This study investigated the factors identified to date in research related to burnout among visiting (home care) nurses and hospital nurses in efforts to help prevent burnout among visiting nurses. “Nursing”, “visiting nursing”, and “burnout” were used as keywords in a search of the Japan Medical Abstract Society database. Eight studies on visiting nursing were identified. The relevant factors for burnout among visiting nurses that have been identified so far are personal factors, work environment, human relations within the workplace and training systems, factors outside of the workplace, personal perceptions such as a sense of responsibility and burden which are thought to derive from these factors, and communication technology. Given these findings, to prevent burnout, it is important to establish a system that 1) enables nurses to work efficiently so that the physical burden from excess labor is lessened, 2) provides a work environment that reduces excessive burden and responsibility, and 3) recognizes nurses’ duties and growth and takes a positive approach to visiting nursing. It will be necessary to create more definitive preventive measures through further research based on the characteristics and difficulties of home nursing and a thorough understanding of the relationship between the relevant factors.

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　Recent advances in pediatric medicine have led to increasing numbers of severely disabled children who require medical care at home. Severely disabled children were defined as those who have or are at increased risk of having a chronic physical and developmental condition. On April 1, 2015, we conducted a survey of these children aged 18 years or younger living in the Saku region of Nagano Prefecture. Forty severely disabled children were identified in the Saku region, accounting for 0.02% of the population. Thirty children were being cared for at home and 10 had been institutionalized. The underlying illness or disorder occurred in the perinatal period in 21 children (52.5%). We further investigated the medical care and social support of those severely disabled children living at home. There were 8 children with an extremely severe disability and 7 with a moderately severe disability. Fifteen children did not fall into either category. One patient regularly received medical examination and care via visiting serv­ices and the remaining patients received outpatient care. Visiting nurses provided support and care for 10 children (33%), especially those who needed medical care, such as for tracheostomy and gastrostomy. Thirteen children (43.3%) used a short-stay service, and 19 children (63%) used outpatient support (after-school daycare service/day care service for holidays). Short-stay facilities and child day care services are lacking. The custody support system needs to be enhanced in this region for children and their family members to lead healthy lives.

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　　This study calculated risk scores associated with cerebral stroke onset by adding the scores of individual risk factors (sex, age, BMI, history of smoking, and presence or absence of diabetes and hypertension) in individuals who underwent medical check-up of the brain at a community medical support hospital, in order to obtain the supporting data for the promotion of primary preventive behaviors in individuals who underwent this specific medical check-up. Subjects were 1,426 individuals aged 40-60 years, comprising 798 men (56.0%) and 628 women (44.0%), who underwent medical check-up of the brain at the a community medical support hospital in southern Akita Prefecture between April 1, 2009 and August 30, 2013. Risk scores were not significantly different between men and women but were significantly higher in women with unruptured cerebral aneurysm than in women without (29.0±8.3 vs 22.00±8.9, p<0.001). Furthermore, scores of individual risk factors (age, BMI, history of smoking, diabetes, and blood pressure) were higher in individuals with unruptured aneurysm irrespective of sex (p<0.001). The findings of this study provide useful information demonstrating that obtaining risk scores in individuals who underwent medical check-up of the brain leads to better understanding of their lifestyle, the proportion of smokers, and the presence or absence of diabetes, obesity, and hypertension, all of which serve as a solid base in giving health instruction on the primary behaviors that prevent cerebral stroke.

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　　Nutritional support for patients who develop cancer is necessary to increase their food intake, which is often insufficient due to the adverse effects of anticancer drugs and radiation treatment. In December 2011, our center introduced Bocchiri meals for cancer patients to improve their quality of life and support ongoing treatment. In this study, we examined the efficacy of Bocchiri meals, which were developed to help increase the amount of food intake during cancer treatment. Target patients were those who could eat half or less than half of their daily required food intake, averaged over 3 days. Patients could order the meal 2 h before serving time and it was served at the temperature and amount that individual patients requested. We evaluated age, sex, main disease, use of anticancer drugs, radiation treatment, time taken to eat the Bocchiri meals, number of orders made, average energy intake before and after eating the Bocchiri meals, and rate of eating a Bocchiri Meal with a side menu order. Average energy intake was increased from 226.6±14.8 kcal with regular meals to 294.1±15.3 kcal with Bocchiri meals. Furthermore, a strong correlation was seen after the Bocchiri meals were introduced between the rate of eating Bocchiri meals with a side menu order and average energy intake. These results suggest that Bocchiri meals may be an effective supportive nutritional measure to enhance food intake among cancer patients.

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　　Hematopoietic stem cell transplantation (HSCT) involves the administration of anticancer treatment at high doses that exceed the patient’s maximum required dose for total body irradiation, to eliminate malignancy and achieve myeloablation. Hematopoietic stem cells are then transfused to re-establish the lost hematopoietic function. The use of radiation, anticancer drugs, and immunosuppressive drugs can cause adverse events in the oral cavity such as mucositis, bleeding, opportunistic infections, and graft versus host disease. This collaborative report by the departments of hematology and oncology as well as dentistry and oral surgery at our institution discusses the perioperative oral functional management of patients undergoing HSCT. Subjects enrolled were 191 transplantation patients (52 autologous, 139 allogeneic) between 2008 and 2015. The subjects underwent professional tooth cleaning before commencing a transplant conditioning regimen. When the professional oral health care (POHC) treatment was completed, professional tooth cleaning (PTC), professional mechanical tooth cleaning (PMTC), and treatment with a dental drug delivery (3DS) system were provided. This perioperative oral functional management resulted in a decrease in the frequency of oropharyngeal candidiasis from 19.3% to 4.3%. We devised a standardized supportive oral care program from the preoperative period onward to minimize adverse oral events associated with HSCT. The program could effectively improve the quality of life of patients undergoing HSCT.

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　In this study, we report a new network system to facilitate functional cooperation between medical and long-term care providers in the progressively aging society of Japan. Currently, medical and long-term care resources are not sufficient to meet the needs of the entire population and this presents a very serious problem. Sado City, on Sado Island in Niigata Prefecture, has a remarkable aging society, with elders accounting for 36.8% of the population. This is because both the patients and medical staff are aging. To conserve the limited medical resources of the island, a new system for inter-regional medical cooperation was initiated in April 2013. In this network system, the patient’s diagnosis, prescription, treatment, examination, and imaging results can be shared with all medical institutions that are part of the system. Every participating medical institution can either opt to introduce the electronic medical records system or use an alternative recording system, because the data for this inter-regional medical cooperation is extracted from medical treatment fees data. Nursing facilities can also access the data. Nursing care staff have information on their patient’s activities of daily living, routine vital signs, and other important data. In December 2013, a new initiative was started where nursing staff can not only receive their patients’ data, but also send data such as those mentioned above. To achieve functional cooperation between medical and long-term care providers, it is important to have access to all data and to communicate openly. The established system easily and effectively facilitates communication among staff and participating institutions.

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　　This study sought to investigate the association between preliminary advance care and decision making, and care planning and participation in community activities, among the rural and advanced aged community in Japan in efforts to enhance advance care planning when it is direly needed. Subjects were 920 people aged 40-74 years in rural areas identified by cluster sampling and who had consented to participate in the survey. The 15 survey items included sex, age, experiences of care for the elderly, degree of health anxiety, degree of participation in community activities, and self-measurement of home blood pressure. Univariate analysis and binary logistic regression analysis using a step-wise principle were used throughout the survey. Of the 920 participants, 23.8% and 25.0% had previously made decisions on care planning and advance care planning, respectively, which were mutually associated, although decision making on care planning did not necessarily presuppose advance care planning. Odds ratios were high for decision making on care planning, awareness of care planning, advance care planning, and conversations about medical checkups. Also, odds ratios were high for advance care planning on awareness of care planning, decision making on care planning, and high participation in community activities. The results suggest that to help participants “make a decision” or undertake “advance care planning”, it is important to have opportunities to participate in community activities and/or converse with another resident about medical checkups.

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　　The purpose of this study was to elucidate the effects of “shoulder girdle training” that is used to correct scapular muscle imbalance. We investigated 100 shoulders in 50 healthy volunteers free of any complaints related to the shoulder joint. In the posture for performing the infraspinatus test, male volunteers held a 5-kg load and female volunteers held a 3-kg load for 3 s thrice, and the muscular activity of the trapezius muscle was simultaneously measured. Next, shoulder girdle training was performed for 5 s twice, followed by muscle activity measurement in the same manner described above. Muscle activity levels before and after this training and also between the dominant and non-dominant sides were compared. The shoulder girdle training significantly reduced the level of muscle activity of the upper fibers of the trapezius muscle and significantly increased the level of muscle activity of the middle and lower fibers of the trapezius muscle (both p<0.05). Moreover, the levels of muscle activity of the upper, middle, and lower fibers of the trapezius muscle were significantly higher on the dominant side than on the non-dominant side (p<0.05).

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　　Clear differences in the medical environment exist between core and local cities in Japan. In particular, there are marked differences in medical examination and treatment of pancreaticobiliary diseases. Therefore, we investigated whether the requirement for medical examination and treatment of pancreaticobiliary diseases is increasing and whether patient care can be improved by dispatching a pancreaticobiliary specialist to a hospital that does not have a pancreaticobiliary division. From August 2013 to March 2015, we retrospectively reviewed data of 68 patients (38 men, 30 women; median age 68 years) who underwent endoscopic ultrasonography (EUS) or transpapillary treatment at the Engaru Kosei General Hospital (Engaru Hospital) either by a visiting specialist from the pancreaticobiliary division of Asahikawa Kosei General Hospital (Asahikawa Hospital) or by doctors at Engaru Hospital. Of the 68 patients, 25 underwent EUS by the visiting specialist, and the accuracy rate based on observation and operative cases was 92.5% (23/25). Furthermore, 43 patients underwent transpapillary treatment by the visiting specialist, which was successful in 88.4% (38/43) of patients. However, the success rate of cases treated by doctors at Engaru Hospital was 75% (3/4). During this period, 14 patients from Engaru Hospital were sent to the Asahikawa Hospital: 2 had failed treatment by doctors at Engaru Hospital and the rest were patients who either preferred to be examined at Asahikawa Hospital or required more extensive examination. Therefore, dispatching pancreaticobiliary specialists to institutions without a pancreaticobiliary division is an effective means of distribution of medical resources. Furthermore, this reduces the patient<s burden of illness. We consider the concept of “hospital cooperation” to be an extremely useful system.

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　　We measured the exposure dose to different parts of the body during general radiography in our hospital and examined the radiographic conditions in comparison with the dose limitation goal announced during a conference held by The Japan Association of Radiological Technologists. In recent years, many researchers have become interested in the exposure dose during radiographic examination. General radiography was discussed at the conference and there is now more certification of facilities with measures aimed at radiation dose reduction. We measured the exposure dose to different parts of the body for 27 items by using a dosimeter and radiation dose estimation software. Basically, radiography conditions in our hospital were below the limitation goal, although some items were above the limitation goal. Even though some were above the limitation goal, we consider that they are within the acceptable range if they are necessary for diagnosis. Through this measure and estimates, all radiation technologists in our hospital have become more conscious of the need to reduce exposure dose.

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　　Despite measures being instituted to prevent agricultural workplace accidents, fatalities still occur. Also research studies evaluating and analyzing work processes involving agricultural machinery are rare. The objectives of this study were, on a trial basis, to generate and examine the usefulness of a work process sheet based on failure mode and effect analysis (FMEA) for prevention of accidents. FMEA is used in medical and other fields. Subjects were 18 of 38 farmers who were interviewed using the work process sheet generated, were assumed to be using agricultural machinery, were located in Prefecture B (a rural area), and had agreed to participate in the survey. The results show that the ratio of accidents to incidents was 1:8. Also, based on the work process sheet for prevention of agricultural workplace accidents, users of agricultural machinery did not pay attention to 10 of the 28 requisite steps. In particular, “I wear a seat belt” and “I regularly use the two-poster safety frame (folding type)”, were commonly not adhered to. Based on the work environment and occupational background, the development of a simpler and more useful working process sheet from an analysis of objective data is warranted.

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　　The purpose of study was to clarify the factors involved in the popularization of a voluntary group in several locations within Shitara Town. A questionnaire survey was administered to participants of a voluntary group concerning its founding, their participation in the group, and continuity within the group. Responses were obtained from 96 participants. Regarding the founding and participation aspects of the voluntary group, participants believed that the presence of others (i.e., the “existence of peers”) had significant effects. They also believed that voluntary participation that was driven by “one’s own health” was more likely to lead to continued participation. It is important to consider regional factors and interpersonal linkages to enhance the relationship between resident-led self-help and mutual assistance measures aimed at improving residents’ health awareness.

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　　Capnocytophaga canimorsus is a spindle-shaped facultatively anaerobic Gram-negative rod in the oral cavity of dogs and cats. C. canimorsus rarely infects humans through an animal bite or scratch. However, it leads to severe sepsis once infection occurs, and the fatality rate is estimated to be up to 30%. The patient was a 56-year-old man with fatigue and fever. Sepsis with thrombocytopenia was suspected from the blood examination results. We decided to conduct microscopic examination of a non-stained peripheral blood smear and identified bacteria; therefore, Gram stain was immediately performed and spindle-shaped Gram-negative bacilli were detected. Additionally, the patient had a history of a bite and scratch by his cat. We suspected C. canimorsus infection from the microscopic examination findings and history. Moreover, we determined early that the pathogenic bacterium was C. canimorsus by blood culture. With immediate and proper treatment based on these results, we could rescue this septic patient with disseminated intravascular coagulation. Microscopic examination of non-stained peripheral blood smear is helpful for the early diagnosis of C. canimorsus infection.

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　　A 48-year-old man with jaundice was referred to our hospital. Endoscopic retrograde cholangiography showed primary sclerosing cholangitis. Endoscopic biliary drainage was not successful because of highly viscous bile, so we performed percutaneous trans-gallbladder drainage (PTGBD), which was able to reduce the total serum bilirubin level from 8 to 10mg/ml. Subsequently, an indwelling drainage catheter was placed in the gallbladder for 13 months. However, liver atrophy worsened with the gradual progression of hepatic failure. Twelve months later, he complained of dyspnea. Computed abdominal tomography showed that the drainage catheter had perforated the diaphragm and become exposed to the chest cavity. In spite of intensive care, the patient died of liver failure while waiting for a liver transplant. Careful attention should be paid to the possibility of this serious complication in such patients.

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　　A major cause of pulmonary thromboembolism (PTE) is deep venous thrombosis (DVT). We report here a case of DVT in a 31-year-old woman during week 29 of her second pregnancy. At week 29, the patient noticed swelling of the left leg and pain in the groin after sitting. At almost week 30, walking became difficult due to pain and she was referred to hospital. Computed tomography (CT) revealed a thrombus from the left common iliac vein to the femoral vein and multiple thrombi in the right pulmonary artery. Blood testing showed elevated D-dimer (3.4μg/ml). Continuous intravenous unfractionated heparin was administered, and the dose was increased due to decreased activated partial thromboplastin time control. Despite conservative therapy for DVT, the thrombi showed no change since admission. At almost week 37, a temporary inferior vena cava filter (t-IVCF) was placed to prevent pulmonary thromboembolism, and she had an uneventful delivery of a baby by Caesarean section. Warfarin was administered postpartum. The t-IVCF was removed 4 days after delivery, and the patient was discharged 10 days after delivery. Within the field of obstetrics, the need for IVCF insertion should be considered on an individual case basis and should not be viewed as a standard option.

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　　The use of adrenaline autoinjectors is generally contraindicated in children weighing less than 15kg. However, their use may be beneficial in life-threatening situations. Here we report the case of a 2-year-old boy who weighed less than 15kg and had a history of 3 episodes of milk-induced anaphylaxis. He was prescribed an adrenaline autoinjector following parental consent. The boy experienced coughing, hives, dyspnea, hoarseness, and reduced consciousness after accidentally consuming dairy products during a family trip. His mother used the adrenaline autoinjector because the family was far from an emergency hospital. The patient’s condition was resolved and he was subsequently transported by ambulance to an emergency center and hospitalized. An antihistamine and a corticosteroid were administered to treat a persistent localized hives. No biphasic reaction was observed, and he was discharged the next day in good condition. An adrenaline autoinjector was effective for the emergency treatment of anaphylaxis in a child weighing less than 15kg. It is important to report such cases to accumulate and provide more information on the utility of adrenaline autoinjectors in children.

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　　We report a case of spindle cell type medullary carcinoma of the thyroid in a 77-year-old man. Fine needle aspiration cytology showed numerous spindle cells without inflammation and hemorrhage. The spindle cells were uniform and exhibited no malignant features. Immunocytochemistry was positive for carcinoembryonic antigen and calcitonin, and the tumor was diagnosed as spindle cell type medullary carcinoma. There are various histological subtypes of medullary carcinoma, and diagnosis by cytomorphology alone is difficult. Preservation with LBC fixative was helpful for diagnosis by immunocytochemistry in this case.

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　　We previously reported that only 49% of alarms in ambulatory electrocardiography (ECG) correctly indicated clinically abnormal electrical conditions in patients admitted to the cardiology ward and that 6 types of precautionary measures including changing the electrodes once a day and wiping sweat off the patient&rsqo;s chest skin might help to reduce false alarms. We sought to investigate the efficacy of these 6 types of measures to reduce false alarms in ambulatory ECG monitoring by comparing the number, variations, and causes of alarms before and after taking these measures. After taking these actions, the number of total alarms reduced from 3,699 to 1,109. The number of alarms indicating poor electrode-to-patient contact reduced from 629 to 30 and alarms indicating wrong diagnosis reduced from 432 to 114. However, the number of alarms indicating body movement of patients did not change (415 versus 418). Furthermore, we sought to investigate whether lowering the sensitivity of ambulatory ECG monitoring system to detect arrhythmia was useful for reducing the impact of inadequate alarms. We evaluated the incidence of missing true arrhythmias in the system and concluded that lowering the sensitivity was not a good option to reduce false alarms because of the increased risk of missing true arrhythmias.

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　　Our ward encounters many cases (approximately 80 every year) requiring end-of-life care. The experiences of nurses, as well as of patients’ families and friends, vary widely and nurses appear to be anxious about providing mortuary care, known as Angel care. There is no standardized manual, and therefore medical care professionals need to optimize good Angel care practices in order to alleviate nurses’ anxiety around the issue. We administered a questionnaire regarding the situation of Angel care to 208 ward nurses in our hospital and extracted difficulties in providing Angel care reported by the 173 respondents. Less than 5% of nurses, regardless of length of nursing experience, experienced no anxiety. Nurses found it difficult to conduct basic technical procedures: 51.7% had difficulties in closing the deceased patient’s mouth and 40.2% had difficulties judging whether the results of mortuary makeup resemble antemortem appearance. Ninety-five percent of nurses wished to study Angel care in the future should learning materials be available. In conclusion, more than half of nurses were anxious about providing Angel care regardless of length of their nursing experience and number of cases handled. Nurses are greatly interested in Angel care and wish to learn more if learning materials are made available.

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　　Laparoscopic ovarian cystectomy is a relatively uncomplicated process, but extraction of the resected cyst can sometimes be difficult, especially with ovarian dermoid cysts. We report here our method of extraction for ovarian cysts measuring 7-10cm, where we trap the cyst laparoscopically and utilize the 12mm trocar of the umbilical port to extract the cyst externally.

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