a strong fear of infection before hospitalization, their views about health and health behaviors changed after hospitalization.

Effects of Vaccination Day Routine Activities on Influenza Vaccine Efficacy and Vaccination-Induced Adverse Reaction Incidence: A Cohort Study.

We aimed to investigate the effect of vaccination day routine activities on the influenza vaccine efficacy and vaccination-induced adverse reaction incidence. Study participants were workers at three hospitals in the Hyogo Prefecture, Japan, who received the influenza vaccine between October and November, 2018 and 2019. Their data were collected using a questionnaire. The main factors, which were examined for vaccination day routine activities, were personal hygiene (bathing), smoking, alcohol consumption, caffeine intake, and exercise. The main outcome markers included influenza incidence during the winter season and vaccination-induced local or systemic adverse reaction incidence. The risk ratio for the main factors of vaccination day routine activities was calculated against the main outcome markers using the modified Poisson regression. Overall, 3780 people received the influenza vaccination, and 2731 submitted the questionnaire. We found that vaccination day routine activities did not affect the influenza vaccine efficacy, and engaging in strenuous exercise on the vaccination day tended to cause systemic adverse reactions. Moreover, lifestyle-related activities had no impact on the incidence of systemic or local adverse reactions. Therefore, it is advisable to only avoid strenuous physical exercise, and no other lifestyle-related restrictions are necessary on the day of influenza vaccination.

Acceptance of a homestay program and attitude toward community medicine among medical students.

BACKGROUND: In community-based medical education, opportunities for medical students to interact with local residents are important. To facilitate such interaction, we aimed to evaluate acceptance of a homestay program and attitude toward community medicine among medical students. METHODS: The participants (n = 39) were allowed to stay in the local homes of residents for one night in August 2016, 2017, and 2018. Before and after the homestays, the students responded to a self-reported questionnaire using the visual analog scale (VAS; 0-100 mm). The questionnaire included four questions on homestay/community medical training and community medicine and four questions about attitude toward community medicine in the local areas of medical students. Then, we compared the VAS scores before and after training. RESULTS: The VAS scores for all questions about homestay/community medical training and community medicine significantly increased: "Is it worthwhile for you to have experience in the field of community medicine," "Did you find the homestay enjoyable," "Does the homestay add educational significance to the program," and "Is direct interaction with residents meaningful?" For the two questions about attitude toward community medicine, the VAS scores significantly increased: "Is there a challenge to practicing community medicine" and "In the future, do you want to work in Tamba area where you stayed?" CONCLUSIONS: The medical students were extremely enthusiastic about the educational program for community medicine involving residential homestays, which improved their attitudes toward practicing community medicine. Moreover, the students appreciated that their training sites could become their future workplaces.