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Background Laparoscopic sacrocolpopexy (LSC) is an increasingly popular treatment for pelvic organ prolapse (POP) because of its low recurrence rate and safety. Although LSC may improve the voiding function, it may also lead to de novo stress urinary incontinence. The detailed impact of LSC on voiding function and its mechanism remain unclear. Therefore, in this study, we evaluated the impact of LSC on voiding function prospectively by performing a pre- and post-operative urodynamic study in patients with stage 3 or greater POP. Methods Urinary status was evaluated before and 3 months after LSC. Pre- and post-operative evaluations included medical history, clinical examination, urodynamic studies, chain cystography, and residual urine volume measurement. Urinary symptoms were assessed using the International Prostate Symptom Score (IPSS) and the Overactive Bladder Symptom Score (OABSS). Results The non-recurrence rate at 3 months was 82.3%. All recurrences involved bladder prolapse. Apart from the fact that there was no significant change in the OABSS, the improvement in IPSS suggests that subjective voiding symptoms have improved. Although the maximum urinary flow rate did not change significantly, the bladder volume at first sensation increased, urinary storage function improved, and residual urine volume decreased. There were no perioperative complications, and none of the patients complained of post-operative difficulty in urination or urinary retention. The retrovesical angle significantly decreased. Conclusions The modified LSC in women with POP provides good functional outcomes in terms of IPSS, post void residual volume (PVR), and urinary storage function.

A 31-year-old nulliparous Japanese woman visited the clinic due to worsening dysmenorrhea. A cystic endometriotic lesion was found in the vesico-uterine pouch. Laparoscopic surgery was chosen due to the severe dysmenorrhea. Her first oocyte retrieval attempt was performed at in-vitro fertilization clinic before the planned surgery. However, she complained of abdominal pain on day 6 after the retrieval. We diagnosed her with peritonitis with an abscessed cystic endometriotic lesion in the vesico-uterine pouch. Conservative treatment was ineffective. Therefore, laparoscopic surgery was performed. The cysts in the vesico-uterine pouch were drained of pus. No adhesions or lesions of endometriosis in the uterus, bilateral adnexa, or pelvic peritoneum were found. Although cystic endometriotic lesions in the vesico-uterine pouch are rare, they can form abscesses after oocyte retrieval. The possibility of abscesses formation risk must be considered. Moreover, following the management of endometrioma, sufficient medication should be administered to prevent this formation.

We report a rare case of an ovarian steroid cell tumor with a diagnosis prompted by heart failure symptoms. A 28-year-old Japanese nulligravida/nullipara with a chief complaint of respiratory discomfort during physical exertion and exhibiting heart failure symptoms was referred to our hospital. She also had signs of virilization, including secondary menorrhea since the age of 20, hirsutism and balding. Cushing's syndrome was suspected, and further examinations showed hypertestosteronemia and right ovarian tumor. Symptomatic treatment for heart failure with diuretics and antihypertensives was followed by abdominal right adnexectomy performed due to the androgen-producing ovarian tumor. The tumor was solid and larger than a fist, and confirmed as a steroid cell tumor through postoperative histopathology. Serum total testosterone levels normalized at day 3 postoperatively, and menstruation resumed 2 months later. Our case was diagnosed due to heart failure symptoms, and its treatment resulted in improvement in virilization signs.

To investigate the extent to which long-term care facilities used ambulances for low-acuity conditions. A large number of instances of ambulance use for low-acuity conditions corresponded to long-term care facilities. Intervention in long-term care facilities may reduce ambulance use for low-acuity conditions, which will help facilitate the timely transportation of patients. Increased ambulance calls affect the timely transportation of patients. Recently, ambulance uses from long-term care facilities (LTCFs) for older adults has been increasing. The aim of this study was to investigate to what extent LTCFs used ambulances for low-acuity conditions. Ambulance records from the fire department of Misato City were used. The participants were patients aged 65 years or older transported from all types of LTCFs (including public nursing homes, geriatric health services facilities, private nursing homes, and group homes) and homes. The proportions of ambulance use for low-acuity conditions and their 95% confidence intervals (CI) were calculated and compared by time (daytime and night-time) and day (weekdays and holidays) of ambulance use for each type of residence. Of 12,494 participants, 1336 (11%) were transported from LTCFs, and 326 (2.6%) for low-acuity conditions. Of 326 patients with low-acuity conditions, 69% were transported from LTCFs. The proportion of low-acuity conditions was 17% among those transported from LTCFs, while it was only 1% among those from homes. The proportion of low-acuity conditions was significantly greater during night-time than daytime among those from public nursing homes, geriatric health services facilities, and group homes, while this proportion was greater on weekdays than holidays among those from geriatric health services facilities. This study found a large number of instances of ambulance use for low-acuity conditions by LTCFs. To reduce unnecessary ambulance use for low-acuity conditions efficiently, LTCFs should be assisted in making proper assessments of both patients’ conditions and appropriate ambulance use.

Aim To investigate the accuracy and clinical value of an adhesion scoring system using transvaginal ultrasonography for endometriotic adhesion. Methods In this prospective observational study, we included 131 patients with endometriosis who underwent surgery. Before surgery, transvaginal ultrasonography and adhesion mapping were performed to determine the presence or absence of adhesions at 10 sites of the pelvis. Mapping accuracy was determined by comparing the mapping findings with the surgical findings. To determine the severity of pelvic adhesions, we developed an adhesion score (0-10). With the adhesion score, we assessed the effect of surgical adhesiolysis and evaluated the relationship between postoperative adhesions and infertility. Results Of the 10 sites assessed for adhesions, the most frequent site of adhesions was the site between the left ovary and the uterus (70.5%). The overall sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio and accuracy of adhesion mapping were 80.4%, 86.1%, 78.8%, 87.2%, 5.79, 0.23 and 83.9%, respectively. The adhesion score in this system was significantly correlated with the adhesion-related score in the revised American Society for Reproductive Medicine classification (R2 = 0.734). Surgical adhesiolysis yielded only about 30% improvement postoperatively. The adhesion score 1 month after surgery in the non-in vitro fertilization (IVF) pregnancy group was significantly lower than that in the IVF pregnancy group (3.45 vs 5.21; P = 0.02). Conclusion Our adhesion scoring system allowed an accurate prediction of the pelvic adhesion status and may potentially be an indicator of postoperative adhesions and infertility.

An emergency care system is an important aspect for healthcare organisations in low- and middle-income countries (LMICs) with a growing burden from emergency disease conditions. Evaluations of emergency care systems in LMICs in broader contexts are lacking. Thus, this study aimed to develop a comprehensive emergency medical system model appropriate for resource-constrained settings, based on expert opinions.We used the Delphi method, in which questionnaire surveys were administered three times to an expert panel (both emergency medical care providers and healthcare service researchers), from which opinions on the model's components were compiled. The panel members were mostly from Asian countries. In the first round, the questionnaire drew a list of model components developed through a literature review; the panel members then proposed new components to create a more comprehensive list. In the second and third rounds, the panel members rated the listed components to achieve consensus, as well as to remove components with low ratings. Finally, we rearranged the list to improve its usability.In total, 32 experts from 12 countries participated. The final model totalled 177 components, categorised into 8 domains (leadership, community-based actions, emergency medical services, upward referral, definitive care, rehabilitation, downward referral, and evaluation and research). No components needed removal.We developed a comprehensive emergency care system model, which could provide a basis to evaluate emergency care systems in resource-constrained LMICs; however, field-testing and validation of this system model remain to be done.Un système de soins d'urgence est un aspect important pour les organisations de soins de santé dans les pays à revenu faible ou intermédiaire (PRFI), qui subissent une charge croissante d'affections de maladie d'urgence. Les évaluations des systèmes de soins d'urgence dans les PRFI dans des contextes plus larges font défaut. Cette étude visait donc à élaborer un modèle de système médical d'urgence complet, adapté aux contextes à ressources limitées, sur la base d'opinions d'experts. MÉTHODES: Nous avons utilisé la méthode Delphi, dans laquelle des enquêtes par questionnaire avaient été administrées à trois reprises à un groupe d'experts (prestataires de soins médicaux d'urgence et chercheurs en services de santé), à partir desquelles des avis sur les composants du modèle ont été compilés. Les membres du panel venaient principalement de pays asiatiques. Lors du premier tour, le questionnaire a dressé une liste des composants du modèle développés à travers une revue de la littérature; les membres du panel ont ensuite proposé de nouveaux composants pour créer une liste plus complète. Lors des deuxième et troisième tours, les membres du panel ont évalué les composants énumérés afin de parvenir à un consensus et d’éliminer les composants faiblement cotés. Enfin, nous avons réorganisé la liste pour en améliorer la convivialité. RÉSULTATS: Au total, 32 experts de 12 pays ont participé. Le modèle final comprenait 177 composants, classés en 8 domaines (leadership, actions communautaires, services médicaux d'urgence, référence ascendante, soins définitifs, suivi, référence postérieure, évaluation et recherche). Aucun composant ne nécessitait d’être exclus.Nous avons élaboré un modèle complet de système de soins d'urgence qui pourrait servir de base à l’évaluation des systèmes de soins d'urgence dans les PRFI aux ressources limitées. Cependant, les essais sur le terrain et la validation de ce modèle de système restent à faire.

Primary healthcare (PHC) principles provide a framework for strengthening the healthcare system to tackle increasing and diversifying health needs in low- and middle-income countries (LMICs). Currently, PHC systems in LMICs require expanded care capabilities in order to deal with noncommunicable diseases and injuries, including emergency conditions. In this article, we discuss the possibility of applying PHC principles to emergency care in LMICs and integrating emergency care into PHC; such principles include providing first points of contact with healthcare through nonprofessional providers close to communities in order to improve accessibility, providing high-quality (i.e., comprehensive, coordinated, and continuous) primary care, and addressing primary causes of ill-health through community empowerment. These principles are applicable to emergency care, which has the same attributes: it also requires increasing first points of contact through layperson first aid and the ambulance system, and it also provides comprehensive care for diverse diseases and injuries, with various facilities and personnel involved in its coordinated and continuous delivery; collective community actions also develop and strengthen the emergency care system, particularly through components outside the health sector (e.g., transport, communication, and mutual aid). Integrating emergency care into PHC could enhance the general health system and is more efficient than having separate systems.

To reduce delays in accessing services and providing early treatment for patients with first-episode psychosis requires an understanding of the causes of treatment delay. We investigated it among patients with the first-episode schizophrenia (FES) across the country. 302 outpatients with a FES were recruited in one psychiatric hospital, six general hospitals, one community hospital, and one university hospital from June 2017 to August 2018. Those who have the duration of untreated psychosis (DUP) 3 months or longer were considered as delayed treatment seekers. The relative influences of patients’ characteristics on the delay in treatment-seeking were estimated on logistic regression analyses. The mean and median DUP was 9 weeks (standard deviation: 12) and 4 weeks (interquartile range: 2–9), respectively. 24% of the enrolled patients were delayed treatment seekers. Those living 6–10 km away and those living more than 20 km away from the hospital tended to be delayed treatment seekers, while those who had a family history of mental disorders tended to have sought treatment timely. Since the distance to the hospitals was a potential barrier to seeking health care among patients with FES, providing outreach mental health services and transportation support may be considered to shorten treatment delay in Thailand.

Background The method of communicating a positive cancer screening result should seek to alleviate psychological distress associated with a positive result. We evaluated whether the provision of information through a leaflet would help reduce psychological distress in a randomized controlled trial. Methods The participants were women aged 20–69 years who were about to undergo cervical cancer screening at health centers. Before the screening, they received hypothetical screening results, with a leaflet (intervention group, n = 493) or without it (control group, n = 479), randomly. Their psychological distress and intention to undergo further examination were then compared between the intervention and control groups. Results After the intervention (providing a leaflet with hypothetical screening results), psychological distress appeared to be higher in the control group than in the intervention group among those who received a hypothetical positive screening result (odds ratio: 2.57, 95% confidence interval: 1.87–3.54), while 95% and 97% of those in the intervention and control groups, respectively, reported that they would undergo further examination. Conclusions Information provision might help reduce psychological distress but not hinder further examination among women who screen positive for cervical cancer. Trial registration: UMIN Clinical Trials Registry UMIN000029894. Date of Registration: November 2017.

Background Nutritional support for surgical care is crucial because hospital malnutrition is rather common. However, low- and middle-income countries have not adequately addressed nutritional management of surgical patients. To highlight need for nutritional management in surgical patients, the present study aimed to describe preoperative nutritional status in patients who underwent gastrointestinal cancer surgery in Vietnam and to investigate the relationship between preoperative malnutrition and adverse outcomes, such as postoperative complications and prolonged length of hospital stay. Methods We reviewed medical records of patients who underwent a major curative surgery for gastrointestinal cancer at the national hospital in Ho Chi Minh City, Vietnam. We identified preoperative malnutrition based on body mass index and serum albumin level, and postoperative complications in the first 30 d postoperative. We estimated the relative influence of malnutrition on complications and length of hospital stay using multivariate regression models. Results Of 459 eligible patients, 63% had colorectal cancer, 33% gastric cancer, and 4% esophageal cancer. The prevalence of malnutrition was 19%. No patients died during hospitalization; however, 26% developed complications after surgery. The average length of hospital stay was 14 d. After controlling for potential confounders, preoperative malnutrition was associated with an increased risk of postoperative complications (odds ratio = 1.97) and prolonged hospital stay (2.8 d). Conclusions Preoperative malnutrition affects surgical outcomes among patients with gastrointestinal cancer in Vietnam. We recommend implementing preoperative nutritional interventions to achieve better outcomes among surgical cancer patients.

Laparoscopic sacrocolpopexy (LSC) is attracting increasing attention as a minimally invasive surgery that provides excellent therapeutic effects on apical vaginal prolapse. However, its therapeutic effects on multi-compartmental pelvic organ prolapse (POP) remain unclear. Therefore, the aim of this review was to evaluate the efficacy of LSC on multi-compartmental POP compared with abdominal sacrocolpopexy (ASC). We extracted three articles on randomized controlled trials that compared LSC and ASC. A total of 247 patients (123 for LSC, 124 for ASC) were evaluated. There was no evidence of recurrence or reoperation in either group for the apical vaginal compartment. Regarding recurrence within the anterior vaginal compartment, there were no significant between-group differences in either of the two randomized controlled trials targeting vaginal vault prolapse. In contrast, in the randomized controlled trial targeting POP including cases with uteruses, there were more recurrent POP with grade II or more in the LSC group than in the ASC group (11/60 [18.3%] vs 1/60 [1.6%], P = 0.004). Reoperation for the posterior vaginal compartment was performed in three cases (2.5%) in the LSC group and in one case (0.8%) in the ASC group. The combined repeat surgery and mesh removal surgery rate was higher in the LSC group (8/119 [6.7%]) than in the ASC group (2/121 [1.7%], P = 0.049). LSC has an excellent therapeutic effect and is comparable to ASC for the treatment of apical prolapse. However, cystocele recurrence, repeat surgery of the posterior compartment, and mesh-related complications were more frequent in patients who had undergone LSC.

Study Objective The objective of this study was to develop a novel morphological classification for Douglas fossa obliteration in endometriosis. Design Retrospective study. Setting Nippon Medical School Hospital. Patients or Participants 29 patients with endometriosis. Interventions On the basis of the recently revealed clinical knowledge of the membrane structure of the Douglas fossa and the anatomical information derived from cadaveric dissection, a hypothetical model of the normal Douglas fossa was established. This was used to examine past surgical videos (n = 29 cases) to evaluate the patterns that exist in Douglas fossa obliteration in endometriosis. Measurements and Main Results The recto–vaginal fascia that constitutes the front of the Douglas fossa has a wing-shaped structure, with the upper edge of the wing corresponding to the uterosacral ligaments (USLs). The tip of the wing is bifurcated (a λ-type structure), and the inside is connected to the rectum to form the upper part of the rectal lateral ligament. The outer side comprises the fusion surface between the peritoneum and the underlying ureterohypogastric fascia. Results The patterns of the Douglas fossa obliteration could be classified into six types: 1: normal, 2: upper peripheral lesion type, 3: lateral displacement type (right or left), 4: forward displacement type, 5: median elevation type, and 6: diffuse median elevation type (frozen pelvis); furthermore, in terms of proportions, there were 2 (7%), 8 (28%), 6 (20%), 1 (3%), 7 (24%), and 6 (21%) cases of each type, respectively. In the median elevation type, the left and right USLs and lateral ligaments were extremely shortened, the uterus and rectum were completely attached, and the Douglas fossa was completely closed. Conclusion The cases that showed complete occlusion of the Douglas fossa were either the median elevation type or the diffuse median elevation type.

Study Objective To investigate the accuracy and clinical value of a new adhesion scoring system using transvaginal ultrasonography for endometriosis. Design Prospective observational study. Setting Nippon medical school hospital, Tokyo, Japan. Patients or Participants 131 patients with endometriosis who underwent surgery at Nippon medical school Hospital. Interventions Before surgery, transvaginal ultrasonography and adhesion mapping were performed to determine the presence or absence of adhesions at 10 sites of the pelvis. Measurements and Main Results To determine the severity of pelvic adhesions, we developed an adhesion score (0-10). With the adhesion score, we assessed the effect of surgical adhesiolysis and evaluated the relationship between postoperative adhesions and infertility.Results: Of the 10 sites assessed for adhesions, the most frequent site of adhesions was the site between the left ovary and the uterus (70.5%). The overall sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, and accuracy of adhesion mapping were 80.4%, 86.1%, 78.8%, 87.2%, 5.79, 0.23, and 83.9%, respectively. The adhesion score in this system was significantly correlated with the adhesion-related score in the r-ASRM classification (R2 = 0.734). Surgical adhesiolysis yielded only about 30% improvement postoperatively. The adhesion score in the non-in vitro fertilization (IVF) pregnancy group was significantly lower than that in the IVF pregnancy group (3.45 vs. 5.00; p = 0.04). Conclusion Our adhesion scoring system allowed an accurate prediction of the pelvic adhesion status and may potentially be an indicator of postoperative adhesions and infertility.

Objective: We evaluated the association between prehospital epinephrine administration by emergency medical services (EMS) and the long-term outcomes of out-of-hospital cardiac arrest (OHCA) with initial pulseless electrical activity (PEA) or asystole. Methods: We conducted a controlled, propensity-matched, retrospective cohort study by using Japan's nationwide OHCA registry database. We studied 110,239 bystander-witnessed OHCA patients aged 15–94 years with initial non-shockable rhythms registered between January 2008 and December 2012. We created 1–1 matched pairs of patients with or without epinephrine by using sequential risk set matching based on time-dependent propensity scores to balance the patients' severity and characteristics. We compared overall and neurologically intact survival 1 month after OHCA between cases and controls using conditional logistic regression models by category of the initial rhythm. Results: Propensity matching created 7,431 pairs in patients with PEA and 8,906 pairs in those with asystole. Epinephrine administration was associated with higher overall survival (4.49% vs. 2.96%; odds ratio [OR], 1.55; 95% confidence interval [CI], 1.30–1.85) but not with neurologically intact survival (0.98% vs. 0.78%; OR, 1.26; 95% CI, 0.89–1.78) in patients with PEA, and with higher overall survival (2.38% vs. 1.04%; OR, 2.34; 95% CI, 1.82–3.00) and neurologically intact survival (0.48% vs. 0.22%; OR, 2.28; 95% CI, 1.31–3.96) in those with asystole. Conclusions: Prehospital epinephrine administration by EMS is favorably associated with long-term neurological outcomes in patients with initial asystole and with long-term survival outcomes in those with PEA.

Objective: Surgical management of dermoid cysts remains controversial, and some surgeons prefer to approach these cysts via laparotomy due to the high risk of intraperitoneal cyst rupture in laparoscopic surgery and the related risks of chemical peritonitis. In our hospital, laparoscopic-assisted cystectomy (LAC) has been performed as a gasless laparoscopic surgery using an abdominal wall lifting method with a 3–5-cm transverse suprapubic incision that enables the dermoid cyst to be approached directly, as in laparotomy. Although LAC is safe and effective, it is performed in only specific areas and limited institutes. Therefore, we developed the “bathtub method,” a modified laparoscopic method that uses an endoscopic bag inserted through the vagina. The cyst is enucleated within the bag to catch cyst spillage. We compared results of the bathtub method with those of LAC. Methods: We evaluated 37 patients scheduled for laparoscopic cystectomy with the bathtub method and 37 patients scheduled for LAC. Results: Intraoperative cyst rupture occurred in 22 patients treated with the bathtub method; the majority of the cyst contents spilled into the endoscopic bag. White blood cell count and C-reactive protein level on postoperative Day 1 were 7708.3±1920.0/μL and 0.91±1.0 mg/dL, respectively, for the bathtub method versus 9913.9±2644.9/μL and 2.7±1.9 mg/dL for LAC (p

Summary Needs for surgical care are growing in low- and middle-income countries. Existing surgical care capacity indicators, focusing on the availability of equipment, personnel, and operation and anaesthetic skills, are not intended to evaluate perioperative nutrition management, which influences surgical outcomes. In this narrative review, we describe the prevalence of malnutrition and its clinical consequences among surgical patients in low- and middle-income countries, suggest potential measures to improve nutrition management and discuss the necessity of considering nutrition management as a component of surgical care capacity.

This study aimed to exhaustively examine associations between prehospital variables and emergency care resource needs among blunt trauma patients. The study included blunt trauma patients aged 15 years or older who were admitted to a tertiary care medical center in Osaka, Japan, from January 2005 to December 2009. The primary end point was a composite measure of overall emergency care resource needs. Predictive variables were easily detectable upper and lower extremity injuries. A multivariate logistic regression model was used to identify associations between the predictive variables and the end point; this model included other covariates known to be associated with emergency care resource needs (demographic characteristics, mechanism of injury, and physiological parameters). Of 982 blunt trauma patients, 81 died, and 573 required overall emergency care resources. Upper extremity injury (odds ratio [OR], 2.60) and lower extremity injury (OR, 4.50) were significantly associated with overall emergency care resource needs after controlling for other covariates. The results of this study suggest that easily detectable extremity injuries may be useful predictors of the emergency care resource needs of trauma patients. Further studies are needed to validate the predictive values of these injuries and to determine ways to use information about extremity injuries to improve triage decisions.

Whereas many people at high risk of developing type 2 diabetes are detected through screening in a Japanese healthcare setting, they do not necessarily seek primary care for diagnosis and treatment in the early stages of the disease. This study aimed to identify the most effective health communication method for the diabetes screening report to encourage primary care consultation. This facility-based cohort study involved 1,128 Japanese participants identified from the routine diabetes screening database from 2003 to 2009 who were considered to be at high risk of type 2 diabetes. Multiple logistic regression analyses were performed to estimate the relative effectiveness of the health communication method—a letter or an interview—regarding the likelihood of seeking primary care. The study controlled for sex, age, family history of diabetes, perceived symptoms, recommendation for diabetes care, undergoing treatment for other diseases, detection of comorbidity, request for referral to a specialist, and counseling by a public health nurse or dietician after screening. The proportion of participants who sought primary care after screening was 7 %. Those who received feedback on diabetes screening via physician interview were more likely to seek primary care consultation (odds ratio 2.6, 95 % confidence interval 1.2–5.6). Health communication in the form of an interview with a physician after diabetes screening may encourage people at high risk of type 2 diabetes to seek primary care, yet very few seek primary care in the early stage of the disease. Therefore, more effective communication methods are needed.

Aim The aim of this study was to assess the cut-off age of the risk factors for postoperative recurrence of ovarian endometriomas and to evaluate the end-points of follow-up after laparoscopic excision of ovarian endometriomas. Material and Methods We retrospectively reviewed 167 patients who underwent laparoscopic excision of ovarian endometriomas at our hospital between 2000 and 2009, and followed up the patients until 2010. Following surgery, patients chose to receive gonadotrophin-releasing hormone agonist, oral contraceptive pills (OCP), dienogest, or no medication and underwent regular ultrasonographic examinations. Potential risk factors for recurrence, including age at surgery, were assessed in the patients receiving no medication. Postoperative recurrence, defined as re-appearance of an ovarian endometrioma > 2 cm in size, was assessed for each treatment group. Results Age at surgery was the only significant risk factor for recurrence, at a cut-off of 32 years, obtained through receiver–operator curve analysis. In patients not receiving medication, the recurrence rate gradually increased up to 50% over 5 years; there was no recurrence 5 years after surgery. Although no recurrence was seen in patients during continuous treatment with OCP or dienogest, the disease recurred in 55.5% of patients after discontinuing OCP. Conclusions Although adjuvant therapy for all patients may represent overtreatment, the findings of the present study suggest that, in the interest of fertility preservation, continuous postoperative hormonal treatment should be administered, at least to patients younger than 32 years. In patients who decline hormonal treatment, we recommend that they undergo follow-up for recurrence until 5 years after surgery.

While cervical cancer screening is useful for detecting and then treating the disease at an early stage, most women with screen-positive results are free from cervical cancer but nevertheless subject to the unnecessary worry entailed in receiving such results. The purpose of this study was to examine whether receiving a screen-positive result was actually related to psychological distress among Japanese women who underwent cervical cancer screening. We conducted a questionnaire survey at health facilities in a semiurban city of Ibaraki prefecture, involving 1744 women who underwent cervical cancer screening and 72 who received screen-positive results and then underwent further testing. We used the K6 scale to assess their psychological distress (K6 score ≥5) and performed multiple logistic regression analyses to estimate the relative effect of receiving screen-positive results on psychological distress. Psychological distress was more prevalent among women with screen-positive results (OR 2.22; 95 % CI 1.32–3.74), while it was also related to history of mental health consultation (OR 2.26; 95 % CI 1.69–3.01) and marital status (OR 1.32; 95 % CI 1.02–1.70). Receiving a positive cervical cancer screening result was associated with psychological distress. To alleviate this psychological impact, the current form of communicating the screening results should be reconsidered.

Introduction: The purpose of this study was to elucidate the feasibility of gasless laparoscopically assisted myomectomy (LAM) using a wound retraction system. This method treats symptomatic uterine myomas by combining laparoscopy with a mini-laparotomy to enucleate myoma nodules and to close the uterine myometrium. Methods: This study includes 275 patients who underwent gasless LAM. For patients with fewer than three myoma nodules, the location of the largest nodule was classified as anterior, fundal, or posterior. The operative outcomes, intraoperative and postoperative courses, and complications were examined. Results: All operations were performed satisfactorily, and no conversions to laparotomy were required. None of the patients developed serious complications. The mean blood loss and operating time were 190.3 mL and 152.2 minutes, respectively. The mean myoma size was 8.9 cm, and the mean number of myomas per patient was 2.8. The average postoperative hospital stay was 5.7 days. There were no significant differences in resected myoma size, blood loss, and surgical duration with respect to the location of the largest nodule. Conclusion: Gasless LAM with a wound retractor is feasible and allows surgeons to perform myomectomy safely and cost-effectively, without requiring advanced laparoscopic surgical skills and while maintaining minimum invasiveness.

Objects Laparoendoscopic single-site surgery (LESS) is an ideal approach for gynecologic surgery and yields better cosmetic results. However, a standard umbilical approach with LESS is not appropriate for gynecologic surgery requiring intra-abdominal suturing and dissection requiring traction. Therefore, we have developed a new multitrocar access system for gynecologic LESS. The purpose of this study was to evaluate the efficacy of gynecologic LESS using this access system. Methods This access system consists of one 12-mm trocar, two 5-mm trocars, and a 5-mm flexible laparoscope. Two 5-mm trocars with small port heads were inserted cross-wise on opposite sides of the sleeve of the centrally positioned 12-mm trocar to maintain triangulation. Thirty-eight patients with various gynecologic conditions underwent LESS with this access system. The results of these surgeries were retrospectively compared to those of conventional laparoscopic procedures. Results Of the 38 LESS procedures performed with this access system, none was up-converted, converted to an open laparotomy, or required blood transfusion. The Salpingo-oophorectomy with LESS had several benefits, such as no extension of the skin incision of the trocar site and no leakage of the contents of the ovarian cyst into the peritoneal cavity, over that with conventional laparoscopy. A comparison of LESS (11 patients) and conventional laparoscopy (16 patients) for total hysterectomy showed no significant difference in total blood loss (234.0 mL vs. 221.6 mL) or the weight of the resected uterus (276.0 g vs. 285.0 g), although the mean total operative time was greater with LESS (199.0 min vs. 168.5 min). Conclusion Our multitrocar access system is safe and secure, and can be adapted for various gynecologic surgeries involving complicated procedures. LESS with this access system achieves results comparable to those of conventional laparoscopy with 4 ports, although the operative time is longer.

We explored the factors influencing voluntary counseling and testing (VCT) utilization among tuberculosis patients attending two referral hospitals in Cambodia. We conducted face-to-face interviews using a structured questionnaire. We compared HIV/AIDS knowledge, HIV testing attitudes, risks for exposure to HIV, and AIDS stigma between VCT users and non-users. Compared to VCT non-users, VCT users had significantly higher risks for HIV and were more likely to have used condoms. Regarding stigma, VCT non-users demonstrated significantly greater AIDS stigmatizing beliefs compared to VCT users. To increase VCT utilization among TB patients, we need effective strategies to reduce AIDS stigma among them. Moreover, initiation of routine HIV testing in TB facilities might be another effective solution.

The aim of this study was to evaluate the available resources for trauma care at health centers (HCs) and referral hospitals (RHs) in rural Cambodia and to examine whether the resources at HCs are allocated on the basis of actual need based on the referral distance and number of severely injured patients referred to RHs. We conducted a cross-sectional facility survey by phone interview or mail using structured questionnaires at nationally representative samples of 85 HCs and 17 RHs from December 2006 to April 2007. The questionnaire included a modified checklist of the guidelines for essential trauma care as well as questions on distance for referral and the number of injured patients received and referred during the last 3 months. We analyzed the association between resource availability at HCs and their need using multivariate linear regression. Median (interquartile range) numbers of available resources at HCs and RHs were 25.5 (22.0–27.5) and 35 (28–41) among 37 and 62 essential items, respectively. Basic equipment, including both consumable supplies and durable devices and life-saving knowledge/skills, were not satisfactory at either HCs or RHs. A longer distance to the RH was associated with more knowledge/skills but not with equipment supplies; the number of referred patients was not associated with equipment or knowledge/skills. Staff training emphasizing life-saving knowledge/skills and better organization and planning to supply physical resources are needed. There is a gap between resource allocation and need, which should be addressed through clear policies to prioritize remote areas and to allocate resources based on reliable injury data.

We examined the effectiveness of school regulations concerning bicycle helmet use in reducing head injuries among student bicycle commuters to junior high schools in the Japanese prefecture of Saitama. This was done by comparing the rates of head injuries and the ratios of head injuries to non-head injuries between junior high schools with and without school regulations concerning helmet use. Bicycle injury data were derived from school insurance records. Information relating to numbers of bicycle commuters and demographics was collected for each school. We identified that the head injury rate was significantly higher in schools that had no regulations governing the use of bicycle helmets (rate ratio 2.97, 95% confidence interval (CI) 1.03-8.56; odds ratio 2.46, 95% CI 0.80-7.60). The observed trend was more prominent in male students than in female students. The actual rate of bicycle injuries did not significantly differ between the schools with and without regulations concerning helmet use. This suggests that students at schools with regulations were no more cautious in riding their bicycles than their counterparts in schools with no regulations, and that there was no significant difference in the traffic environments surrounding each school. Thus implicating that the observed difference in the head injury rate was most accounted for by the presence of school regulations governing helmet use.

Summary Objectives In Nepal, male adolescent students are at high risk for infection with human immunodeficiency virus (HIV) because of their risky sexual behaviours. This study examined whether two subscales of the Health Belief Model (HBM), perceived severity and perceived susceptibility, are associated with abstinence intention among Nepalese male adolescent students for HIV/acquired immunodeficiency syndrome (AIDS) prevention. Study design and methods A school-based study was conducted at a single school located in central Kathmandu from July to August 2002. Participants included 183 male students in Grades 9–12 aged 14–19 years. Anonymous self-reported questionnaires were used, and Zagumny's AIDS Health Belief Scale was adopted as a measure of perceived severity and perceived susceptibility. Results Over half of the students (53%) strongly agreed with abstinence intention. Students with higher levels of perceived severity strongly agreed with abstinence intention [crude odds ratio 1.86, 95% confidence interval (CI) 1.02–3.38; adjusted odds ratio 1.94, 95% CI 1.05–3.58], but those with higher levels of perceived susceptibility did not. Moreover, age-stratified analysis showed that a high level of perceived susceptibility tended to decrease strong abstinence intention among students aged 16–19 years. Conclusions Perceived severity enhanced abstinence intention. The interpretations of perceived susceptibility need further examination through a longitudinal study among students aged 16–19 years. Furthermore, future research is needed to assess the effect of HIV/AIDS education on HIV/AIDS prevention strategies using perceived severity as a motivational tool to help persuade Nepalese male students to abstain from sexual intercourse.

In many developing countries, poor women have multiple roles, and often their time constraints are so severe that their participation in income-generating activities results in reduced childcare time, which in turn affects child health. Previous studies have tended to investigate how childcare support influences nutrition of children with working mothers' based on comparisons with non-working mothers. However, non-working mothers are not a homogeneous group, and we therefore need to distinguish between those who need not work and those who wish to but cannot, for example, due to a lack of substitute caregivers. We examined the association between availability of childcare support and the nutritional status of children of both non-working and working mothers in poor areas of Pokhara, a sub-metropolitan city in Nepal. We recruited 150 children of age 10-24 months from the waiting lists of 17 daycare centers and measured their weights and heights. Those with height-for-age and weight-for-age Z scores of less than -2 were defined as stunted and underweight, respectively. To collect information on childcare practices and socioeconomic characteristics, mothers were interviewed using a pre-tested structured questionnaire. Unavailability of adult childcare support was associated with increased risk of malnutrition among children of both non-working and working mothers. Peer childcare was not significantly associated with child malnutrition among children of non-working mothers, but it was associated with an increased risk of malnutrition among children of working mothers. Although further longitudinal research is required, we suggest that childcare support from adult substitute caregivers is essential for children of non-working mothers with limited resources.

全国の救命救急センターと大学病院救急部における外傷登録の現状とそのデータベース化における問題点を検討するため,アンケート調査を実施した。上記全224施設に調査票を郵送し,84施設から回答を得た(回収率38%)。調査票の内容はおもに各施設における診療記録のデータベース化の現状とその問題点,日本外傷学会が試案した外傷登録データベース「日本外傷データバンク(JTDB)」に対する期待,参加予定についてである。回答施設のうち47施設(56%)が診療記録をデータベース化しており,そのうち入力スタッフを有していたのは9施設であった。データベース化におけるおもな問題点として,入力に伴う負担と入力情報の質の問題が挙げられた。その対策として入力スタッフの確保・育成,人件費の予算化,入力作業と入力項目の簡素化などの必要性が指摘された。JTDBへの参加は61施設が予定しており,JTDBに対しては医療の質の向上,病院間・地域間格差の是正,スタッフの外傷に対する意識の向上,救急隊との情報の共有,事故防止の観点から期待が寄せられていた。JTDBは医療の質の監査だけでなく,入力負担の軽減や入力情報の質の向上にも資することから,その普及が望まれる。

Objectives: Translation and psychometric evaluation of a Thai version of the Medical Outcomes Study HIV Health Survey (MOS-HIV) in Thailand. Methods: A cross-sectional survey in Chiang Mai province, northern Thailand, with data collected in face-to-face interviews using a structured questionnaire designed to measure 10 scales of quality of life (QOL). We recruited 200 people with HIV/AIDS attending self-help groups in the municipal area. Standard guidelines were followed for questionnaire translation and psychometric evaluations. Results: Item-level internal consistency and discriminant validity were reasonably established. Success rates were 93.8 and 97.4%, respectively. Scale-level internal consistency reliability of multi-item scales was satisfactory, ranging from 0.74 to 0.88, with all exceeding inter-scale correlations. Principal components analysis of item and scale scores identified two hypothesized dimensions of the MOS-HIV. The mental health component was strongly loaded by health distress, mental health, vitality and cognitive function scales, and physical health by role, physical and social functions, and pain scales. Respondents manifesting symptoms or reporting worsening health status scored significantly lower on all scales. Conclusions: These preliminary studies have shown the Thai version of the MOS-HIV to have psychometric properties comparable with those reported in previous surveys. Further testing and modification should make it useful as an HIV-specific QOL measure in Thailand.

Context: Pregnant women are exempted from the current seatbelt legislation in Japan despite the fact that seatbelt use is essential to reduce the risk of fatalities for these women and their fetuses in car crashes. Objective: To examine factors that might influence seatbelt use during pregnancy. Methods: A cross sectional study, with data collected via an anonymous, self administered questionnaire at obstetric clinics in suburban areas of Japan. Altogether 880 pregnant women receiving prenatal care in July 2001 were recruited. The relative effects of factors that might influence seatbelt use during pregnancy were estimated using logistic regression analysis. Results: Almost 70%–80% of pregnant women were consistent seatbelt wearers before pregnancy but seatbelt compliance was reduced by about half at 20 weeks or more gestation. Only 20% had received information on maternal seatbelt use, with one third reporting that seatbelt use is beneficial during pregnancy. Those who perceived that maternal seatbelt use is beneficial tended to maintain use, but daily car users and those who knew that they were exempted from seatbelt legislation were more likely to reduce use. Conclusions: Knowledge of the legislative exemption for pregnant women, misunderstanding of the benefits, and daily car use contributed to the reduction in seatbelt use after pregnancy.

In Japan, child restraint use among preschool children started to increase before compulsory child restraint use for children aged 0-5 years was introduced by legislation in April 2000. This study determined the effects of increased child restraint use in reducing motor vehicle occupant injuries among children aged 0-5 years.We obtained monthly police data of child vehicle occupant injuries from 1990 to 2009. We calculated monthly ratios of morbidity rates per population of children aged 0-5 years to those of children aged 6-9 years. Time trends of the morbidity rate ratios were analyzed using a joinpoint regression model to determine whether there were trend changes in child occupant injuries and when they occurred if there were trend changes.The morbidity rate ratios showed a slightly increasing trend of 0.03% per month (95% confidence interval [CI], -0.02% to 0.09%) until the change-point in December 1997 (95% CI, July 1996 to January 1999), which then changed to a decreasing trend of -0.14% per month (95% CI, -0.16 to -0.11), with an overall trend change of -0.17% (95% CI, -0.23 to -0.11). No change-point was identified in or around April 2000 when compulsory restraint use was introduced.The present study used comparative indicators relative to age groups that were not covered by the legislation and showed that a decreasing trend of occupant morbidity among children aged 0-5 years started before the introduction of compulsory restraint use. This change probably reflects the prelegislative voluntary increase in child restraint use.

Background: Although various trauma triage protocols have been developed to reduce undertriage with acceptable overtriage, risk factors for undertriage have rarely been examined. The objective of this study was to determine factors that can predict undertriage. Study Design: The study involved blunt trauma patients aged ≥15 years admitted to a critical care medical center, equivalent to a level one trauma center, from its catchment area (two medical districts in southern Osaka, Japan) from October 2001 to September 2004, who had at least one severe injury with an Abbreviated Injury Scale score of ≥3 (N = 396). We compared patients who were directly transported to the center with patients who were transferred to the center from non-critical care medical center hospitals. Results: Age of 45 years to 54 years (odds ratio [OR], 6.76), Injury Severity Score of ≥16 (OR = 3.67), Glasgow coma scale score of 13 to 15 (OR = 4.79), and nighttime (OR = 2.31) were significantly associated with a higher risk of undertriage. Chest injuries (OR = 0.40) and lower limb injuries (OR = 0.26) were significantly associated with a lower risk of undertriage. Among patients with a single injury, isolated head injuries (OR = 9.10) and pelvic injuries (OR = 14.2) were associated with a higher risk of undertriage. Conclusions: Injury characteristics (severe injuries, and head and pelvic injuries), patients' characteristics (middle-aged and conscious), and time of day (nighttime) are predictive factors for undertriage. Suggested improvements in the triage protocol include changing the age criteria, flexible application of the protocol at night, training of paramedics to identify easily missed injuries, and inclusion of predictive factors for such injuries into the protocol.

Aim: To evaluate postoperative declines in serum human chorionic gonadotropin (hCG) levels (percentages of preoperative hCG levels) to rule out persistent ectopic pregnancy (PEP). Methods: A retrospective study was conducted on 50 patients who underwent laparoscopic salpingotomy between April 1995 and March 2008. The postoperative course was divided into four periods: (period A: days 1–2; period B: days 3–4; period C: days 5–6; and period D: days 7–8), and the postoperative serum hCG declines in the PEP and control groups (successfully treated patients) were compared. A cutoff value of serum hCG decline to rule out PEP was established by receiver operating characteristic (ROC) analysis. Results: Ten of the 50 patients (20%) were diagnosed with PEP. There were no differences in clinical findings or preoperative serum hCG levels between the two groups. From period C, the serum hCG decline in the control group was significantly greater than in the PEP group, and all individual serum hCG declines in the PEP group were outside the 95% confidence interval of the control group. Furthermore, analysis by ROC using a 14% decline in postoperative serum hCG as a cutoff revealed that the specificity and sensitivity of the test were equal to 100% from period C. Conclusion: Declines in serum hCG during period C (days 5–6) constitute an important marker of the presence or absence of PEP. Decisions regarding a second intervention for PEP should be made by this time postoperatively.

Aim: To examine the efficacy of local methotrexate (MTX) administration following linear salpingostomy for tubal pregnancy in the prevention of persistent ectopic pregnancy (PEP). Methods: Patients who underwent a laparoscopic linear salpingostomy between January 1996 and December 2006 were enrolled in the study. Patients who were assigned to the prophylaxis group were administered MTX (50 mg) into the tubal wall in the vicinity of the lesion immediately following linear salpingostomy (n = 41). Patients who were treated without MTX were assigned to the control group (n = 40). Serum human chorionic gonadotrophin levels were followed in both groups postoperatively once every 3 days until they became undetectable. The incidence of PEP was compared between the two groups. Results: Persistent ectopic pregnancy occurred in seven patients (17.5%) in the control group compared with zero patients in the prophylaxis group (P

To investigate the prevalence of non-alcoholic fatty liver disease (NAFLD) in children and its relationship to metabolic syndrome, insulin resistance, and waist circumference (WC).This was a population-based cross-sectional, case-control study. Cases were selected among students of a primary and junior high school, respectively, and age- and sex-matched control subjects were selected randomly (ratio of cases to control subject was 37:113).Of the 846 students, aged between 6 and 15 years, enrolled in the study and screened by ultrasonography, 37 children were diagnosed as having NAFLD (score/= 1). There was a significant sex difference in the prevalence of NAFLD(P = 0.003). The trend test revealed a strong dose-response relationship (P0.001) between pediatric NAFLD and the number of the proposed components of pediatric metabolic syndrome in Japan (MetS-JC), such as a clustering of the components of MetS-JC. Additionally, the linear trend of the odds ratios (ORs) with increasing percentile of the homeostasis model assessment-insulin resistance (HOMA-IR) was statistically significant (P0.001). However, when WC was added to the logistic model, the ORs were no longer significant, whereas WC turned out to be an independent risk factor for NAFLD regardless of the HOMA-IR index.The prevalence of NAFLD in children and adolescents is closely related to metabolic syndrome, insulin resistance, and WC.

We present here a case of B-cell-type mediastinal malignant lymphoma during pregnancy complicated by placental involvement. In this case, some nodular high-echo patterns were recognized in the placenta by ultrasonography. A cesarean section and resection of the mediastinal tumor were performed at 33 weeks and 6 days of gestation due to the deterioration of the dyspnea. A female infant weighing 1,868 g was delivered and she is now a healthy 2-year-old. The mother, however, died of the disease 1 month after surgery, due to progression of the tumor. The placenta showed numerous white firm nodules varying from 3 mm to 3 cm in diameter. The pathologic findings of both the mediastinal tumor and the placenta indicated primary mediastinal (thymic) B-cell lymphoma.

Objectives To evaluate the effectiveness of pre-hospital adrenaline (epinephrine) administered by emergency medical services to patients with out of hospital cardiac arrest. Design Controlled propensity matched retrospective cohort study, in which pairs of patients with or without (control) adrenaline were created with a sequential risk set matching based on time dependent propensity score. Setting Japan’s nationwide registry database of patients with out of hospital cardiac arrest registered between January 2007 and December 2010. Participants Among patients aged 15-94 with out of hospital cardiac arrest witnessed by a bystander, we created 1990 pairs of patients with and without adrenaline with an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) and 9058 pairs among those with non-VF/VT. Main outcome measures Overall and neurologically intact survival at one month or at discharge, whichever was earlier. Results After propensity matching, pre-hospital administration of adrenaline by emergency medical services was associated with a higher proportion of overall survival (17.0% v 13.4%; unadjusted odds ratio 1.34, 95% confidence interval 1.12 to 1.60) but not with neurologically intact survival (6.6% v 6.6%; 1.01, 0.78 to 1.30) among those with VF/VT; and higher proportions of overall survival (4.0% v 2.4%; odds ratio 1.72, 1.45 to 2.04) and neurologically intact survival (0.7% v 0.4%; 1.57, 1.04 to 2.37) among those with non-VF/VT. Conclusions Pre-hospital administration of adrenaline by emergency medical services improves the long term outcome in patients with out of hospital cardiac arrest, although the absolute increase of neurologically intact survival was minimal.