Objective: Schwannomas are the most common type of neoplasm of the peripheral nerves. Enucleation is a standard surgical procedure; however, it occasionally results in iatrogenic nerve injury, even with atraumatic procedures. Herein, we present the clinical characteristics of schwannoma arising in the extremities and discuss the clinical outcomes of extra- and intra-capsular enucleation.

Patients and Methods: We reviewed 122 schwannomas treated at our institute. Schwannomas arising from the minor nerve (n=30) or intramuscularly (n=15) were operated using the extra-capsular technique. Of the 77 major nerve schwannomas, 62 schwannomas were treated using the intra-capsular technique and 15 schwannomas using the extra-capsular technique.

Results: Neurological deficits following enucleation were significantly lower using the intra-capsular technique than with the extra-capsular technique. The patient age, duration of symptoms, maximum tumor diameter, and site of occurrence were not associated with subsequent neurological deficits. With both techniques, no tumor recurrence was observed at the final follow-up.

Conclusion: These results support the use of intra-capsular micro-enucleation as a safe and reliable treatment for every type of schwannoma. To minimize the risk of nerve injury, en bloc resection should not be used because the main purpose of schwannoma surgery is the relief of symptoms, not tumor resection.

Objective: To study the improvement of the mental health of Japanese male registered nurses, we investigated the predictors associated with the Japanese version of the 12-item General Health Questionnaire (GHQ-12). For those predictors, we focused on environments with many female registered nurses and female patients’ refusal to accept nursing services from male registered nurses.

Materials and Methods: This study was conducted in 93 hospitals in the Aichi, Gifu, and Mie prefectures of Japan. The analyzed subjects were 1,216 full-time male registered nurses. The average age (standard deviation) was 34.5 (9.2) years. Multiple logistic regression analysis was conducted. A GHQ-12 score of ≤3 indicated good mental health, and a score of ≥4 indicated poor mental health. “Mental health” was a dependent variable. The independent variables were: “Age”, “Male registered nurses as important partners on the job”, “Female registered nurses’ good manners toward male registered nurses”, “Fairness regarding male registered nurses’ promotions”, and “Female patients’ refusal to accept nursing services from male registered nurses”.

Results: There were 728 (59.9%) full-time male registered nurses with good mental health and 488 (40.1%) with poor mental health. The mental health of the male registered nurses who had negative feelings regarding, “Male registered nurses as important partners on the job” was significantly worse, and that of those who had negative feelings regarding, “Female registered nurses’ good manners toward male registered nurses” was also significantly worse.

Conclusion: Female registered nurses must recognize that their attitudes toward male registered nurses influence the mental health of male registered nurses. Hospital managers should provide male registered nurses who cannot establish appropriate relations with female registered nurses with consultation opportunities. Such organizational action by managers is necessary.

Objective: Peritoneal function during peritoneal dialysis (PD) declines over time due to peritoneal inflammation; however, the immunological mechanism has not been fully clarified. Here, we examined changes in each cellular fraction in the peritoneal dialysis effluent by flow cytometry and their relationship to peritoneal damage.

Patients and Methods: We enrolled 23 patients who began PD between 2006 and 2017 and had available datasets of the peritoneal equilibration test and flow cytometric analysis for at least three consecutive visits, with an interval of six months from six months after introducing PD. The levels and changes in each cellular fraction, dialysate/plasma (D/P) creatinine ratio, and the forward scatter (FSC) ratio of mesothelial cells to lymphocytes were compared using a simple linear regression analysis.

Results: Among the examined variables, only the fraction of CD8⁺ T_CM cells during the first observation was significantly correlated with the change rate in the D/P creatinine ratio (β=1.47, P=0.001, adjusted R²=0.379). The CD8⁺ naïve T and CD8⁺ T_CM cell fractions were negatively correlated with the change rate of the D/P creatinine ratio (naïve T cells: β=−0.058, P=0.022, adjusted R²=0.188; T_CM cells: β=−0.096, P=0.046, adjusted R²=0.137). In addition, the change rates of the D/P creatinine ratio tended to be higher, though not significantly (one way ANOVA; P=0.080), in accordance with the increase in the change rate of the CD8⁺ effector memory T cells (T_EM).

Conclusion: The CD8⁺ naïve T and T_CM cells may transition into T_EM cells by repeated exposure to the dialysate over time. The T_EM cells residing in the peritoneum may play a significant role in the progression of peritoneal damage.

Objective: Medical science students, especially nursing students, are more likely to experience academic stress; therefore, resilience helps them focus on their lessons attentively. However, the results of a few existing studies regarding how resilience impacts the academic performance of medical science students are incongruent. This study aimed to investigate whether resilience impacts the academic performance of Japanese nursing students.

Methods: We conducted a cross-sectional, self-administered questionnaire survey from September to November 2020. A total of 229 undergraduate nursing students participated in this study; here, resilience was measured using the Bidimensional Resilience Scale, which includes innate factors (optimism, control, sociability, and vitality) and acquired factors (problem-solving, self-understanding, and understanding others). Academic performance was measured using the functional grade point average (f-GPA). Covariates were demographics, pre-entry academic performance levels, medical history, time spent walking, psychological distress, subjective economic status, and part-time jobs. Multivariate regression analyses were performed.

Results: Among the 229 participants, the f-GPA mean (standard deviation) was 2.93 (0.46). Only vitality was significantly associated with a higher f-GPA after multiple imputations (β = 0.06; 95% confidence interval = 0.03–0.09; P<0.01). The Poisson regression analysis of 212 participants with all data indicated that vitality was associated with the fourth quartile f-GPA (prevalence ratio, 1.05; 95% confidence interval, 1.03–1.08; P<0.01).

Conclusion: There was a significant association between the vitality of resilience components and academic performance among Japanese nursing students. This study suggests that an approach that develops resilience is necessary for the academic success of nursing students.

Objective: Falls in older adults are a major public health issue, and it is unclear whether the neighborhood environment is associated with falls among this group. This cross-sectional study investigated whether hilly neighborhood environmental factors were associated with fall status (falls or fear of falling) in rural Japanese older adults.

Materials and Methods: Data obtained from 965 participants aged 65 years and older living in Unnan City, Shimane Prefecture, Japan, in 2017 were analyzed. Fall status was assessed based on the 1-year fall incidence (yes/no) for the past year and fear of falling (yes/no) using a self-report questionnaire. For hilly neighborhood environmental factors, the mean elevation and land slope were assessed using a geographic information system. The logistic regression model examined the odds ratios (OR) and 95% confidence intervals (CIs) of fall status in quartiles for elevation and land slope, respectively, and was adjusted for confounders.

Results: Falls and fear of falling were observed in 16.8% and 43.2% of participants, respectively. Falls were associated with elevation (OR 1.99, 95% CI 1.17–3.37 for Q2 vs. Q1; OR 2.02, 95% CI 1.19–3.44 for Q3 vs. Q1) and land slope (OR 1.74, 95% CI 1.04–2.93 for Q3 vs. Q1; OR 1.74, 95% CI 1.04–2.93 for Q4 vs. Q1). Fear of falling was associated with elevation (OR 1.78, 95% CI 1.19–2.65 for Q3 vs. Q1) and land slope (OR 1.51, 95% CI 1.01–2.25 for Q4 vs. Q1).

Conclusion: Our study found that elevation and land slope as hilly neighborhood environment factors were positively associated with falls or fear of falling among older adults living in rural Japan. Prospective observational studies that investigate the effects of region-specific environmental factors on falls among older adults should be conducted.

Objective: The non-medical needs of patients, such as values and personal preferences, are likely to be omitted from advance care planning (ACP) discussions because of a lack of readiness and awareness on the part of healthcare professionals. The aim of the present study was to identify core components perceived by multidisciplinary healthcare professionals to improve person-centered ACP conversations with older people.

Methods: The study participants were healthcare professionals (physicians, nurses, and care managers) working in different cities. This qualitative study was performed online using eight individual in-depth interviews and one subsequent focus group composed of eight healthcare professionals. The interviews and focus group discussion were audio-recorded online and transcribed verbatim. The aim of the analysis of the individual in-depth interviews was to summarize the transcribed results, create a conceptual framework for person-centered ACP conversation, and provide meaningful interpretations of the focus group participant discourse. The qualitative data were then analyzed by inductive manual coding using a qualitative content analysis approach.

Results: Five themes capturing the core components for successful person-centered ACP were extracted from the ideas voiced by participants: Placing highest value on patient autonomy and human life; uncovering patient’s true feelings and desires; sharing collected information on patients’ end-of-life wishes with other team members; relaying patients’ wishes to the physician; and handling conflicts among patients, relatives, and healthcare professionals.

Conclusion: The results provide guidelines for the future development of novel, value-based, person-centered ACP practice for multidisciplinary healthcare professionals.

Objectives: Several reports have shown that Tai Chi Chuan can be an effective way to prevent falls among the elderly. However, an exercise program that can prevent injury during falls has not been reported previously. The judo technique called ukemi is used to prevent injuries. To evaluate whether a judo-based exercise program could prevent falls in the elderly, we had the participants practice ukemi as part of a therapeutic routine. The purpose of this study was to examine the clinical significance of the program and to predict its safety.

Methods: From July 2016 to March 2017, we examined 53 individuals who participated in the exercise program. The individuals were divided into high (n=39) and low (n=14) movement ability groups (HMA and LMA groups, respectively), and their physical and psychological functions were evaluated using scores from the Short-Form Health Survey 36. We also collected and analyzed data from questionnaires obtained from 384 patients who participated in the program from July 2016 to July 2019.

Results: The HMA group showed a significant increase in the mental component summary scores before and after the exercise program. In the LMA group, physical functioning, social functioning, and physical component summary scores were significantly improved. Of the participants surveyed, 94.8% had a high level of satisfaction, and 93.2% began accepting the exercise as a daily habit. No adverse events were observed during these exercises.

Conclusion: This novel exercise program was performed safely, and positive effects were observed, especially in individuals with a low quality of life.

Objective: Community-based integrated care wards (CICW) play a role in supporting the return of patients to their homes. However, studies investigating the readmission risk associated with CICW are lacking. To investigate the influence of CICW on readmission, we conducted a retrospective cohort study among Japanese elderly people.

Materials and Methods: This study used data from the Diagnosis Procedure Combination (DPC) and medical records of the Hamada Medical Center, Shimane Prefecture in 2014–2019. The number of subjects and readmission in each hospitalization case (general ward only [GW] and CICW) were 1,521 and 416 subjects and 152 and 49 cases, respectively. We selected the hospitalization cases for heart failure (I30–I52), ischemic heart disease (I20–I25), pneumonia (J09–J18), chronic lower respiratory tract diseases (J40–J47), intestinal diseases (K55–K64), cerebrovascular disease (I60–I69), gallbladder, bile duct, and pancreatic diseases (K80–K87) from the International Statistical Classification of Diseases and Related Health Problems (ICD-10). The hazard ratios (HRs) and 95% confidence intervals (CIs) for readmission via a CICW were estimated using a multivariate Cox proportional hazards model.

Results: The HRs for readmission associated with CICW were not different between the shorter and longer durations, considering the percentage of CICW stay. Compared with GW cases, the HR of CICW cases was 0.40 (95% CI, 0.17–0.92) in coordination with outside agencies of hospital discharge support. While the HR of GW cases was 2.35 (95% CI 1.01–5.47), a significantly increased risk was observed in people living alone. A similar risk was not observed in CICW cases with the HR of 0.56 (95% CI 0.15–2.07).

Conclusion: The present study observed decreased risk of readmission among the patients discharged from CICW, compared to GW. Further research is required to clarify the causal factors for this decreased risk.

Objective: The authors retrospectively investigated prognostic factors for severe isolated head trauma in patients evacuated by a physician-staffed helicopter emergency medical service (HEMS) or ground ambulance using data from the Japan Trauma Data Bank (JTDB).

Patients and Methods: This study was a retrospective analysis of data housed in the JTDB database. The study period was from January 2004 to May 2019. Subjects were divided into two groups according to the method of transportation: helicopter (i.e., HEMS), which included patients transported by a physician-staffed helicopter; and ambulance, which included patients transported by ground ambulance.

Results: A total of 41,358 patients were enrolled in the study, including 2,029 in the helicopter group and 39,329 in the ambulance group. The ratio of males, median head Abbreviated Injury Scale and Injury Severity Scale (ISS) scores were significantly greater in the helicopter group than in the ambulance group, while the average age, median Glasgow Coma Scale, average Revised Trauma Score (RTS), and survival rate were significantly lower in the helicopter group than in the ambulance group. Of the variables that demonstrated statistical significance in the univariate analysis and classification of transportation and included in the multivariate analysis, the following were identified as significant predictors of survival outcomes: younger age, lower ISS, female sex, and greater RTS. HEMS was not a significant predictor of survival.

Conclusion: The present study revealed no effect of HEMS transport on the outcomes of patients who experienced severe isolated head trauma compared with ground ambulance transportation. Further prospective studies, including an analysis of the operation time or distance traveled by the HEMS and the functional outcome(s) of patients with severe head injury transported by HEMS, are warranted.

Objective: The utility of topotecan monotherapy for relapsed small-cell lung cancer (SCLC) after failure of amrubicin monotherapy has not been evaluated. We aimed to investigate the efficacy and safety of topotecan monotherapy in patients with relapsed SCLC after amrubicin monotherapy.

Patients and Methods: We retrospectively analyzed data from 16 patients with relapsed SCLC who were treated with topotecan monotherapy after amrubicin monotherapy at our hospital.

Results: The response rate, progression-free survival, and overall survival were 0%, 32.5 days (95% confidence interval [CI] = 18–51), and 112 days (95% CI = 55–267), respectively. The most common adverse events (grade ≥3) were leukopenia (31.3%) and thrombocytopenia (31.3%), followed by anemia, anorexia, edema, and lung infections.

Conclusion: The efficacy of topotecan monotherapy for relapsed SCLC after amrubicin monotherapy is inconclusive. Therefore, further studies are warranted.

Objective: Currently, immune checkpoint inhibitors (ICIs) play a central role in the treatment of lung cancer. However, ICI re-administration is still uncommon, and its utility should be evaluated as early as possible.

Patients and Methods: Twenty-five patients who received ICIs twice or more in any of the drug treatment lines for advanced/relapsed non-small cell lung cancer were included. OS, PFS, ORR, and DCR were examined, and factors such as age, sex, histopathological type, PD-L1 expression, whether radical surgery was performed, driver gene mutations, and immune-related adverse events (irAEs), were evaluated for their relevance and as prognostic factors.

Results: Of the 25 patients, 17 were men and 8 were women, with an average age of 68 ± 8.4 (range, 48–85 years), and histology was non-squamous cell carcinoma/squamous cell carcinoma in 19/6 cases. One driver gene mutation positive case was included. PD-L1 TPS was ≥50%/1–49%/0–1%/ unknown in 7/8/5/5 cases. The first ICI administered was pembrolizumab/nivolumab/atezolizumab in 5/13/7 cases. The median number of courses was 9 (range, 1–52) months, and the median PFS was 9 (95% CI, 6.0–12.0) months. Cytotoxic chemotherapy or radiation therapy was administered to 6 patients during the interval up to re-administration. The second ICI administered was pembrolizumab/nivolumab/atezolizumab in 5/8/12 cases, and all patients received antibody drugs different from those given as the first ICI. The median number of courses was 5 (range, 1–24), and the median PFS was 3 months (95% CI, 1.0–5.0) months. In 5 of the 6 patients (24%) who achieved PFS of 6 months or longer after re-administration, the order of administration was anti-PD-1 antibody to anti-PD-L1 antibody.

Conclusion: The effect of re-administration is limited, but it may be effective depending on the type of cases and the order of ICI administration. Further studies are required to verify its effectiveness.

Objective: The clinical course of human metapneumovirus (hMPV) infection is similar to that of coronavirus 2019 disease (COVID-19). However, community-acquired hMPV infections in adults have not yet been sufficiently investigated. We examined the detection status of hMPV antigens and the clinical features of positive patients during the first wave of COVID-19, which coincided with the epidemic season of hMPV infection in Japan.

Methods: In this cross-sectional, observational, and single-center study, we recruited consecutive individuals who visited the Japan Agricultural Cooperatives Kochi Hospital due to fever, respiratory symptoms, or close contact with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected persons during the period from January to May 2020.

Results: The positive rate of immunochromatography for hMPV antigens from nasopharyngeal swabs was 9.5% (4/42), and four positive cases were community-acquired pneumonia (CAP) (5.3% of all CAP). The positive rate of hMPV antigens in the CAP group (30.8%, 4/13) was higher than that in the non-pneumonia group (0.0%, 0/19) (p < 0.05). The average age of the four adult patients with CAP was 69.8 years (range 35–93). Mean white blood cell counts and C-reactive protein blood levels were 6,250 cells/μL (3,500–12,180) and 4.30 mg/dL (4.05–7.04), respectively. Chest computed tomography images were diverse and two patients showed dense consolidation. No multi-organ disorder was noted during the clinical course in any of the four cases, and their prognoses were good.

Conclusion: hMPV infection may be considered in the differential diagnosis of COVID-19 and CAP in Japan under the preventive measures for SARS-CoV-2 infection, at least during the epidemic season of hMPV infection.

Objective: Physical frailty has been considered a risk factor for certification of long-term care needs (hereafter referred to as Certification) under Japan’s long-term care insurance (LTCI). Therefore, assessment of frailty in elders should be studied from multiple perspectives. The Kihon Checklist (KCL) is widely used to identify need for support/care among Japanese older adults. This study aims to examine the relationship between changes in KCL items and Certification among Japan’s young-old and old-old.

Material and Methods: The KCL responses of 7,092 participants were assessed in April 2012 and March 2016, along with gender, age, and living environment. Deaths, Certifications, and relocations were tracked until March 2018. Changes in KCL items were categorized as bad, worse, improved, or good.

Results: Between March 2016 and March 2018, about 7.3% of respondents obtained Certifications. KCL item changes increased the risk of new Certification for bad and worse groups, while improved cognitive function among the old-old possibly reduced the risk of new Certification.

Conclusion: Therefore, rather than administering the KCL once, identifying KCL changes among people at risk could help prevent or delay their need for long-term care.

An insulinoma is a pancreatic neuroendocrine tumor that causes hypoglycemia. In the elderly, as surgery is not always possible, drugs are an important alternative. However, the effects of lanreotide on insulinomas have not yet been elucidated. We report the case of an 85-year-old Japanese woman who was admitted for loss of consciousness and hypoglycemia, which was resolved after intravenous glucose infusion. Insulin secretion was not inhibited during hypoglycemia. Enhanced computed tomography and OctreoScan scintigraphy revealed a pancreatic tumor (diameter, 13 mm) with radiotracer accumulation. Thus, clinical insulinoma was confirmed. However, the patient refused further examination and surgery. Diazoxide (150 mg/day) therapy resolved hypoglycemia but caused fluid retention. Consequently, we switched to lanreotide (120 mg/6 weeks). Continuous glucose monitoring revealed that both drugs had comparable effects on interstitial glucose normalization. Furthermore, 447 days after the initiation of lanreotide treatment, the patient had no hypoglycemic symptoms. Therefore, lanreotide may be a useful alternative treatment option for inoperable insulinomas in elderly individuals.

A 57-day-old boy presented with fever, watery diarrhea, and anorexia and was admitted with suspected acute gastroenteritis. His laboratory data suggested low-level inflammation and cholestasis. His stool culture was positive for Salmonella Litchfield. With suspicion of bacterial infection, the patient received intravenous ampicillin for 5 days. On the fifth day after admission, his inflammatory and cholestasis markers normalized, and he was discharged from the hospital in good condition. His family kept five Japanese pond turtles as pets for one year. As Salmonella Litchfield was isolated from a swab sample of the turtle’s body. The patient was diagnosed with turtle-associated salmonellosis. In conclusion, families, particularly those with infants, should avoid keeping turtles in their homes. Pet shop owners and public health authorities must provide appropriate information regarding Salmonella in turtles.

Objective: Although much is known about acute carbon monoxide (CO) poisoning, little is known about chronic CO poisoning. Chronic CO poisoning is often diagnosed based on the patient’s living environment and medical history. Herein, we report the case of an older patient who presented with repeated unconsciousness due to chronic CO poisoning.

Case presentation: A 90-year-old man was brought to the emergency department after being found at home with a disturbance of consciousness. Arterial blood gas measurements in room air revealed a carboxyhemoglobin level of 18.0%. Impaired consciousness was caused by chronic CO poisoning. The patient received high-flow oxygen therapy, which promptly improved his condition. According to his family, briquette kotatsu was the cause of chronic CO poisoning.

Conclusion: Although high-flow oxygen therapy has been said to be less effective than hyperbaric oxygen therapy in CO poisoning treatment, recent studies have demonstrated that high-flow oxygen has similar effects and benefits. Thus, in institutions that do not have hyperbaric oxygen, high-flow oxygen may be sufficient to treat patients with CO poisoning, as seen in the present case. It should be noted that briquette kotatsu can lead to CO poisoning. This case highlights the need for clinicians to consider patients’ living conditions.

Objective: Deep femoral artery (DFA) aneurysms are extremely rare cases of aneurysms that are difficult to diagnose. The objective of this report was to discuss the timing and method of surgery for this disease.

Patient: We encountered an asymptomatic left DFA aneurysm that was discovered along with a symptomatic aneurysm of the right superficial femoral artery (SFA). Both sides of the aneurysm were resected with Dacron knitted artificial vascular grafts (Gelsoft™ Plus, Vasctek, UK) simultaneously.

Result: After the operation, the right SFA had good blood flow, but the graft of the left DFA was occluded. The occlusion was considered to be caused by insufficient blood flow in the graft. The patient was discharged without any complications.

Conclusion: The coexistence of DFA aneurysms should be examined if other aneurysms are found. DFA aneurysms are at a high risk of rupture. Careful follow-up is required, and intervention is recommended when the diameter exceeds 35 mm.

High-speed information and communication technology (ICT) networks stretch all over Japan. However, their utility in facilitating rural healthcare remains uncharacterized. A nationwide questionnaire survey was sent by mail to 1,018 rural clinics constructed in a public manner in municipalities throughout Japan. ICT use was classified by type, including a doctor-to-doctor manner. Only 19% of the 303 clinics surveyed (with a response rate of 30%) used ICT. Specifically, 50% used it in a doctor-to-doctor manner, while 35% used it to obtain electronic medical records. Differences in proficiency levels among ICT users were cited by 21% of the respondents as a major problem associated with ICT use. In Japan, the prevalence of ICT use for rural healthcare appeared low. We suggest a policy reform to facilitate ICT use in rural healthcare.