Evaluation of primary care practice in the University of Tokushima

The shortage of medical doctors is now a serious social problem in Japan. There are 2.1 physicians per 1000 residents in Japan, fewer than most other OECD countries. Tokushima Prefecture has the second highest population of medical doctors in Japan, but the shortage of medical doctors in rural areas was observed by an uneven distribution. Primary care practice was started in the education of clinical clerkship for 5th grade medical students of our university since July, 2008. They round a variety of hospitals, clinics and facilities for nursing-care during one week in Kaihu county where has a severe problem in the shortage of medical doctors in Tokushima Prefecture. In order to research the efficacy of the primary care practice, we have administered a questionnaire for medical students before and after the lecture and practice, and the intensity was estimated in each student by using visual analogue scale. The results showed that the practice was more meaningful in increasing the intensity for interest and passion for community medicine and medicine in remote area than the lecture. Our data indicate that it is important to prepare more courses to learn primary care and general medicine in our clinical practice system to continue the interest and passion in community medicine

Perspectives on enteral tube feeding in Japan

[Introduction] The purpose of this study was to investigate the differences in the preference of enteral tube feeding between elderly inhabitants of Mugi town, Tokushima Prefecture, Japan, and their parents in various physical conditions. [Methods] This population-based questionnaire survey studied 300 randomly selected participants aged 65–80 years. Respondents were to consider a situation where eating was difficult, and were questioned on their desire for tube feeding, using a visual analogue scale (VAS) ranging from “do not want tube feeding (0)” to “want tube feeding (100).” [Results] Valid responses of 103 (34.4%) participants were analyzed. Under conditions of being “healthy,” “bedridden,” “with dementia,” and “bedridden and with dementia,” the median (IQR) of the VAS values for the desire for tube feeding were 31.8 (3.3 to 83.8), 19.3 (2.4 to 52.3), 5.2 (0.7 to 18.9), 4.0 (0.3 to 15.2) for respondents and 55.2 (11.6 to 92.2), 48.7 (5.5 to 85.5), 9.0 (1.2 to 46.8), 5.1 (0.1 to 36.5) for parents, respectively. The VAS values for the parents were significantly higher (p=0.001, 0.002, 0.001, and 0.01, respectively for the four conditions described) for the same items. [Conclusion] Surrogate decisions made by family members often differ from what the patients would have desired

Past infections and low ACPA in RA

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

CRP in PMR and RS3PE syndrome

Polymyalgia rheumatica (PMR) and remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome are common inflammatory rheumatic diseases in the elderly. In this study, we investigate predictive factors which correspond to subsequent disease control of PMR and RS3PE syndrome. Twenty four patients, which contained 18 PMR and 6 RS3PE syndrome, were treated with initial dosages of 10-20 mg per day oral prednisolone, and the dosage of prednisolone was then tapered. Significantly higher initial CRP was observed in patients with poor disease control than in those with good disease control afterwards. The number of patients with negative CRP after 4 weeks was significantly more in patients with good disease control after 1 year than in those with poor disease control. Patients were shown to be in good disease control status after 1 year when CRP after 4 weeks became negative even if they had initial high CRP. Our study clarify that to make CRP negative after 4 weeks is associated with subsequent suppression of the disease activity and with decreased dosages of corticosteroids

ヘキチ イリョウ キョテン ビョウイン ニオケル センモン ガイライ ノ カンジャ ジュリョウ ドウコウ ニ オヨボス エイキョウ

There were few reports about the role of medical specialists in community medicine organizations such as hospitals in rural area where the number of doctors is insufficient. The aim of this study was to investigate the effect of a medical specialist for collagen vascular diseases having started periodically ambulatory care in the medical institution of the area where the specialist was absent. We examined the trend of outpatients with a collagen vascular disease about moving the hospital comparing before and after the specialist started to work in the medical institution. The number of outpatients with a collagen vascular disease in the medical institution became 95 at 3 years and a half after the specialist started to work there. There were many transfer patients from medical institutions other than the area, and the distance from their home to the hospital was shortened by changing the hospital in most of patients. The ambulatory care performed periodically and continuously by the specialist in a community medicine organization showed significances that patients became to receive the special medical care by the specialist

Atopic Dermatitis in Mouth Breathers

As mouth breathing is associated with asthma and otitis media, it may be associated with other diseases. Therefore, this population-based cross-sectional study evaluated the association of mouth breathing with the prevalences of various diseases in children. Preschool children older than 2 years were included. A questionnaire was given to parents/guardians at 13 nurseries in Tokushima City. There were 468 valid responses (45.2%). We defined a subject as a mouth breather in daytime (MBD) if they had 2 or more positive items among the 3 following items: “breathes with mouth ordinarily,” “mouth is open ordinarily,” and “mouth is open when chewing.” We defined subjects as mouth breathers during sleep (MBS) if they had 2 or more positive items among the following 3 items: “snoring,” “mouth is open during sleeping,” and “mouth is dry when your child gets up.” The prevalences of MBD and MBS were 35.5%and 45.9%, respectively. There were significant associations between MBD and atopic dermatitis (odds ratio [OR]: 2.4, 95% confidence interval [CI]: 1.4–4.2), MBS and atopic dermatitis (OR: 2.4, 95% CI: 1.3–4.2), and MBD and asthma (OR: 2.2, 95% CI: 1.2–4.0). After adjusting for history of asthma and allergic rhinitis; family history of atopic dermatitis, asthma, and allergic rhinitis; and nasal congestion; both MBD (OR: 2.6, 95% CI: 1.3–5.4) and MBS (OR: 4.1, 95% CI: 1.8–9.2) were significantly associated with atopic dermatitis. In preschool children older than 2 years, both MBD and MBS may be associated with the onset or development of atopic dermatitis

ゼンシッカン オ タイショウ トスル リハビリテーション ノ ガイネン : シッカン ニ カカワラナイ ソウキ ドウニュウ ノ ユウコウセイ

The right Japanese translation of rehabilitation is a “return” and is not the meaning “training.” It is a cure aiming at returning to the state before suffering from the illness in the body, soul, and social environment. Therefore, the rehabilitation should be performed to not only bone and joint diseases and apoplexy but also other diseases or states including infectious diseases and the state after surgery. Patients who are compulsorily stayed on the bed for a long time, especially in an acute care ward, easily become bedridden with various complications such as gait or eating disorder. It is important to try for all the staff in connection with medical care to have a rehabilitation concept, and to return a patient to the former condition falling ill

Community-based clinical education increases motivation of medical students to medicine of remote area : comparison between lecture and practice

In this study, we administered a questionnaire to medical students to evaluate the effect of community-based clinical education on their attitudes to community medicine and medicine in remote area. Questionnaires were given 4 times to all the students from first-year to sixth-year. Of 95 students, 65 students (68.4%) who completed all questionnaires, were used in this study. The intensity of students’ attitudes was estimated by using visual analogue scale. The intensity of interest, a sense of fulfillment and passion in medicine of remote area was significantly increased　after the community-based practice. On the other hand, the level of understanding in medicine in remote area was increased by the lecture not by the practice. The intensity of desire both to become a generalist and a specialist was significantly increased when the grade went up. Most of sixth-year students desired to have abilities of a generalist and a specialist simultaneously. This study shows that the community-based practice is more meaningful in increasing motivation in medicine in remote area than the lecture, and suggests that it is　important to prepare more courses to　experience community medicine to increase the number of physicians who desire to work in remote area

Characteristics of medical students who would like to be a generalist physician and contribute to remote area medicine

We administered a questionnaire to 5th grade medical students to examine the effect of communitybased clinical practice on their attitudes to remote areamedicine and their course after the graduation.Data from 192 students were obtained. The intensity of students’ attitudes was estimated by using visual analogue scale. The intensities of the interest and a sense of fulfillment in remotearea medicine were significantly increased after the practice. A significantly lower level of the intensity to becomea generalist than that to becomea specialist was seen inthe students with low intensity in a sense of fulfillment. The percentages of the students who answered that they can work for 5 years or more in remote area were significantly lower in students with low intensity of a sense of fulfillment than in those with high intensity. A significantly higher percentage in students who worked at a familiar prefecture to them after the graduation was seen in female than in male. This study shows that the community-based practice is meaningful in increasing motivation which desire to work in remote area medicine, and that themotivation may affect their course after the graduation

Treatment responses and their predictors in patients with rheumatoid arthritis treated with biological agents

Biological agents represent an important advancement in for the treatment of rheumatoid arthritis (RA), but there is a subset of patients who do not improve despite therapy. This study aimed to determine the efficacy of biological agents for RA and to identify clinical factors that are associated with their response. We studied 98 patients with RA who started an initiating biological agent which was selected from infliximab, etanercept, adalimumab and tociliximab at 4 medical institutions. Etanercept was the most frequently used biological agent followed by infliximab although there was a difference in the selection of the biological agents among medical institutions. We found that etanercept achieved the highest treatment response, remission rate and drug survival rate. A high disease activity in the baseline disease activity score-c-reactive protein (CRP) was shown to be a negative predictor of the treatment response, and high patient global assessment was significantly less likely to achieve a good response. At week 4, decreases in 28 swollen joint counts and CRP were useful as predictors for sustaining the efficacy up to week 48. These data demonstrate that assessments of the disease activity at baseline and the early treatment response may be useful in predicting the efficacy and drug survival rate of biological agents