Yonaguni Island is a remote and isolated westernmost island in Japan, which is the fastest aging country in the world. This study evaluated the current status of medical supply-and-demand on the ...island and compared these results with previous surveys carried out in rural parts of Japan. This was a retrospective cohort study conducted at the Yonaguni Municipal Clinic, the only medical facility in Yonaguni Island. The participants were patients who visited the clinic over one year, between July 2015 and June 2016. We calculated the rate per 1,000 persons per month of clinic visits, referrals to off-island medical facilities (e.g., hospitals and specialist clinics), referrals to off-island emergency departments, off-island hospitalizations after referral, home visits, and overnight observations at the clinic. In total, 6,197 patients (males, 46.3%) visited the clinic. The rate of clinic visits per 1,000 persons per month was 516.4 (Standard deviation SD 28.1, 95% confidence interval CI: 500.5-532.3). The rate per 1,000 persons per month was 14.0 (SD 3.9, 95% CI: 11.8-16.2) for off-island referrals, 3.8 (SD 2.1, 95% CI: 2.6-5.0) for referrals to emergency departments, 4.8 (SD 2.6, 95% CI: 3.3-6.2) for hospitalizations, and 3.2 (SD 1.7, 95% CI: 2.2-4.1) for home visits. The rate of clinic visits was higher in Yonaguni Island than in other rural areas, although the rate of off-island referrals was lower. There were no significant differences between the number of referrals to emergency departments, hospitalizations, and home visits in Yonaguni Island, in comparison to other studies. Our study showed that patients presenting with emergencies had similar rates of healthcare-seeking behavior to those reported in previous studies in Japan; however, the referral rate was lower. We assessed the ecology of medical care in this district by evaluating patient behavior on an isolated island where access to medical care is geographically limited.
We conducted a prospective single-arm interventional study of the treatment efficacy of ultrasound-guided fascia hydrorelease (US-FHR) on the coracohumeral ligament (CHL) of patients with global ...limitation of shoulder range of motion (ROM) without local inflammation. The primary outcome was the change in passive ROM (pROM) of external rotation (ER) after first US-FHR. Secondary outcomes included the change in pROM of other directions from baseline, the pain visual analogue scale (pVAS) at the timepoints after each procedure (first, second US-FHR and rehabilitation) as well as the change in the Shoulder Pain and Disability Index (SPADI) from the first to the second visit. Eleven patients underwent US-FHR. The pROM of ER after the 1st US-FHR changed by a median of 7.1° (p < 0.01). There was a statistically significant improvement in the pROM of flexion, extension, abduction, external rotation, and internal rotation from baseline to each timepoints. The pVAS at rest showed no significant improvement, although the pVAS at maximal ER showed a trend towards improvement. The SPADI score decreased by a median of 13.4 (p < 0.01). No adverse events were observed. US-FHR on the CHL with or without rehabilitation might be an effective, less invasive treatment for patients with global limitation of shoulder ROM.
Objective: General practitioners in rural clinics are required to deal with musculoskeletal problems, but they often lack the confidence. We aim to confirm changes in their confidence in orthopedic ...practices after using tele-education.Materials and Methods: We conducted tele-education in orthopedic practices from June 1, 2022, to November 30, 2022. Using a teleconference system, the first author, an orthopedic specialist, provided tele-education training to an independent general practitioner in a rural clinic. We adopted a 7-point Likert scale to assess the general practitioner’s confidence levels. In pre- and post-research, the counts and confidence levels in the scale were assessed for 18 types of orthopedic practices each month. Furthermore, we interviewed the general practitioner to examine the factors influencing their confidence.Results: The confidence levels increased for all measurement items. The most experienced orthopedic practice was “Advising on daily care for musculoskeletal problems”, with confidence levels increasing from 3 to 6. The least experienced orthopedic practice was “Manipulative reduction of radial head subluxation”, with confidence levels increasing from 4 to 5. The factors that influenced the change in confidence levels were regular feedback and unrestricted availability of consultations.Conclusion: Tele-education in orthopedics may enhance general practitioners’ confidence in orthopedic practices.
To elucidate the accuracy and optimal cut-off point of self-diagnosis and clinical symptoms of seasonal influenza compared with rapid influenza diagnostic tests as the reference standard, we ...conducted a cross sectional observational study at a rural clinic in Japan.
Data during three influenza seasons (December 2013 to April 2016) were retrospectively collected from the medical records and pre-examination sheets of 111 patients aged >11 years (mean age 48.1 years, men 53.2%) who were suspected of influenza infection and underwent rapid influenza diagnostic testing. Patients' characteristics (age, sex, and past medical history of influenza infection), clinical signs (axillary temperature, pulse rate, cough, joint and muscle pain, and history of fever acute or sudden, gradual, and absence of fever), duration from the onset of symptoms, severity of feeling sick compared with a common cold (severe, similar, and mild), self-reported likelihood of influenza (%), and results of rapid influenza diagnostic tests.
At the optimal cut-off point (30%) for estimation of self-diagnosis of seasonal influenza, the positive likelihood ratio (LR+) was 1.46 (95% confidence interval 1.07 to 2.00) and negative likelihood ratio (LR-) was 0.57 (0.35 to 0.93). At a 10% cut-off point, LR-was 0.33 (0.12 to 0.96). At an 80% cut-off point, LR+ was 2.75 (0.75 to 10.07). As for clinical signs, the combination of acute or sudden onset fever and cough had LR+ of 3.27 (1.68 to 6.35). Absence of cough showed LR-of 0.15 (0.04 to 0.61).
Self-diagnosis of influenza using the optimal cut-off point (30%) was not found useful for ruling in or ruling out an influenza diagnosis. However, it could be useful when patients self-report extremely high (80%) or low (10%) probability of having influenza. Clinically useful signs were the combination of history of fever and cough, and absence of cough.
Far fewer opioids are prescribed in Japan than in the United States.
We conducted an online physician survey assessing attitudes and perceptions that might influence prescribing. A Japanese version ...was distributed to members of the Japan Primary Care Association and an English version to members of the American Academy of Family Physicians practicing in Oregon.
We received 461 Japanese responses and 198 from the United States, though overall response rates were low (Japan: 10.1%, United States: 18.5%). Japanese respondents reported far less opioid prescribing than US respondents, especially for acute pain (acute pain: 49.4% vs 97.0%; chronic pain: 63.7% vs 90.9%;
< .001 for both). Almost half of respondents from both countries indicated that patient expectations and satisfaction were important factors that influence prescribing. US respondents were significantly more likely to identify medical indication and legal expectation as reasons to prescribe opioids for acute pain. Most US respondents (95.4%) thought opioids were used too often, versus 6.6% of Japanese respondents.
Lower opioid use was reported in Japan, especially for acute pain, which may help minimize long-term use. Patient expectations and satisfaction seem to influence opioid prescribing in both countries. The United States could learn from Japanese regulatory and cultural perspectives.
Abstract
Objective
An ultrasound-guided interfascial injection, which targets the space between the epimysia, is often performed for myofascial neck and shoulder pain. However, the relationship ...between the injection volume and clinical effectiveness has been controversial. We conducted an anatomical study with cadavers to measure the distribution of a small amount of pigment solution injected into the interfascial space.
Design
An experimental cadaveric study.
Setting
An institutional clinical anatomy laboratory.
Methods
We performed 20 ultrasound-guided injections with pigment solutions of 1.0 mL each into the space between the trapezius muscle and rhomboid muscle bilaterally on 10 cadaver specimens. Cadavers were then dissected and macroscopically evaluated for pigment distribution on the fascia of the muscular surfaces. The pigment distribution area of each injection site was visually confirmed and calculated using automatic area calculation software.
Results
Pigment solution exclusively within the interfascial space was visually confirmed in 95% (19/20) of injection sites. The median pigmented surface area (interquartile range) was 24.50 (16.17–30.76) cm2 on the deep side of the trapezius muscle and 18.82 (13.04–24.79) cm2 on the superficial side of rhomboid muscle; these measurements were statistically significantly different (P = 0.033).
Conclusions
A pigment solution comprising as little as 1.0 mL injected under ultrasound guidance separated two adjacent muscles and spread to the wide area within the interfascial space. The difference in the pigment distribution area between the two adjacent muscles can be explained by the path made by the injection needle and several layers of fascia between the epimysium.
A 33-year-old man was referred to our hospital with chief complaints of fever, dizziness, and headache. Although he had recurring fever and dizziness for 7 months, neurological examination, magnetic ...resonance imaging, computed tomography, electrocardiograms, and blood tests were normal. He was diagnosed with functional hyperthermia, cervical vertigo, and tension headache and was treated with oral medication and physical therapy. After treatment, the dizziness and headache resolved; however, the fever and anxiety did not. During follow-up, he noticed differing results from different electronic thermometers. The physician decided to use an accurate analog thermometer, a gallium thermometer, in combination with the other thermometers. The results differed significantly among the thermometers, and the electronic thermometer readings were found to be inappropriately high. The physician made a diagnosis of pseudo-fever, and the patient recognized that the gallium thermometer’s results were the most accurate reflection of his physical condition, resolving his anxiety.
A 47-year-old farm worker with diabetes mellitus, dyslipidemia, and hyperuricemia was referred to our hospital for a 3-month history of fever and malaise. He had no respiratory tract or abdominal ...symptoms, skin rashes, or joint pain. There was no change to his regular medication or pesticide exposure. Blood tests and echocardiography revealed no abnormalities. Whole-body computed tomography revealed a fatty liver; however, non-alcoholic steatohepatitis was excluded. We diagnosed the patient with functional hyperthermia. He had a history of snoring and weight gain, and we suspected the obstructive sleep apnea syndrome to be a stressor. Polysomnography revealed severe obstructive sleep apnea syndrome with an apnea–hypopnea index of 44.5. Continuous positive airway pressure was introduced; the axillary temperature decreased gradually and malaise was resolved. Functional hyperthermia should be considered a cause of fever with a negative inflammatory response. Obstructive sleep apnea syndrome can be a stressor for functional hyperthermia, which can be improved by interventions.
Hemiplegic migraine is a rare form of migraine characterized by aura with unilateral paralysis; however, studies on its treatment are limited. A 39-year-old man with migraine headaches and myofascial ...pain syndrome was referred to our hospital with transient right hemiplegia, after presenting to an outside emergency department with headache and right hemiplegia 2 days prior. Computed tomography, magnetic resonance imaging, and blood test results revealed no abnormalities. The symptoms resolved spontaneously; he was referred to our hospital. Based on the International Classification of Headache Disorders, Third Edition criteria, he was diagnosed with sporadic hemiplegic migraine. Propranolol was added to his regular regimen as prophylactic treatment, which resulted in reduction in his migraine frequency. Over the next 2 years, no recurrent paralysis occurred. Hemiplegic migraines should be considered in patients with migraine exhibiting transient hemiplegia without obvious intracranial abnormalities. Prophylactic treatment with propranolol could be effective in treatment of hemiplegic migraine.
ObjectiveTo elucidate the diagnostic accuracy of pretest probability of influenza (%) by physicians and the factors affecting the clinical diagnosis.DesignRetrospective, single-centre observational ...study.SettingA community primary care clinic in Japan.ParticipantsThe participants were recruited from a database of studies conducted during the influenza season from December 2017 to April 2019.Primary outcome measureSensitivity and specificity of the physician’s clinical diagnosis of influenza recorded in the medical record as pretest probability.ResultsA total of 335 patients (median age, 31 years; male, 66.6%) were analysed in this study. The area under the curve (AUC) of the physician’s pretest probability was 0.77. At a cut-off value of 30%, the sensitivity and negative likelihood ratio were 92.0% (95% CI 86.7 to 95.7) and 0.19 (95% CI 0.11 to 0.33), respectively. At a cut-off value of 80%, the specificity and positive likelihood ratio were 90.8% (95% CI 85.4 to 94.6) and 4.01 (95% CI 2.41 to 6.66), respectively. The AUCs of patients who had and had not taken any medications before visiting the clinic were 0.77 (95% CI 0.69 to 0.85) and 0.78 (95% CI 0.71 to 0.84), respectively. The AUCs of patients with type A and B influenza were 0.78 (95% CI 0.72 to 0.84) and 0.76 (95% CI 0.70 to 0.82), respectively. The AUCs of vaccinated and unvaccinated patients were 0.80 (95% CI 0.72 to 0.88) and 0.76 (95% CI 0.63 to 0.89), respectively. The AUC for patients less than 12 hours after onset was 0.69 (95% CI 0.51 to 0.88), and that for patients aged younger than 6 years was 0.69 (95% CI 0.49 to 0.88).ConclusionsThe physician’s pretest probability of influenza (%) may be useful for both definitive and exclusionary diagnoses within the limits of our study.
PDF
