Our Health Care Systems, especially our hospitals, were designed primarily to provide episodic care for acute occurrences of single diseases. With our aging population and the predominance of chronic diseases, highly integrated and coordinated care is required. This demands a “systems re-design”, not just making the old system better. Additionally, higher expectations of patients and families to be involved in and co-direct their care, and the advent of rapidly evolving mobile information technology (mHealth), requires an innovative and “agile” approach to this re-design process. To be sustainable, innovation must improve the experience of care for both patients and health care providers, as well as produce clinical and financial outcomes that are at least as good as or better than current care. Health Systems Centres of Innovation can be provide “new ways of thinking” about health care, and the creativity to sustainably re-design our Health Care Systems.

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Background: Although community-based training is included in medical undergraduate education in Japan, little assessment of the outcomes of community-based education programs has been performed. The aim of this study was to investigate the outcomes of a community-based education program using a mixed method.
Methods: The study design utilized both qualitative and quantitative methods (mixed method). The subjects (n = 278) were fifth-grade medical students who were involved in the program from 2008 to 2010 inclusive. We collected two types of data: a six-item pre-and-post questionnaire (quantitative) and an open-ended questionnaire (qualitative) to evaluate the impressions this experience left on the students.
Results: Pre-and-post questionnaires were completed by 263 (95%) of 278 subjects; on all items, the scores of the post- data were significantly higher than that of pre- data (P < 0.001). From the responses given by 139 respondents (total 181, 77%) in the open-ended questionnaire survey, 10 themes were extracted: 1. Inter-professional cooperation; 2. Role and cooperation among university hospitals, community hospitals, clinics, and welfare facilities; 3. Patient-centered medicine; 4. Trust-based relationships; 5. Competency in general medicine; 6. Professionalism; 7. Medical management; 8. Communication; 9. Common diseases; and 10. Long-term care.
Conclusions: We found that medical students gained four major perspectives from their experiences: Inter-professional cooperation, trust based relationships, roles of community hospitals and clinics, and patient-centered medicine, respectively. Our findings suggest this program contributed significantly to their understanding of community medicine.

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Background: Blood culture is an essential examination for diagnosis of causative microorganisms and determination of optimal antimicrobials in serious cases of infectious diseases. We examined temporal trends in the number and multiplicities of blood culture submission, two pre-analytic parameters indicating quality of the examination, in the Minami Ibaraki Area.
Methods: We reviewed all computerized and available paper-based laboratory records of microbiological examination in five hospitals in the area between 2002 and 2011.
Results: Blood culture submissions, estimated to be 2.4–7.3 (median: 5.1) sets per hospital bed, 8.6–23 (17) per 1,000 inpatient-days, and 0.13–0.41 (0.25) per newly admission in 2011, almost constantly increased during the study period in all hospitals. Proportions of blood specimens to all materials for microbiological cultures also increased up to 15–30% (20%) in 2011. In contrast, it was not until the latter half of the study period that solitary submission, accounting for 26–56% (35%) in 2011, decreased. Positive blood cultures were between 11 and 28% through the study period. Coagulase-negative staphylococci accounted for approximately one fourth of recovered organisms in 2006 and 2011.
Conclusion: Frequency and multiplicity of blood culture submission markedly increased in hospitals in the Minami-Ibaraki Area of Japan.

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Background: Socioeconomic status (SES) is correlated with morbidity and mortality rates, in addition to people of a lower social status. Many of such people have health-related problems and do not undergo a regular health checkup or consult a medical practitioner. We investigated whether a correlation exists between SES, psychological state and the number of weeks of gestation at the time of the first examination. We clarified the influence of SES on the subjects’ life events (e.g. pregnancy and childbirth), in order to understand appropriate support measures.
Methods: A total of 151 female study subjects were selected from among women hospitalized for postpartum care, who underwent prenatal checkups, and delivered their children in the study center. Questionnaire surveys, one of which involved an interview, were conducted in a cross-sectional manner for the subjects’ during their pregnancy and in the postpartum period.
Results: The results show that women who perceived financial constraints showed a significantly stronger tendency to develop depression. Multiple logistic regression analysis showed that women whose partners had an educational background of junior high school level underwent their first gestational examination at week 12 or later of pregnancy (odds ratio of 10.99, P = 0.001; 95% confidence interval, 3.15–86.79).
Conclusion: The present study suggests the importance of observing the correlation between SES and health among pregnant women, such that strategic interventional services can be provided to such persons.

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We report the case of a 34-year-old man who was initially diagnosed with a tension-type headache after complaining of a headache and nausea. His headache worsened in severity and it was exacerbated on standing in the upright position. The patient was admitted to the hospital on suspicion of spontaneous low cerebrospinal fluid (CSF) pressure headache. Gadolinium-enhanced brain magnetic resonance imaging (MRI) revealed diffuse pachymeningeal enhancement, brain sagging, cerebellar tonsillar herniation, brainstem descent and a subdural hematoma. Successful emergency surgery was undertaken.
Spontaneous low CSF pressure headache syndrome is characterized by orthostatic headache, and if such a headache worsens, clinicians should consider a subdural hematoma, a life-threatening complication of this unusual disorder.

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A 31-year-old healthy mother of twins developed Guillain-Barré syndrome in her fourth gestational week of pregnancy. Impaired motor coordination, sensation, and joint position sense were observed. Immunoglobulin therapy was not performed given the early stage of pregnancy. She received rehabilitation to accommodate changes in her body shape and movements necessary for pregnancy, childbirth, and childcare. The patient delivered a healthy baby by cesarean section. By 42 weeks postpartum, she was capable of almost all housework activities and childcare. Family support was important in this case. Patient-oriented intervention, which included periodic confirmation and establishment of goals in each phase and continuity of intervention, was also essential.

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Herein we report a case of restless legs syndrome (RLS) during pregnancy in a 32-year-old woman who began feeling pain in her feet at night at 30 weeks of gestation. She could relieve the pain by moving her legs, but her symptoms worsened, preventing sleep. She was diagnosed with pregnancy-related RLS. Neither carbamazepine nor gabapentin alleviated her symptoms effectively, but the discomfort spontaneously improved two months after delivery. RLS during pregnancy leads to sleep disorders, which are associated with adverse pregnancy outcomes. More attention should be given to RLS during pregnancy.

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We describe a rare case of lower leg infection caused by Haemophilus influenzae serotype b (Hib) in a previously healthy 14-month-old boy. In primary care, H. influenzae is a common pathogen affecting children, and which causes respiratory and central nervous system infection alike. Conversely, skin and soft tissue infections caused by Hib are a somewhat rare occurrence. Beta-lactamase-negative ampicillin-resistant strains have been spreading throughout Japan, although the type of Hib in our case was cephalosporin-sensitive. As a result, we need to pay attention to Hib infection in various clinical settings.

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Myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA) associated glomerulonephritis is commonly diagnosed in elderly patients with acute kidney injury (AKI). Prompt diagnosis and rapid initiation of appropriate therapy are essential to avoid the development of ANCA-associated vasculitis, which can be a life- and organ-threatening disease. We report a rare case of a 91-year-old male with a high MPO-ANCA titer, who took allopurinol, and showed no symptoms for >20 months, following which sudden AKI and severe bronchial asthma necessitated hemodialysis and steroid administration. Chronically elevated ANCA titers should be examined for causes and followed up to limit the risk of subsequent disease development.

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A 72-year-old woman on dialysis acutely developed disturbed consciousness and severe hypertension. Head computed tomography (CT) demonstrated only ventriculomegaly without bleeding. Her consciousness level further deteriorated after dialysis using heparin, and subsequent head CT revealed a new, minor intraventricular hemorrhage. Hemorrhage-associated hydrocephalus was diagnosed, and the installation of a ventriculoperitoneal shunt resulted in good recovery. The patient might have experienced minor repeated bleeding and developed latent post-hemorrhagic hydrocephalus. Even minor bleeding could cause acute exacerbation of hydrocephalus; therefore, clinicians should be alert to hydrocephalus when a dialysis patient develops disturbed consciousness without any evidence of stroke on head CT.

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A 58-year-old female was admitted due to severe sepsis and multi-organ failure with a fulminant purpuric rash. Meropenem, vancomycin and levofloxacin were administered, although no focus of infection was detected. However, computed tomography revealed a profoundly hypoplastic spleen, and a blood smear detected Howell-Jolly bodies. Blood cultures grew Streptococcus pneumoniae (serotype 22F) three hours after admission. The patient was finally diagnosed as overwhelming pneumococcal sepsis with hyposplenism precipitated by splenic hypoplasia. Clinicians should pay attention to the splenic size and Howell-Jolly bodies in cases of sepsis of unknown origin.

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22q11.2 deletion syndrome (22qDS) resulting from a microdeletion of 22q11.2, is usually diagnosed in the postnatal period, and generally manifests as various combinations of cardiac defects, hypoparathyroidism, facial dysmorphism, palate deformity and cellular immunodeficiency. We report a case of a 32-year-old woman presenting with seizures and hypocalcemia, who was diagnosed with 22qDS, along with a literature review of adult cases. Physicians should recognize the 22qDS in adults presenting with any combinations of hypocalcemia, hypothyroidism, cardiac defects and psychiatric disorders. Pathognomonic facial dysmorphism or short stature can be the key to diagnosis.

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