Journal of Rural Medicine Vol. 12(2017) No. 1

Sales of cut-flowers depend much on the outer appearance of the flowers. They are not intended to be used as foodstuffs; thus, pesticides are used more liberally for cut flower growing than for other agricultural products. Flower production is often carried out in greenhouses; therefore, pesticide exposure seems to reach not only the person spraying the pesticides, but also the non-spraying workers as well. In 2009, a special research project on pesticide poisoning, affiliated with the Japanese Association of Rural Medicine, developed a study that focused on cut-flower farmers’ exposure to pesticide, subsequent adverse symptoms experienced, and treatment modalities to relieve pesticide-related symptoms. In this group of farmers, the pesticide sprayers were almost entirely male, while the females did not do any spraying. The organophosphate metabolite level in the urine of the males was higher than that of the females. However, in the female group, a positive relation was found between average working times in the greenhouse, and urine concentration of dialkylphosphates. In 2 males of this group, the level of dimethylphosphate was detected at 1,000 times the median level. Their butyrylcholinesterase activity levels on the day of testing had declined to 64%, 72% of their average level of the proximate 4 years, respectively. Communication with these subjects regarding pesticide exposure and methods of prevention appeared to be an effective approach for reducing symptom severity. Among soil fumigants, chloropicrin and 1,3-dichloropropene were most often used. Difficulty breathing was one of the subjective symptoms associated with chloropicrin, as well as watery eyes, coughing, and runny nose. These symptoms were effectively suppressed by the preventative practice of wearing gas masks and goggles while using soil fumigants. It would be beneficial to strongly encourage use of suitable protective gear among farmers exposed to soil fumigants.

Objective: Involvement of all regional medical facilities in a trauma system is challenging in rural regions. We hypothesized that the physician-staffed helicopter emergency medical service potentially encouraged local facilities to participate in trauma systems by providing the transport of patients with trauma to those facilities in a rural setting.

Materials and Methods: We performed two retrospective observational studies. First, yearly changes in the numbers of patients with trauma and destination facilities were surveyed using records from the Miyazaki physician-staffed helicopter emergency medical service from April 2012 to March 2014. Second, we obtained data from medical records regarding the mechanism of injury, severity of injury, resuscitative interventions performed within 24 h after admission, secondary transports owing to undertriage by attending physicians, and deaths resulting from potentially preventable causes. Data from patients transported to the designated trauma center and those transported to non-designated trauma centers in Miyazaki were compared.

Results: In total, 524 patients were included. The number of patients transported to non-designated trauma centers and the number of non-designated trauma centers receiving patients increased after the second year. We surveyed 469 patient medical records (90%). There were 194 patients with major injuries (41%) and 104 patients with multiple injuries (22%), and 185 patients (39%) received resuscitative interventions. The designated trauma centers received many more patients with trauma (366 vs. 103), including many more patients with major injuries (47% vs. 21%, p < 0.01) and multiple injuries (25% vs. 13%, p < 0.01), than the non-designated trauma centers. The number of patients with major injuries and patients who received resuscitative interventions increased for non-designated trauma centers after the second year. There were 9 secondary transports and 26 deaths. None of these secondary transports resulted from undertriage by staff physicians and none of these deaths resulted from potentially preventable causes.

Conclusion: The rural physician-staffed helicopter emergency medical service potentially encouraged non-designated trauma centers to participate in trauma systems while maintaining patient safety.

Object: To clarify the emotional and instrumental support influencing male caregivers for people with dementia living at home.

Patients/Materials and Methods: The subjects were 298 male caregivers. Nursing care burden was assessed using the Zarit Caregiver Burden Scale. Ability to cope with care problems was assessed using the Nursing Care Problems Coping Scale for Male Caregivers for People with Dementia Living at Home (NCSM). Emotional support was assessed using the Emotional Support Network Scale. Instrumental support was assessed using the question “Do you have someone to help when you have a problem with nursing care?”.

Results: There was a significant correlation (P < 0.04) between the point (index) of NCSM and Zarit Caregiver Burden Scale. A positive significant correlation was found in three coping styles. A negative significant correlation was found in one coping style, and no significant correlation in one coping style. The ‘Solve the problem’ coping style was linked to support from both within and beyond the family. Both ‘Emotional avoidance’ and ‘Cognitive transformation’ coping styles were linked to support from within the family, and “Request assistance” style only to external support. There were no correlations between the source of support and the “Careful supervision and waiting” coping style.

Conclusion: Emotional and instrumental support for male caregivers was more than three times more likely to be obtained from within the family than outside it. With families becoming smaller, it is becoming more important for communities and society in general to provide emotional and instrumental support for male caregivers. Male caregivers need support from someone with whom they feel comfortable. It is particularly necessary to consider how to support male caregivers who use the “Emotional avoidance” coping style.

Introduction: High-quality, community-based dementia care requires a comprehensive, holistic approach. This study aimed to identify the barriers to achieving efficient cooperation and coordination among medical professionals, care managers, and medical social workers, and to improve the management model of community-based, integrated dementia care.

Methods: We collected qualitative data through three focus group discussions at JA Konan Kosei Hospital. Thirteen participants (four directors of nursing service departments, three chief nurses, four medical social workers, and two care managers) were recruited for the discussions. The data were analyzed using an inductive, multi-step approach referred to as the qualitative content analysis.

Results: Nine themes arose as follows: little attention given to patient wishes, lack of time and space to provide high-quality care, disturbing hospital environment, poor compensation for staff members, refusing to visit outpatient clinics, declined admission, daily life support by family members and caregivers, dementia care team, and community bonding.

Conclusion: The participants wanted to launch a dementia care team in their hospital to improve the care environment and the quality of dementia-specific care. The study also suggested that advance care planning could be systematically implemented in clinical practice as a way to honor the decisions made by dementia patients.

Objective: Postoperative knee range of motion (ROM) is among the most important factors influencing patient satisfaction after total knee arthroplasty (TKA). The purpose of this study was to clarify the time course of improvement in knee ROM up to 12 months after TKA, including intraoperative knee ROM after implantation, and to clarify a target ROM for rehabilitation after TKA.

Patients and Methods: In total, 39 knee joints in 26 patients with osteoarthritis who underwent TKA (retaining the posterior cruciate ligament) were evaluated. Goniometry was used to measure the knee range of extension and flexion preoperatively; intraoperatively; at 1 and 2 weeks after TKA; and then at 1, 3, 6, and 12 months after TKA.

Results: The postoperative extension range gradually improved up to a maximum at 6 months after TKA; there were no significant differences in the extension range between intraoperative and 6 months after TKA, intraoperative and 12 months after TKA, or 6 and 12 months after TKA. The postoperative flexion range gradually improved, with the maximum improvement observed at 3 months after TKA; there were no significant differences in the flexion range before TKA and 3, 6, and 12 months after TKA. There were no significant differences between flexion ROM measured at 3, 6, and 12 months after TKA.

Conclusions: The changes in the knee range of extension plateaued 6 months after TKA, and those in the knee range of flexion plateaued 3 months after TKA. The target range of extension for rehabilitation from 6 months to 12 months after TKA was the intraoperative range, and the target range of flexion for rehabilitation from 3 months to 12 months after TKA was the preoperative range.

Objectives: The factors associated with quality of life (QOL) and anthropometric measurements as outcomes of food consumption were examined among school-age children in Tanzania.

Methods: A cross-sectional study was undertaken in September 2013 in Tanzania. Anonymous self-administered questionnaire surveys were conducted in the Kiswahili language among primary school children in the fifth and/or sixth grade aged 10–14 years. The survey probed sociodemographic characteristics such as age, gender, living with family members, number of meals/snacks per day, food consumption in the previous 24 hours, and QOL, as well as anthropometric measurements (height and weight). The Rohrer index was calculated based on height and weight. After presenting the mean and standard deviation (SD) of height, weight, and the Rohrer index score by age and gender, the Rohrer index score was categorized into three groups (low weight, normal weight, and overweight) and analyzed according to sociodemographic characteristics and food consumption using the chi-square test. Furthermore, the QOL score was analyzed using the t test. Multivariate linear regression analysis was used to analyze the associations between the QOL score and sociodemographic characteristics and food consumption.

Results: A total of 694 children (male: 312; female: 382) participated in this study. According to the Rohrer index, 273 (39.3%) children were classified as low weight, 353 (50.9%) were normal weight, and 68 (9.8%) were overweight. A total of 459 (66.1%) children reported having had three or more meals and/or snacks on the day before the study. In addition, 127 (18.3%) children had not eaten any protein-rich food on the day before the study, although almost all had eaten at least one carbohydrate-rich food per day. Regardless of region, location, gender, and age, living without parents was associated with short stature (P = 0.010). A high QOL score was associated with having three or more meals and/or snacks per day (P < 0.001).

Conclusions: The security of physiological needs such as a guarantee of three meals per day could contribute to higher QOL among underserved children.

Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic method and treatment approach for biliary diseases. However, biliary cannulation can be difficult in some cases. We performed ERCP in a 97-year-old woman with abdominal pain resulting from acute cholangitis caused by choledocholithiasis and observed difficult biliary cannulation. Eventually, the patient was successfully treated with the rendezvous technique. We could not cannulate the biliary duct during ERCP twice. Therefore, we placed a percutaneous transhepatic gallbladder drainage (PTGBD) tube without intrahepatic dilation. The rendezvous technique was performed using the PTGBD tube. The patient did not experience pancreatitis or perforation.

Objective: To report the first case of ciguatera-associated rheumatoid arthritis in Japan.

Patient: A 53-year-old man presented to our clinic with morning stiffness and pain in the fingers and wrists.

Results: For six months, he had suffered from chronic pain in both hands and shoulders caused by ciguatera poisoning. He was referred to a local general hospital and diagnosed with RA.

Conclusion: When synovitis becomes evident in chronic ciguatera poisoning, reevaluation is necessary, including investigation of chronic arthritis, which might be associated with the onset of RA.

Objective: To clarify the scope of practice on rural islands of Okinawa.

Patient: A 59-year-old man presented to our clinic with shortness of breath. He was intubated due to acute respiratory failure caused by severe pneumonia. We could not transfer him owing to bad weather, and had to continue patient care in the clinic for more than 24 hours.

Discussion: In remote regions, rural physicians may require a broad scope of practice from primary to tertiary care, in addition to preventive and end-of-life care.

Conclusion: This case illustrates the current state of emergency care and unique scope of practice on rural islands of Okinawa.