Based on previous reports, we propose a practical guide to choose dabigatran 150 mg twice daily or apixaban 5 mg twice daily for patients with atrial fibrillation. We recommend the use of dabigatran 150 mg twice daily for patients with atrial fibrillation who have a high risk of embolism (e.g., ischemic stroke on other oral anticoagulants, presence of left atrial appendage thrombus) and a low risk of bleeding. However, the prevalence of such patients with atrial fibrillation is considered low because patients with atrial fibrillation with a high risk of embolism usually have a high risk of bleeding. In most other patients with atrial fibrillation, the use of apixaban 5 mg twice daily should be considered.

Objective: The present study aimed to examine the role that caregiver burden plays in the familial functioning, social support, and quality of family life (QOFL) of caregivers of elderly family members with dementia.

Methods: A survey was conducted with 200 primary caregivers of elderly dementia patients who resided in prefecture “S”. The questionnaire consisted of items that required demographic information, the Japanese versions of the Zarit Burden Inventory (ZBI) and the Family Adaptability and Cohesion Evaluation Scales (FACES II), and scales that measure quality of family life and social support. On the basis of the median ZBI score (i.e., 30.8), participants were divided into two groups: group A (i.e., ZBI score < 30) and group B (i.e., ZBI score > 30). Stepwise multiple regression analysis was conducted with QOFL as the dependent variable. Version 24 of the Statistical Package for the Social Sciences for Windows was used to conduct all the statistical analyses; the statistical significance level was specified as 0.05.

Results: Group A and B obtained average ZBI scores of 18.5 and 43.8, respectively. The study targeted 81 patients from group A (average age = 61.0 years) and 77 patients from group B (average age = 61.7 years). Time that was spent on caregiving tasks was significantly higher for group B, when compared to group A. In addition, significant differences in cohesion and adaptability, which are two dimensions that are measured by the FACES II, and QOFL emerged between the two groups. The results of the multiple regression analysis showed that cohesion (β = 0.38), practical support (β = 0.32), adaptability (β = 0.30), and living arrangement (β = −0.12) significantly predicted QOFL.

Conclusion: Family cohesion and adaptability are indicators of healthy familial functioning. In order to improve the QOFL of caregivers of elderly dementia patients, it is necessary to strengthen emotional ties, maintain emotional attachment, and flexibly respond to the burden of nursing care and changes in power structures and role relationships.

Objectives: Increasing activity levels in older people is important for maintaining quality of life and ameliorating the risks of morbidity related to falls, depression, and dementia. This study aimed to clarify the seasonal variation effects on total energy expenditure, number of steps, time spent in low- and moderate- or high-intensity physical activities, and daily activities performed.

Patients and Methods: This was a cross-sectional study of 22 community-dwelling older individuals (3 men, 19 women; mean age, 75.1 ± 7.3 years) living in three districts of Gero, Gifu, who participated in the Gero Salon Project hosted by the Social Welfare Councils. Evaluations were conducted in each season from September 2016 to August 2017. We used a uniaxial accelerometer, the Lifecorder device, which measures physical activity, and the Physical Activity Scale for the Elderly to evaluate activities of daily living. Data were analyzed using the multiple comparisons (Bonferroni correction) method.

Results: Total energy expenditure and time spent in moderate- or high-intensity activities did not show seasonal variations. However, the lowest number of steps was taken during the winter, and the number of steps increased significantly from winter to spring. The time spent in low-intensity physical activities was significantly longer in the spring and summer than in the winter. There was no significant seasonal difference in total Physical Activity Scale for the Elderly score, leisure activities, domestic activities, or work-related activities. However, there was a significant difference between the summer and winter scores in “outdoor gardening,” with the lowest score observed during the winter.

Conclusions: With climate changes in the winter months, “outdoor gardening” becomes difficult, thus decreasing the number of steps taken. Therefore, it is necessary to identify other ways for older people to maintain physical activity during the winter season.

Objectives: The purpose of this study was to evaluate the relationship between exercise time and musculoskeletal problems and to determine the appropriate amount of exercise for children in both lower- and higher-grade levels of elementary and junior high schools.

Materials and Methods: Mark-sheet-type questionnaires were distributed to and collected from all elementary and junior high schools in two cities. We collected 22,494 questionnaires in total. The relationship between exercise time and musculoskeletal problems was analyzed. The χ² test and multivariate logistic regression analysis were used for statistical analyses.

Results: The mean exercise time in school, in addition to physical education time, was 3.1 hours per week. In 56% of the children, the exercise time was less than 2 hours per week, and in 13% of the children, the exercise time was more than 10 hours per week. Although the rate of sports injury increased with an increase in exercise time, the duration of one-leg stand (a test of balance and muscle strength) also increased with an increase in exercise time. The cut-off values for sports injuries in boys/girls were 2.9/2.9 hours, 4.0/2.9 hours, and 7.5/4.2 hours in lower grade elementary school, higher grade elementary school, and junior high school, respectively.

Conclusions: Although an appropriate amount of exercise improves one’s physical health and ability, excessive exercise leads to musculoskeletal problems. Approximately 7 hours/week of exercise is recommended for junior high school students. In elementary school, the exercise time should be carefully decided as the musculoskeletal system of the students is still immature.

Objective: To establish work environments that prevent Japanese nursing assistants from leaving their jobs, we investigated the associations between their job satisfaction levels and intentions to remain on their jobs.

Materials and Methods: We distributed anonymous self-administered questionnaires to Japanese female nursing assistants in 30 different hospitals. Regarding job satisfaction, we investigated various items relevant to both intrinsic facets (e.g., gaining various experiences) and extrinsic facets (e.g., salary), and conducted factor analyses of those items. Standardized partial regression coefficients were then calculated using multiple regression analyses. Intention to remain on the job was the dependent variable for this study. The factor scores calculated by the factor analyses of job satisfaction and respondents’ characteristics were the independent variables. Since multicollinearity occurred, we utilized two types of statistical models. After questionnaires with one or more missing values were excluded, 618 questionnaires were analyzed.

Results: Using factor analyses, we discovered six factors related to job satisfaction among nursing assistants: “Intrinsic motivation”, “Salary”, “Relationships among nursing assistants”, “Registered nurses’ attitudes”, “Fatigue reduction”, and “Opportunities for vocational skills”. In statistical model 1, “Intrinsic motivation”, “Salary”, “Fatigue reduction”, “Age”, “Employment status”, and “Certified care worker status” were significantly associated with “Intention to remain on the job”. In statistical model 2, “Salary”, “Registered nurses’ attitudes”, “Fatigue reduction”, “Opportunities for vocational skills”, “Age”, and “Employment status” were significantly associated with “Intention to remain on the job”.

Conclusion: “Intrinsic motivation” and “Opportunities for vocational skills” are included in intrinsic facets. To prevent nursing assistants from leaving their jobs, raising only their extrinsic job satisfaction levels is insufficient. Because nursing assistants have not received formal nursing education, they cannot take pride in having the same skills and expertise as registered nurses. However, hospital managers must respect their feelings and establish an appropriate working environment.

Background: The use of prophylactic contralateral pinning for slipped capital femoral epiphysis (SCFE) remains controversial. This study evaluated the outcome of SCFE treatment and examined the use of prophylactic pinning.

Methods: The study included 44 patients (33 men, 11 women; 54 hips [right, 31; left, 23]), with mean age of 12.9 (7.3–29) years, who underwent treatment between 1986 and 2017, with follow-up for more than 6 months. Patients were divided into 3 groups: group 1 had bilateral SCFE at first presentation, group 2 developed contralateral side SCFE during follow-up, and group 3 had unilateral SCFE until final follow-up. Three patients who received prophylactic pinning were excluded. Univariate and multivariate logistic analyses were performed.

Results: Overall, 93% (50/54) of hips underwent positional reduction and in situ fixation and 7.4% (4/54) underwent open reduction. Mean follow-up period was 4.8 (0.5–25) years. Groups 1, 2, and 3 had 7, 3, and 31 cases, respectively. Sex, age, and follow-up period showed no significant differences among the groups. The Rohrer index was significantly higher in group 1, the affected side posterior sloping angle (PSA) was significantly higher in group 3, and the contralateral side PSA and percentage with endocrinopathy were significantly higher in group 2. In multivariate logistic analysis, age, sex, Rohrer index, affected side PSA, and endocrinopathy were significantly correlated with bilateral SCFE.

Conclusion: We recommend prophylactic contralateral side pinning in patients with risk factors of obesity, high PSA before slipping, and endocrinopathy. Careful observation until growth plate closure is required in patients without risk factors.

Introduction: This study aims to explore experiences of romantic relationships and to examine determinants of desires to marry and have children in the future among Japanese university students.

Methods: A cross-sectional study was conducted among undergraduate students of A University, located in the capital city of a Japanese prefecture, using an anonymous self-administered and structured questionnaire developed by an online survey software.

Results: A total of 815 respondents with complete data were analyzed by logistic regression analysis. Over 80% of males and females expressed the desire to marry and have children in the future. It was found that for both female and male respondents, the “desire to marry” was associated with currently being in a romantic relationship or having experience of sexual intercourse. On the contrary, the “desire to have children” was associated with currently being in a romantic relationship or having experience of sexual intercourse only among male respondents, and no significant association was observed among female respondents.

Conclusion: “Currently being in a romantic relationship” and “having experience of sexual intercourse” were associated with wanting to marry and have children in the future among male university students. This suggests that these may be important factors in providing a positive perception regarding having children when they attain childbearing age.

Objective: Spontaneous spinal epidural hematoma is rare and therefore difficult to diagnose. This study evaluated the clinical features of this condition in patients admitted to our hospital.

Patients and Methods: We evaluated 12 patients with spontaneous spinal epidural hematoma who were treated at our hospital. We investigated the following variables in these patients: underlying diseases, medications used, initial symptoms, spinal level affected, whether transported to the hospital by ambulance, department where first evaluated, mass lesion on computed tomography with soft tissue window settings, time interval between symptom onset and diagnosis, treatment received, and Frankel classification on arrival and when last observed.

Results: Five patients reported the use of antiplatelet or anticoagulant drugs. All patients in this study reported acute onset of severe pain as the initial symptom, and 10 patients reported some degree of paralysis accompanying the pain. With respect to the morbidity level, the cervical region was the most common site of involvement (n=7). Ten patients were transported to the hospital at night via ambulance. Five patients first visited the Department of Internal Medicine. Seven patients presented with a mass lesion on computed tomography with soft tissue window settings. The time interval between symptom onset and diagnosis ranged from 2 hours to 6 days. Three and 9 patients received conservative and surgical treatments, respectively. No patient showed worsening of Frankel classification.

Conclusion: Acute onset of severe pain was the most characteristic clinical symptom. Spontaneous spinal epidural hematoma should be included in the differential diagnosis. Computed tomography with soft tissue window settings may rule out cerebrovascular disease and cardiovascular disease, and specifically detect a hematoma. Subsequent magnetic resonance imaging can diagnose a spontaneous spinal epidural hematoma at an early stage.

Objective: To treat vertebral fractures with posterior wall injury in the elderly, vertebral bone grafting is generally performed through a posterior transpedicular approach, combined with pedicle screw fixation. An autologous bone is ideal to treat this disorder. However, harvesting autologous bones from the elderly with osteoporosis is limited by the amount and quality of available autologous bone. Thus, we developed a bone-grafting substitute. The newly developed unidirectional porous β-tricalcium phosphate, with a porosity of 57% (UDPTCP; Affinos^®, Kuraray Co., Ltd., Tokyo, Japan), is used in the bone-grafting procedure. This is the first report of UDPTCP used as an artificial bone graft in patients with an acute vertebral burst fracture.

Materials and Methods: UDPTCP (mean: 4.2 g) was implanted through the pedicle, and posterior instrumentation was achieved with pedicle screws in five elderly patients. Resorption of UDPTCP and substitution with the autologous bone were evaluated on computed tomography (CT) and plain X-ray performed immediately and at 3, 6, and 12 months after the operation.

Results: In case 1, the pedicle screws did not loosen, and UDPTCP was completely resorbed and replaced with the autologous bone at 3 postoperative months. In the other four cases, although the pedicle screws or the caudal part loosened because of osteoporosis, resorption of UDPTCP was observed at 3 postoperative months. At 6 postoperative months, progressive substitution with the autologous bone was confirmed, and at 12 postoperative months, formation of the good autologous bone was confirmed.

Conclusion: This preliminary case series demonstrated that the newly developed UDPTCP shows good clinical potential as a bone-graft substitute for acute vertebral burst fractures in the elderly, including patients with osteoporosis.

Objective: Previous studies have investigated medical students’ interest in family medicine, as well as their intentions to work in rural areas after taking part in community-based clinical clerkships. Community-based clerkships are designed to teach medical students community healthcare and to increase the number of physicians working in rural communities following their graduation. However, few studies have examined which clerkship experiences, specifically, enhance medical students’ positive perceptions on community healthcare. This study aimed to examine the association between experiential learning in community-based clerkships and students’ positive perceptions on community healthcare.

Patients and Methods: From 2015 to 2017, we conducted a questionnaire survey of 290 final year medical students, before and after completion of their community-based clerkships. The survey asked the students about their perceptions (categorized into “Worthwhile” and “Confident”) of community healthcare and experiential learning during their clerkships. We assessed 13 medical learning areas involving healthcare, medical care, welfare, and nursing care practice. Multivariable logistic regression was used to evaluate the factors associated with positive student perceptions.

Results: Of the 290 students, 265 (91.3%) completed both the pre- and post-questionnaires. Of these, 124 (46.8%) were female, 67 (25.2%) were from small towns (of <100,000 people), and 87 (32.8%) selected clinical clerkships within depopulated areas. A total of 205 (73.3%) students reported positive perceptions on community healthcare. There was a significant association discovered between students’ positive perceptions on community-based healthcare and them taking part in experiential learning in mobile medical services (43 [16.2%] students experienced mobile medical services—adjusted odds ratio 6.65, 95%, confidence intervals 1.67–26.4, p = 0.007).

Conclusion: Medical students’ positive perceptions on community healthcare were discovered to be associated with them taking part in experiential learning in mobile medical services during their community-based clerkships.

Objective: This study aimed to retrospectively determine which laboratory data on arrival for patients with mamushi bites was useful to predict the severity of mamushi bites.

Materials and Methods: The subjects were divided into the following two groups: the mild group included subjects with mamushi bites Grades I and II, while the severe group included subjects with mamushi bites Grades III, IV, and V. The subjects’ variables were compared between the two groups.

Results: There were no significant differences between the two groups regarding the levels of hematocrit, total protein, alanine aminotransferase, aspartate aminotransferase, creatinine phosphokinase, blood urea nitrogen, creatinine, and international normalized ratio of prothrombin time on arrival. Moreover, white blood cell count and platelet count on arrival in the mild group were significantly lower than those in the severe group. Furthermore, activated partial thromboplastin time on arrival was significantly higher in the mild group than in the severe group. Multivariate analysis using white blood cell count and platelet count and level of activated partial thromboplastin time revealed the following significant prognostic indicators of severity of mamushi bites: white blood cell count (Log Worth, 2.1; p<0.01) and platelet count (Log Worth, 1.6; p<0.05).

Conclusion: White blood cell count and platelet count on arrival of patients with mamushi bites are considered significant prognostic indicators in determining the severity of mamushi bites.

Objective: This study aimed to assess the efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients with an Eastern Cooperative Oncology Group performance status (ECOG-PS) score of 3 or 4.

Patients and Methods: We reviewed the data of 287 patients with native papillae who underwent therapeutic ERCP for biliary disease at our hospital between October 2016 and October 2018. The patients were divided into two groups; those with an ECOG-PS score of 3 or 4 (group A; n=78) and those with an ECOG-PS score of 0–2 (group B; n=209).

Results: The rate of technical success was not significantly different between the two groups (95% versus 89%, P=0.13). Although the occurrence rate of overall adverse events (10% versus 11%, P=0.95) was not significantly different between the groups, the occurrence rates of aspiration pneumonia (3.8% versus 0%, P=0.0044) and heart failure (2.6% versus 0%, P=0.020) were significantly higher in group A.

Conclusion: The rates of technical success and overall adverse events did not significantly differ between patients with an ECOG-PS score of 3 or 4 and those with a score of 0–2; however, aspiration pneumonia and heart failure were more likely to occur among patients with an ECOG-PS score of 3 or 4.

Objective: We herein report our analysis of patients evacuated by a physician-staffed helicopter (doctor helicopter; DH) from a Japan Self Defense Force (JSDF) base.

Methods: From March 2004 to November 2018, a medical chart review was retrospectively performed for all patients who were transported by a DH from the temporary heliport at the JSDF Fuji base. The subjects were divided into two groups: the Before-2013 group (n=6) and the After-2013 group (n=7).

Results: The rate of military-patient involvement and the heart rate of the After-2013 group were greater than those of the-Before 2013 group, and the percutaneous oxygen saturation in the After-2013 group was lower than the Before-2013 group. Furthermore, the Glasgow Coma Scale in the After-2013 group was significantly lower than in the Before-2013 group. The survival rate was not significantly different between the two groups.

Conclusion: Patients transported by DHs in the After-2013 group tended to be in more severe conditions than those transported in the Before-2013 group. This might be due to the fact that over time, the fire department, or JSDF, began to appreciate the useful role played by the DH in life-saving management.

Objective: This study examines the job satisfaction of Mongolian hospital nurses by comparing their status and workload of Mongolian nurses with Japanese nurses’ one.

Settings and participants/Methods: Survey data were collected from randomly selected 200 nurses (100 were Mongolians and the other 100 were Japanese) who agreed to participate in the survey. Data were collected through a self-administered survey questionnaire. Survey items were age, the duration of work experience, work position, health condition, accumulated fatigue, stress level, and whether having family members who need child care or nursing care. Collected data were analyzed by t-test and Wilcoxon Rank Sum test.

Results: The average age of Mongolian nurses was significantly lower than that of Japanese nurses. Consequently, the average work experience of Mongolian nurses was less than that of Japanese nurses. More Japanese than Mongolian nurses had family members in need of care. Job satisfaction and status were significantly higher among Japanese than Mongolian nurses. However, Japanese nurses have family members who need child care or nursing care at a higher rate than Mongolian nurses. Job satisfaction of Japanese nurses about their work and job status was significantly higher than Mongolian nurses’ one. However, the opposite result was found in the job satisfaction about their workload. The influence of the relationships among nurses on the job satisfaction was significantly greater in Mongolian nurses than in Japanese nurses. Job satisfaction of Japanese nurses about their salaries was significantly higher than Mongolian nurses’ one.

Conclusion: In order to raise nurses’ job satisfaction in Mongolia, it is necessary to raise their “occupational status” and salary of nurses.

A 76-year-old Japanese man visited a nearby medical clinic complaining of abdominal distention. He had undergone extraperitoneal laparoscopic prostatectomy at our institution 5 months before the onset of abdominal distention. An imaging study revealed a large cystic lesion, and biochemical examination of a sample obtained via cyst puncture led to a diagnosis of lymphocele. As the lymphocele was resistant to puncture, drainage, and sclerotherapy with minomycin, laparoscopic fenestration was performed. Although the patient developed an adhesive ileus postoperatively, the cyst has not recurred. Fenestration surgery is a feasible option for lymphocele refractory to various conservative therapies.

Objectives: Rectus sheath hematoma (RSH) can result from bleeding into the rectus abdominis muscle or a direct muscular tear; nontraumatic spontaneous RSH is a rare condition. Here, we report a case of spontaneous RSH associated with warfarin administration for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH).

Patient: An 87-year-old woman was referred to our hospital because of abdominal pain, nausea, and vomiting for 3 days. She was receiving warfarin for treating CTEPH. She had a bulging and hard lower abdomen with ecchymosis. Moreover, the bulging portion was highly tender, and a positive Carnett’s sign was also observed. She reported no history of abdominal trauma. Abdominal computed tomography (CT) scan revealed right RSH.

Results: She was diagnosed with spontaneous RSH and admitted to our hospital. Warfarin was antagonized with an intravenous injection of vitamin K; hemostatic agents were intravenously administered. Gradually, her abdominal pain improved. She was finally discharged 12 days after the admission. Abdominal CT scan performed 17 days after the discharge revealed a reduction in the size of RSH.

Conclusion: Despite not having a history of trauma, it is necessary to consider the possibility of RSH for patients receiving warfarin and complaining of abdominal pain.

Objective: To demonstrate the use of a portable X-ray system at the scene.

Patient: A 59-year-old man collapsed under a small power shovel and was discovered by his colleague. The fire department dispatched an ambulance and requested the dispatch of a doctor helicopter (DH) immediately after receiving the emergency call. When the staff of the DH used a portable X-ray system to assess the patient at the rendezvous point, he was found to have experienced a cardiac arrest with deformity of the face. Portable chest X-ray in the ambulance revealed decreased radiolucency of the lung fields without pneumothorax, and tracheal tube insertion was successful. Portable pelvic X-ray also showed no trauma. Portable cranial X-ray revealed orbital fracture. Although we urgently transported the patient to our hospital by the DH, he unfortunately died of circulatory arrest caused by his severe injuries. Based on the portable X-ray findings obtained at the scene, we suspected that the patient’s cardiac arrest had been caused by severe head and/or neck injuries.

Conclusion: This portable X-ray system may be able to change and facilitate the management of patients with trauma dramatically by simplifying prehospital diagnoses even in rural areas.

A 32-year-old man started building a wooden desk atop Mount Fuji at an altitude of 3,776 m. Over the course of the second day, he developed lassitude and cough and experienced a headache that night; however, he continued to work. He was transported to our hospital with an altered level of consciousness. On arrival, chest radiography revealed increased opacities in both lungs, and magnetic resonance imaging (MRI) revealed a high-intensity signal in the splenium on diffusion-weighted imaging. He received mechanical ventilation following tracheal intubation. His respiratory function improved, and he was extubated on the fourth hospital day. Physical examination showed no motor weakness, and although he responded to verbal commands, he was unable to speak and was unresponsive to visual stimulation. On the seventh hospital day, head MRI showed improvement in the lesion in the splenium, although other signal changes were observed in the body of the corpus callosum. His verbal responsiveness and voice volume improved on a daily basis. Two months after the incident, he continued to experience mild recent memory disturbance. The patient described in this case report showed delayed signal changes in the body of the corpus callosum, possibly secondary to the onset of microbleed-induced edema.

Background: Gitelman syndrome (GS) is an autosomal recessive salt-losing renal tubulopathy resulting from mutations in the thiazide-sensitive Na-Cl cotransporter (NCC) gene. Notably, lack of awareness regarding GS and difficulty with prompt diagnosis are observed in clinical practice, particularly in rural settings.

Case presentation: We report a case of a 48-year-old man with GS who presented to a local clinic on a remote island. Occasional laboratory investigations incidentally revealed a reduced serum potassium level of 2.6 mmol/L. A careful medical interview revealed episodes of intermittent paralysis of the lower extremities and muscular weakness for >30 years. Subsequent laboratory investigations revealed hypomagnesemia, hypocalciuria, and hypokalemic metabolic alkalosis. Based on the patient’s history, clinical presentation, and laboratory investigations, we suspected GS. Genetic testing revealed a rare homozygous in-frame 18 base insertion in the NCC gene that might have resulted from the founder effect, consequent to his topographically isolated circumstances.

Conclusion: More case studies similar to our study need to be added to the literature to gain a deeper understanding of the functional consequences of this mutation and to establish optimal management strategies for this condition, particularly in rural clinical settings.