Introducing Objective Structured Clinical Examinations for Undergraduate Orthoptic Education

Aim: Introducing the objective structured clinical examination (OSCE) to improve orthoptic education and clinical competence including the clinical attitude and skills of orthoptic students.Methods: Subjects were thirty-one fourth grade orthoptic students from our department. Six basic examinations were included in stations for trial use of OSCE. The OSCE were performed and compared before and after the eight weeks clinical training. Ten items of clinical attitude and six examinations were evaluated respectively. Six experienced orthoptists evaluated students\u27 clinical attitude and examination techniques while they were performing simulated patient (SPs) examinations according to the evaluation sheets we designed.Results: After clinical training, both students\u27 attitudes toward SPs and examination techniques including correction of refractive errors improved significantly (p<0.05). However, the refractive correction score did not reach sixty. Attitudes toward SPs improved in eight areas out of ten. Safety procedures during examination and signaling the end of examinations did not attain a score of sixty.Conclusion: We were able to evaluate objectively the effect of clinical training on the clinical competence (attitude toward patients and examination techniques) of students by OSCE. Improvements in the evaluation sheets and crossed-check system are still necessary

Population health and regional variations of disease burden in Japan, 1990–2015:a systematic subnational analysis for the Global Burden of Disease Study 2015

BackgroundJapan has entered the era of super-ageing and advanced health transition, which is increasingly putting pressure on the sustainability of its health system. The level and pace of this health transition might vary across regions within Japan and concern is growing about increasing regional variations in disease burden. The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) provides a comprehensive, comparable framework. We used data from GBD 2015 with the aim to quantify the burden of disease and injuries, and to attribute risk factors in Japan at a subnational, prefecture-level.MethodsWe used data from GBD 2015 for 315 causes and 79 risk factors of death, disease, and injury incidence and prevalence to measure the burden of diseases and injuries in Japan and in the 47 Japanese prefectures from 1990 to 2015. We extracted data from GBD 2015 to assess mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), life expectancy, and healthy life expectancy (HALE) in Japan and its 47 prefectures. We split extracted data by prefecture and applied GBD methods to generate estimates of burden, and attributable burden due to known risk factors. We examined the prefecture-level relationships of common health system inputs (eg, health expenditure and workforces) to the GBD outputs in 2015 to address underlying determinants of regional health variations.FindingsLife expectancy at birth in Japan increased by 4·2 years from 79·0 years (95% uncertainty interval [UI] 79·0 to 79·0) to 83·2 years (83·1 to 83·2) between 1990 and 2015. However, the gaps between prefectures with the lowest and highest life expectancies and HALE have widened, from 2·5 to 3·1 years and from 2·3 to 2·7 years, respectively, from 1990 to 2015. Although overall age-standardised death rates decreased by 29·0% (28·7 to 29·3) from 1990 to 2015, the rates of mortality decline in this period substantially varied across the prefectures, ranging from -32·4% (-34·8 to -30·0) to -22·0% (-20·4 to -20·1). During the same time period, the rate of age-standardised DALYs was reduced overall by 19·8% (17·9 to 22·0). The reduction in rates of age-standardised YLDs was very small by 3·5% (2·6 to 4·3). The pace of reduction in mortality and DALYs in many leading causes has largely levelled off since 2005. Known risk factors accounted for 34·5% (32·4 to 36·9) of DALYs; the two leading behavioural risk factors were unhealthy diets and tobacco smoking in 2015. The common health system inputs were not associated with age-standardised death and DALY rates in 2015.InterpretationJapan has been successful overall in reducing mortality and disability from most major diseases. However, progress has slowed down and health variations between prefectures is growing. In view of the limited association between the prefecture-level health system inputs and health outcomes, the potential sources of regional variations, including subnational health system performance, urgently need assessment.FundingBill &amp; Melinda Gates Foundation, Japan Ministry of Education, Science, Sports and Culture, Japan Ministry of Health, Labour and Welfare, AXA CR Fixed Income Fund and AXA Research Fund

根治切除不能再発胃malignant GISTに対しSTI571が著効した1例

症例は40歳男性.胃malignant GIST原発巣切除術後再発をきたし,約2年6ヵ月の間に5回の再発巣切除を行った.しかし,再度再発し,骨盤から胸腔内まで多発転移巣を認め,腹部大動脈周囲を取り巻くように再発巣があることから根治切除不能と診断した.原発巣および切除転移巣の免疫染色においてc-kit陽性であったことからイマニチブの投与を開始した.6週間後の腹部CT検査において大動脈周囲転移巣の消失,肝転移巣,腹腔内転移巣の縮小,壊死化を認め,4ヵ月後の肝転移巣超音波下穿刺組織診において腫瘍細胞を認めなかった.これまでGISTに対する有効な化学療法はなかったがイマニチブの投与は再発GISTの治療において第一選択となる可能性があると考えられた.Gastrointestinal stromal tumors (GIST) have been considered chemoresistant, but recent reports have demonstrated the efficacy of STI571 (imatinib), a tyrosine kinase inhibitor, for c-kit positive GIST. We describe our experience with a patient with radically unresectable recurrent gastric GIST which significantly responded to STI571. A 40-year-old man underwent cardiectomy due to cardial submucosal tumor, which was diagnosed as malignant GIST by histopathology. However, this tumor relapsed in the abdominal cavity 15 months after the first surgery and the recurrent tumor was resected again. The patient experienced five relapses in the abdominal cavity and liver in about 30 months, and every time surgical resection was performed. Finally this patient was admitted for the seventh time due to tumors developing in the mesenterium and remnant liver in October 2001. Encouraged by recent successful clinical reports of STI571 against GIST, STI571 twice daily at 400 mg/day was administered orally, and CT scan at week 6 showed disappearance of the tumor surrounding the aorta, regression of the metastatic liver tumor and the tumor beside the spleen. Abdominal CT scan after 4 months showed further regression of the tumors. Aspiration cytology of metastatic liver tumor did not show any distinctive tumor cells. STI571 is thought to be a possible standard treatment for patients with GIST

胃癌リンパ節転移初期像の検討 : 見張りリンパ節を指標とした胃癌手術は有効か

胃癌外科治療におけるリンパ節廓清術は,術後QOLを考慮して,拡大廓清から縮小廓清の方向へ転化している.さらに近年では症例個々の癌病巣からのリンパ流を確認し,流れの最上流に位置するリンパ節をsentinel nodeとし,このリンパ節を術中病理検索して転移のない場合は,転移なしと考え縮小手術を行うsentinel node navigation surgeryが広く行われ始めている.しかし,本法はほとんどの症例で癌局在部位からのリンパ流が単一流でないと多数のリンパ節を術中に検索する必要性があり,また転移リンパ節を見落とす可能性がある.そこで今回我々は,胃癌においてリンパ節転移の初期症例として少数個リンパ節転移例を対象に,そのリンパ流が単一かを検討した. [対象]標準的2群リンパ節までの廓清が行われ治癒切除となった深達度ssまでの胃癌症例で,転移リンパ節個数が2個から4個までの145症例を対象とした. [結果]全症例の30～40%に複数のリンパ流によるリンパ節転移が存在し,早期癌においても30%, mp癌では38%, ss癌では41%に複数リンパ流による転移が存在した. [考察]胃癌はリンパの流れが多方向にあるため,すべてのsentinel nodeを同定することは困難と考えられた.In consideration of the quality of life of patients, there is a trend in gastric cancer surgery to perform limited rather than extended lymph node dissection. If a sentinel node dissected during surgery is negative for cancer cells pathologically, there is believed to be almost no chance of lymph node metastasis. In this study we focused on gastric cancer cases with lymph node metastasis in order to reveal whether the lymphatic flow is a single stream from the cancerous lesion. Of 145 gastric cancer cases, about 30-40% had lymph node metastasis by multiple routes, and 30% of m, sm cancer, 38% of mp cancer, and 41% of ss cancer cases had multiple routes. Multiple sentinel nodes were involved in gastric cancer, and thus we conclude that it is difficult to identify the sentinel node in gastric cancer

Possible Case of Novel Spotted Fever Group Rickettsiosis in Traveler Returning to Japan from India

A 60-year-old woman experienced fever, headache, rash, and altered vision after returning to Japan from India. Testing detected elevated antibody titers to spotted fever group rickettsia; PCR on blood yielded positive results for the rickettsial outer membrane protein A gene. We isolated a unique rickettsial agent and performed a full-genome analysis