The Clinical Pathway with Regional Alliance (CPRA) system for proximal femoral fractures in the southern region of Ibaraki prefecture: comparison of the proportion of patients who return to living at home from acute care and rehabilitation (kaihukuki) hospitals / Journal of Rural Medicine

Objective: We investigated whether elderly patients treated for a proximal femoral fracture would be able to return home.Patients and Methods: The subjects of this study were 834 patients. We defined the acute care hospital group as patients who returned home from the acute care hospital and the kaihukuki group as patients who were transferred from an acute care hospital to a rehabilitation hospital. We recorded the proportion of patients who returned home. We also analyzed walking ability and the Barthel index (BI) of patients.Results: After 2013, the proportion of patients who returned home from the acute care hospital fell below 20%. The proportion of patients who returned home from the kaihukuki hospital stayed within the 75–85% range. The BI before injury and at discharge was 86 and 76 points, respectively, in the acute care hospital group. The acute care hospital group included patients who walked without an aid before the injury or when leaving the hospital. In the kaihukuki group, the BI before an injury, at admission, and at discharge from the rehabilitation hospital was 85, 56, and 74 points, respectively. In the kaihukuki group, the ability of patients to walk recovered more slowly than that of patients in the acute care hospital group.Conclusion: Walking ability and BI are important factors for determining whether patients with a proximal femoral fracture are able to return home.

Oxidized human serum albumin as a possible correlation factor for atherosclerosis in a rural Japanese population: the results of the Yakumo Study

BACKGROUND@#The effect of the redox state of human serum albumin (HSA) on the antioxidant properties of the entire body has been a focus of recent research. The usefulness of HSA redox state as a biomarker for reducing oxidative stress has been investigated in clinical settings; however, evidence for its significance as a health index in non-clinical settings is yet to be established. This study aimed to examine the associations between HSA redox state and the atherosclerotic indices of carotid intima-media thickness (IMT) and plaque formation in a rural Japanese population.@*METHODS@#We conducted a cross-sectional study as part of a health check-up program in the rural area of Hokkaido, Japan, at the end of August 2013. A total of 281 residents (124 men and 157 women) were included in the final analysis. Lifestyle-related data were obtained through a self-reported questionnaire, and ultrasound examinations were performed to measure IMT and determine plaque formation. The high-performance liquid chromatography postcolumn bromocresol green method was used to separate HSA into human nonmercaptalbumin and human mercaptalbumin (HMA).@*RESULTS@#We found a significant negative relationship between the fraction of HMA [f(HMA)] and IMT (standardized β = - 0.132, p = 0.03). Moreover, f(HMA) was significantly associated with plaque formation (p < 0.01) with an odds ratio of 0.89 (95% confidence interval, 0.81-0.97) for every 10% increment in f(HMA).@*CONCLUSIONS@#We found that the HSA redox state, as determined by f(HMA), was associated with atherosclerotic indices in Japanese subjects. These results suggest that the HSA redox state indicates the risk of developing atherosclerosis.

Elderly Patients with Proximal Femoral Fracture Who Returned to Living at Home with Their Spouse / 日本農村医学会雑誌

　　We investigated whether elderly patients treated for a proximal femoral fracture who lived together with an elderly spouse were able to return home and walk after treatment. Subjects were 85 patients aged > 65 years with a proximal femoral fracture that were treated between January 2007 and December 2013 and who lived at home with their spouse. We recorded the number (proportion) of patients who were directly discharged home from the hospital. We also analyzed their activities of daily living (ADL) using the Barthel index before the injury and again at the time of discharge. We investigated whether there was a sex difference in the ability to return home. Seventy patients (80%) returned home directly from the hospital or from a rehabilitation hospital. The Barthel index before injury and at the time of discharge was 90 points and 81 points in female patients and 84 points and 70 points in male patients, respectively. Forty women (85%) and 30 men (75%) returned home.

Elderly Patients with Proximal Femoral Fracture Who Returned to Living at Home with Their Spouse / 日本農村医学会雑誌

　　We investigated whether elderly patients who were treated for proximal femoral fracture and who lived with an elderly spouse in the community were able to return home and walk. We identified 85 patients aged over 65 years with proximal femoral fracture treated between January 2007 and December 2013 who were living with only their spouse. We recorded the number (proportion) of patients who were directly discharged to home and the duration of hospitalization, and their walking ability before the injury and at the time of discharge. We also investigated whether dementia and age affected the ability to return home. Thirty-two patients (36%) returned home directly from an acute care hospital, and 35 patients (83%) returned home directly from a rehabilitation hospital. The mean duration of hospitalization was 31 days (range, 17-71 days) at an acute care hospital, and 61 days (range, 5-143 days) at a rehabilitation hospital. The walking ability of all patients was worse at the time of discharge. Dementia and increasing age were each associated with not being able to return home.

Evaluation of Bony Impingement in Regard to InternalRotation Limit after Total Hip Arthroplasty UsingRotation Matrix / Journal of Rural Medicine

<b>Objectives:</b> Bony impingement of the proximal femur on the pelvis is an important factor for dislocation after total hip arthroplasty (THA). We evaluated bony impingement after THA using the rotation matrix derived from postoperative computed tomography (CT) images.<br><b>Patients and Methods:</b> One hundred and seven hip joints were subjected to primary THA via a posterolateral approach. We used the rotation matrix derived from CT images to calculate internal rotation (IR) limit prior to bony impingement, and compared this limit with the intraoperative limit.<br><b>Results:</b> The average calculated IR limit was 63 degrees (range: 30 to 85 degrees). The average intraoperative IR limit was 49 degrees (range: 20 to 70 degrees). The correlation between the intraoperative IR limit (Y) and the calculated IR limit (X) was expressed as Y=8.9+0.66X (R=0.73; p < 0.0001).<br><b>Conclusions:</b> We could show a patient´s safe range of motion prior to bony impingement, and this will be a good indicator for dislocation not occurring during postoperative rehabilitation.

THA in Patients with Idiopathic Thrombocytopenic Purpura (ITP): A Case Report / Journal of Rural Medicine

We report a case of idiopathic thrombocytopenic purpura (ITP) accompanied by steroid-induced avascular necrosis of the femoral head in a 68-year-old woman. Extremely low platelet counts of ITP patients prohibit any surgical interventions. Her platelet count was 25,000/μL. We performed a total hip arthroplasty with high-dose immunoglobulin therapy and transfusion of platelet concentrates. Her platelet count increased to 94,000/μL just before the operation. No hemostatic complications were encountered perioperatively, and the postoperative course was uneventful. She left the hospital 20 days after the operation with a T-cane. Her platelet count decreased to 34,000/μL on the day she left the hospital. Three years after the operation, she had no groin pain and could walk without ambulatory assistive devices. We did not observe implant loosening.

Relationship between dietary habits and urinary concentrations of 3-phenoxybonzoic acid in a middle-aged and elderly general population in Japan

<p><b>OBJECTIVES</b>The ingestion of pesticides in the daily diet is assumed to be the main modality of pesticide exposure for most people. A widely used class of pesticides in agricultural or residential settings is pyrethroid. We have examined the relationship between the intake frequency of selected items of vegetables and fruits and urinary metabolites of pyrethroid pesticides in a healthy general population.</p><p><b>METHODS</b>A total of 535 residents (184 men and 351 women) who attended a healthcare checkup program conducted in a rural area of Hokkaido, Japan, in August 2005 provided informed consent for their spot urine samples to be used for the determination of 3-phenoxybenzoic acid (3-PBA) levels. They also completed a self-administered questionnaire regarding the intake frequency of 12 food items. The concentrations of creatinine-corrected 3-PBA were predicted by the intake frequency of each item, using analysis-of-covariance models to adjust for age, sex, body mass index, and drinking and smoking status.</p><p><b>RESULTS</b>Both a significant association between the 3-PBA concentration and the frequency of tomato consumption and a significant positive linear trend was found in female subjects. In contrast, no such association was found in the male subjects.</p><p><b>CONCLUSIONS</b>The frequency of tomato consumption was confirmed to strongly predict the urinary pyrethroid metabolite levels in the general population-presumably because tomatoes are most often consumed raw and unpeeled (more so than all other vegetables and fruits analyzed in the current study). However, it should be noted that the 3-PBA levels, even among those subjects with the highest consumption of tomatoes, were far below the levels of toxicological significance, although the health consequences from long-term low-level exposure to pyrethroid requires further exploration.</p>

Association of serum NO( x ) level with clustering of metabolic syndrome components in middle-aged and elderly general populations in Japan

<p><b>OBJECTIVES</b>The aim of this study was to determine whether the serum nitrite plus nitrate (NO( x )) level correlates with biomarkers that are known components of the metabolic syndrome (MetS).</p><p><b>METHODS</b>Serum NO( x ) levels were measured using a commercial kit in 608 Japanese men and women between the ages of 39 and 85 years. Multivariate adjustments for age, smoking status, alcohol consumption and exercise were made in the analysis of covariance (ANCOVA). The components of the metabolic syndrome were defined based on the following criteria: body mass index (BMI) >/=25.0 kg/m(2), glycated hemoglobin (HbA1c) >/=5.6%, systolic blood pressure >/=130 mmHg or diastolic blood pressure >/=85 mmHg, high-density lipoprotein-cholesterol (HDL-C) </=1.03 mmol/l for men and </=1.29 mmol/l for women and triglyceride >/=1.69 mmol/l.</p><p><b>RESULTS</b>The logarithmically transformed age-adjusted serum NO( x ) (lnNO( x )) value was significantly higher in the low HDL-C group (1.76 +/- 0.05 mumol/l; p < 0.05) than MetS component groups (1.65 +/- 0.01 mumol/l) in men, but no difference was found in women. The means of serum lnNO( x ) after multivariate adjustment were 1.64, 1.65, 1.64, 1.66, and 1.81 mumol/l for 0, 1, 2, 3, and 4-5 MetS components for all subjects, respectively. The results of ANCOVA confirmed that the serum lnNO( x ) level was significantly correlated with the clustering of MetS components in both men and women (p < 0.0001 for trend).</p><p><b>CONCLUSION</b>Our results suggest that an increase in the clustering of MetS components was associated with the increase in serum NO levels in our general population.</p>

Increase in Knowledge of Ignorance During Problem-Based Learning Sessions: Possible Improvement of Metacognition / 医学教育

To seek longitudinal changes in metacognitive processes through problem-based learning (PBL), we analysed the contents of all comments written reflectively by the third-year students after they finished discussions in each PBL session. After dividing their comments into meaningful units, we focused on two major thematic categories and five sub-categories to be analysed.<BR>1) The number of units decreased significantly (chi-square: p=0.02).<BR>2) Only the proportion of units categorised as “comprehension” in “individual learning” showed significant increase (Bonferroni: p<0.001).<BR>3) Comments in this category stated that “I don't understand so-and-so.”<BR>4) The increase of “comprehension” as they experienced more PBL suggested that students' knowledge of ignorance as metacognition was fostered through sessions in medical PBL.

Blood pressure, levels of serum lipids, liver enzymes and blood glucose by aldehyde dehydrogenase 2 and drinking habit in Japanese men

<p><b>OBJECTIVES</b>The association of blood pressure and levels of serum lipids, liver enzymes, blood glucose and aldehyde dehydrogenase 2 (ALDH2) with drinking habit was examined in Japanese men.</p><p><b>METHODS</b>The subjects were 264 men aged 39 to 80 years who were classified into the ALDH2 deficiency or sufficiency group using the ethanol patch test and the Tokyo University ALDH2 Phenotype Screening Test. A self-administered questionnaire including drinking habit was used. Blood pressure and the levels of biochemical markers in groups with ALDH2 sufficiency, ALDH2 deficiency and drinking habit were compared using multiple regression models for adjusting age, smoking habit, physical exercising habit and body mass index.</p><p><b>RESULTS</b>The levels of serum high-density lipoprotein cholesterol, triglycerides, aspartate aminotransferase (AST) and gamma-glutamyl transpeptidase (γ-GTP) were significantly higher in current drinkers of 20 g of ethanol or more per day than in nondrinkers of the ALDH2 sufficiency group. The levels of serum AST and γ-GTP in current drinkers of 20 g of ethanol or more per day, and fasting blood sugar in current drinkers of less than 20 g of ethanol per day were significantly higher than those in nondrinkers of the ALDH2 deficiency group.</p><p><b>CONCLUSIONS</b>These results suggest that alcohol consumption increases the levels of serum lipids and liver enzymes in ALDH2-sufficient individuals and liver enzymes and blood glucose levels in ALDH2-deficient individuals.</p>

Association of abdominal circumference with serum nitric oxide concentration in healthy population

<p><b>OBJECTIVES</b>We determined the relationship between abdominal circumference and the concentration of nitric oxide (NO), an endothelial cell product known to play an important role in the regulation of vascular tone and thrombocyte activations.</p><p><b>METHODS</b>Subjects were 177 men and 339 women aged 40 or over who were free from a history of diabetes or malignancy. Analysis of covariance was applied to examine the gender-specific and smoking-status-specific associations of abdominal fat volume measured as waist circumference, waist-hip ratio, and waist-to-stature ratio, with serum NO level represented by the concentration of NO metabolites (NOx; nitrate plus nitrite).</p><p><b>RESULTS</b>Although men showed no statistical association between abdominal fat accumulation and NOx concentration, abdominal adiposity seemed to inversely affect the serum NOx concentration of never- and current-smoking women.</p><p><b>CONCLUSION</b>Our results suggest that a reduction in NO bioactivity occurs with abdominal fat accumulation in women. The underlying biological mechanism might involve adipocytokines secreted from visceral fat, but is yet to be elucidated.</p>

Association of Abdominal Circumference with Serum Nitric Oxide Concentration in Healthy Population

Objectives: We determined the relationship between abdominal circumference and the concentration of nitric oxide (NO), an endothelial cell product known to play an important role in the regulation of vascular tone and thrombocyte activations. Methods: Subjects were 177 men and 339 women aged 40 or over who were free from a history of diabetes or malignancy. Analysis of covariance was applied to examine the gender-specific and smoking-status-specific associations of abdominal fat volume measured as waist circumference, waist-hip ratio, and waist-to-stature ratio, with serum NO level represented by the concentration of NO metabolites (NOx; nitrate plus nitrite). Results: Although men showed no statistical association between abdominal fat accumulation and NOx concentration, abdominal adiposity seemed to inversely affect the serum NOx concentration of never- and current-smoking women. Conclusion: Our results suggest that a reduction in NO bioactivity occurs with abdominal fat accumulation in women. The underlying biological mechanism might involve adipocytokines secreted from visceral fat, but is yet to be elucidated.

Blood Pressure, Levels of Serum Lipids, Liver Enzymes and Blood Glucose by Aldehyde Dehydrogenase 2 and Drinking Habit in Japanese Men

Objectives: The association of blood pressure and levels of serum lipids, liver enzymes, blood glucose and aldehyde dehydrogenase 2 (ALDH2) with drinking habit was examined in Japanese men. Methods: The subjects were 264 men aged 39 to 80 years who were classified into the ALDH2 deficiency or sufficiency group using the ethanol patch test and the Tokyo University ALDH2 Phenotype Screening Test. A self-administered questionnaire including drinking habit was used. Blood pressure and the levels of biochemical markers in groups with ALDH2 sufficiency, ALDH2 deficiency and drinking habit were compared using multiple regression models for adjusting age, smoking habit, physical exercising habit and body mass index. Results: The levels of serum high-density lipoprotein cholesterol, triglycerides, aspartate aminotransferase (AST) and gamma-glutamyl transpeptidase (γ-GTP) were significantly higher in current drinkers of 20 g of ethanol or more per day than in nondrinkers of the ALDH2 sufficiency group. The levels of serum AST and γ-GTP in current drinkers of 20 g of ethanol or more per day, and fasting blood sugar in current drinkers of less than 20 g of ethanol per day were significantly higher than those in nondrinkers of the ALDH2 deficiency group. Conclusions: These results suggest that alcohol consumption increases the levels of serum lipids and liver enzymes in ALDH2-sufficient individuals and liver enzymes and blood glucose levels in ALDH2-deficient individuals.

Introducing Problem-Based Learning Tutorials into a Traditional Curriculum / 医学教育

Problem-based learning (PBL) tutorials were introduced at our university in April 2001. Because a complete PBLbased curriculum could not be adopted, a transitional curriculum incorporating 3-hour PBL tutorial sessions into the traditional curriculum was introduced. More than 80% of students agreed that PBL is an effective way of learning problem solving at the bedside. Twenty percent to 40% of teachers felt that students who took PBL were more motivated for bedside learning and self-directed learning and had better at presentation than were students who did not take PBL. Because of 80% of the curriculum comprised didactic lectures, most students considered PBL tutorials a type of lecture. For this reason, motivating students to learn additional material originating from PBL tutorials was difficult. Although the combination of a traditional curriculum and PBL tutorials may appear to be a new curriculum, this type of PBL has limited value as a method for studying problem solving.

Usefulness of electronic medical record system for clinical clerkship / 医学教育

We compared the effects on clinical clerkships of an electronic medical record (EMR) system and a standard medical record system. Using an EMR system, students described medical records with a problem-oriented medical record system/subject objective assessment, and plan that was much better than the standard medical record system. In the EMR system, students cannot see physicians' medical records, including laboratory data and X-ray films. Instead, students themselves must obtain the patient history and request examinations as physicians do. This system helps supervisors give suitable comments and provide data that students have requested. Directors can also evaluate supervisors by reviewing their comments. Therefore, an EMR system has the advantage of problem-oriented medical record system-based learning for students and is also useful for clinical clerkships.

The Effect of Serum Carotenoids on Atrophic Gastritis Among the Inhabitants of a Rural Area in Hokkaido, Japan

A total of 206 residents (76 males and 130 females) of a rural area of Hokkaido, Japan, attending a health check in August, 1997, were studied to assess the relationship between serum carotenoids and atrophic gastritis (AG). Of the participants, 91 had AG, as indicated by their serum levels of pepsinogen I and pepsinogen II. Logistic regression analysis, after adjusting for gender and age, revealed that the odds ratios for serum carotenoid levels were lower for subjects with high serum levels of α-carotene (odds ratio, 0.41; 95% C.I., 0.19−0.88) and β-carotene (odds ratio, 0.41; 95% C.I., 0.18−0.91) than for those with low serum carotenoid levels. In addition, the odds ratios of subjects with high serum levels of β-cryptoxanthin (odds ratio, 0.60; 95% C.I., 0.28−1.31), provitamin A (odds ratio, 0.38; 95% C.I., 0.17−0.85), and retinol (odds ratio, 0.67; 95% C.I., 0.31−1.48) were found to be lower than the odds ratios for those with low serum levels. Odds ratios for subjects with high serum zeaxanthin/lutein levels were higher than odds ratios for those with low serum levels. These results suggest that frequent intake of foods rich in carotenoids with provitamin A activity may reduce the risk of AG.