In Lao People's Democratic Republic (PDR), the mortality rate forchildren under 5 years of age is high (131 per 1000 live births in 2003),partly as a consequence of poor basic services provided by district hospitals.A simplified management tool, “Ten MR (Minimum Requirement)”, was developed inLao PDR. The tool assured the quality of health services including theprocesses of planning, implementing, self-monitoring, supervision, reportingand evaluation. The tool focused on ten basic services, integratingstakeholders from district hospitals and governing agencies. Each districthospital develops feasible annual activities, designating responsible peoplebased on a consensus between hospital staff and local governing agencies.Hospitals can self-monitor their activities on a monthly basis. Supervisoryvisits to district hospitals by local governing agencies improved activitiesand communication between staff. Visualization of progress promoted the sharingof achievements between staff and highlighted activities in need of more work.In 2004, district hospitals in Vientiane andOudomxay province initiated the introduction of the tool. These districthospitals included primary care hospitals for outpatients, emergency care andin-patients, with a capacity of 10-20 beds, providing care for a population ofbetween 30,000 and 80,000 people. The Ministry of Health recognized theeffectiveness of Ten MR and implemented the expansion of the tool to alldistrict hospitals in Lao PDR from 2011. Ten MR benefits district hospitals andgoverning agencies. Ten MR focuses on the daily routine work, enhancing teamwork and communication between all stakeholders.

In Lao People’s Democratic Republic (PDR), the mortality rate among children under 5 years of age is high (131 per 1000 live births in 2003), partly as a consequence of poor basic services provided by district hospitals. A simplified management tool, “Ten MR (Minimum Requirement)”, was developed in Lao PDR. The tool assured the quality of health services including the processes of planning, implementing, self-monitoring, supervision, reporting and evaluation. The tool focused on ten basic services, integrating stakeholders from district hospitals and governing agencies. Each district hospital develops feasible annual activities, assigning responsibility to people based on a consensus between hospital staff and local governing agencies. Hospitals can self-monitor their activities on a monthly basis. Supervisory visits to district hospitals by local governing agencies improved activities and communication between staff. Visualization of progress promoted the sharing of achievements between staff and highlighted activities in need of more work. In 2004, district hospitals in Vientiane and Oudomxay provinces initiated the application of the tool. These district hospitals included primary care hospitals for outpatients, emergency care and in-patients, with a capacity of 10–20 beds, providing care for a population of between 30,000 and 80,000 people. The Ministry of Health recognized the effectiveness of Ten MR and implemented the expansion of the tool to all district hospitals in Lao PDR from 2011. Ten MR benefits district hospitals and governing agencies. Ten MR focuses on the daily routine work, enhancing team work and communication among all stakeholders.

Recently, patient safety has become a social concern in Japan. Even though cases of “incidents” and “accidents” by interns have been collected and analyzed in each hospital, few published reports have concerned teaching hospitals. The purpose of this study was to identify the incidence of “incidents” and “accidents” by first-year and second-year interns in Japan.
1) In August 2005, a questionnaire was mailed to 231 interns at 14 teaching hospitals. A total of 192 interns participated in this study, with a response rate of 83.1%.
2) The number of cases of “incidents” and “accidents” involving interns since the start of their training was collected.An “incident” was defined as an error that was prevented before occurrence, whereas an “accident” was defined as an unplanned, unexpected, and undesired event with adverse consequences.
3) Among first-year interns, “incidents” occurred at a rate of 0.79 per resident-month (95% confidence interval [CI]: 0.30-1.28), while “accidents” were observed at a rate of 0.13 per resident-month (95% CI: 0.06-0.20).
4) Among second-year interns, “incidents” occurred at a rate of 0.24 per resident-month (95% CI: 0.14-1.34), and “accidents” were observed at a rate of 0.06 per resident-month (95% CI: 0.01-0.11).
5) There was no significant difference in the number of cases of “incidents” and “accidents” in regards to sex, age, or the number of beds of teaching hospitals.

[Objective]Although warm-tube moxibustion is easy-to-use in acupuncture therapy, the timing of moxa removal varies among practitioners. In the present study, we used near infrared spectroscopy (NIRS) to compare effects of different durations of moxibustion stimulation on improvement in local circulation as measured by changes in blood oxygenation dynamics in muscle tissue.
[Methods]Twelve healthy adults underwent warm-tube moxibustion with a single cone applied to the upper right shoulder region;measurements of tissue blood oxygenation dynamics (ΔOxy-Hb, ΔTotal-Hb) were obtained at intervals of 0.5 s. Control measurements were first taken for 15 min without intervention (Control);then, subjects received moxibustion 2 min after the start of measurement and had the moxa removed at the following time points: 30 s after patients experienced heat pain (Removal 30, moxibustion group); 45 s after heat pain (Removal 45, moxibustion group);or did not have the moxa removed (Continuous moxibustion group). These 4 different conditions were compared. Additionally, we determined the burning temperature of moxa and the skin temperature and intensity of heat pain sensation at the site of moxibustion.
[Results]Compared with the Control, the Removal 30, Removal 45, and Continuous moxibustion groups had significant increases in ΔOxy-Hb, ΔTotal-Hb, and skin temperature, with no significant differences among the moxibustion groups. No significant difference in the intensity of heat pain sensation was observed among the moxibustion groups. All moxibustion groups began to show rapid increases in both ΔTotal-Hb and ΔOxy-Hb around the time when subjects began to feel heat pain, suggesting that the axon reflex evoked by noxious stimuli of heat pain increased blood volume and arterial blood flow.
[Conclusion]Hemodynamic improvement in muscle tissue through the use of continuous warm-tube moxibustion for 30 s or longer after the occurrence of heat pain was confirmed.

The patient was a 74-year-old woman who had undergone mitral valve replacement with a mechanical valve for rheumatic mitral valve stenosis at age 60. She was scheduled for aortic valve replacement for severe aortic stenosis. However, she had significantly worsening anemia before the operation. Capsule endoscopy showed angiodysplasia with bleeding in her small intestine, which was considered the cause of the anemia. Because of progressive anemia, we tried embolization under angiography. However, there was no evidence of extravasation. Neither melena nor exacerbation of anemia was observed, and she underwent aortic valve replacement. She was discharged on postoperative day 22 without gastrointestinal bleeding. Heyde syndrome is aortic valve stenosis associated with gastrointestinal bleeding induced by von Willebrand disease and angiodysplasia in small intestine. Molecular multimeric analysis of von Willebrand factor and the existence of angiodysplasia with hemorrhage of the digestive tract are important for definitive diagnosis. Capsule endoscopy, which is a general examination, is more useful for diagnosis than molecular multimeric analysis of von Willebrand factor. Aortic valve replacement is the only therapeutic option for Heyde syndrome. It is important to decide the appropriate timing of AVR with cardiopulmonary bypass.

We report a case of type A acute aortic dissection in an elderly woman with immune thrombocytopenia (ITP) who underwent replacement of the ascending aorta and aortic arch and later required aortic root replacement for redissection of the aortic root one month after her initial surgery. She was an 86-year-old woman with severe mitral regurgitation, and surgery was contraindicated because of her age and ITP. In October 2014, the patient presented with back pain. Computed tomography confirmed the diagnosis of her condition as type A acute aortic dissection, and she was immediately transferred to our hospital. Because echocardiography showed severe aortic regurgitation, severe mitral regurgitation, and moderate tricuspid regurgitation, we performed replacement of the ascending aorta and aortic arch, mitral valve repair, and tricuspid annuloplasty. We used Bioglue to fuse the false lumen of the type A acute aortic dissection and used a Teflon felt sandwich for the proximal anastomosis technique. Respiratory support was discontinued 91 h after her first operation ; however, 30 days after surgery, she developed a to-and-fro murmur-a sign of the progression of heart failure. Echocardiography showed aggravation of aortic regurgitation, and computed tomography showed aortic root redissection ; therefore, 39 days after the initial surgery, we performed aortic root replacement. During the operation, we found the entry under the proximal anastomosis with an almost semicircle form at the right coronary cusp to the noncoronary cusp, and the dissection extended close to the right coronary artery ; thus, we performed bypass to the right coronary artery. Pathologic findings did not establish a causal association between the redissection and Bioglue, and we believed the fragility of the tissue and the selection of the surgical procedure to be the cause of redissection. The patient was transferred to another hospital when she was able to walk and eat, which was 121 days after her first operation. The patient required 50 units of platelet transfusion during her first and second operations, but her bleeding was easily controlled during surgery. She needed two procedures of pericardium drainage for pericardiac effusion and cardiac tamponade, which may relate to ITP. The diagnosis of redissection of the aortic root was made 30 days after the patient's first operation, on the basis of exacerbation of the to-and-fro murmur. Here, we emphasize the clinical importance of basic observations over time, such as auscultation, that are liable to be overlooked in the intensive care unit.

There have so far been no studies examining the physical fitness and physical activity (PA), measured using objective measures, in homebound elderly people. The purpose of this study was to examine physical fitness levels and PA patterns and evaluate their relationships in homebound elderly people. In 2004, a total of 3964 community-dwelling elderly aged 65 years and over participated in a base line survey. The subject data were directly collected by in-home interviewer. Subjects were defined as being homebound if they went outdoors less than once a week. However, the subjects who could not go out without assistance due to sickness and/or disability were excluded from the analysis. In 2005, 38 homebound (22 men, 16 women) and 70 non-homebound (33 men, 37 women) older adults who participated in the base line survey were selected. Measurements of physical fitness levels and PA patterns measured using an accelerometer, were taken in 2005. The total steps per day did not significantly differ between homebound and non-homebound men and women. The time spent in 1.8 METs activity (corresponding to activity level 1 of the accelerometer) was significantly higher in women than in men for non-homebound and homebound, respectively. The time spent in lower-, moderate-, and high-intensity PA did not significantly differ between homebound and non-homebound men and women, respectively. Handgrip strength, knee extensor strength, leg extensor power, stepping and maximum walking speed were significantly higher in non-homebound than in homebound men and women. These results suggest that the physical fitness levels of homebound were lower than those of non-homebound, but no difference was observed in the PA levels between homebound and non-homebound.

Objective: The purpose of this study was to assess the opinions of healthcare professional regarding the contributions of the Medical Affairs department. Furthermore, we aimed to identify factors influencing and reasons for the contributions in the new coronavirus disease 2019 (COVID-19) pandemic situation.Design/Methods: A web-based survey was conducted among healthcare professionals (Key Opinion Leader/Key Thought Leader, KOL/KTL) who had multiple contacts with the Medical Affairs department, Japan.Results: The responses of 141 KOL/KTLs in Japan were collected; 77.3% of the respondents indicated that the contributions of the Medical Affairs department exceeded their expectations (achieved the expected level of contribution). The most common responses were “the identification of unmet medical needs” and “the dissemination of medical and scientific information, providing advanced medical and scientific information;” other responses included “promoting sales of the company's drugs.” The requests from KOL/KTLs regarding quality were “knowledge about biological and clinical statistics” and “proposal and quick response ability from the perspective of medical staff and patients,” but these responses were partially different between physicians and pharmacists. COVID-19 has resulted in substantial changes, for example, “face-to-face” interactions have significantly decreased from 91.5 to 50.4% and “Online” interactions have significantly increased from 20.6 to 70.9%. However, the effects of the declaration of emergency state could not be identified. The KOL/KTLs requested to make the meeting times more appropriate, conduct in-depth two-way discussions, provide latest information, and discuss about professional manners and behaviors.Conclusion: In summary, regardless of the changes in the types of activities caused by COVID-19, the Medical Affairs department has made substantial contributions to healthcare professionals, who highly appreciated them. Furthermore, depending on responses of individuals whose expectations could not be met, areas of improvements have been suggested.

Background/Aims: Although risk factors of reflux esophagitis (RE) have been investigated in numerous cross-sectional studies, little is known about predictive factors associated with future onset of RE. We investigated time courses of clinical parameters before RE onset by a longitudinal case-control study using health checkup records. Methods: We used health checkup records between April 2004 and March 2014 at 9 institutions in Japan. A multivariate logistic regression analysis was performed to evaluate associations of baseline clinical parameters with RE. The time courses of the clinical parameters of RE subjects were compared with those of non-RE subjects by the mixed-effects models for repeated measures analysis or longitudinal multivariate logistic analysis. Results: Initial data were obtained from 230 056 individuals, and 2066 RE subjects and 4132 non-RE subjects were finally included in the analysis. Body mass index, alanine aminotransferase, smoking, acid reflux symptoms, hiatal hernia, and absence of atrophic gastritis at baseline were independently associated with RE. The time courses of body mass index, fasting blood sugar, triglyceride, aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transpeptidase, percentages of acid reflux symptoms, feeling of fullness, and hiatal hernia in the RE group were significantly worse than in the non-RE group. Conclusions The RE group displayed a greater worsening of the clinical parameters associated with lifestyle diseases, including obesity, diabetes, hyperlipidemia, and fatty liver for 5 years before RE onset compared with the non-RE group. These results suggest that RE is a lifestyle disease and thus lifestyle guidance to at-risk person may help to prevent RE onset.

OBJECTIVESThe objective of this study was to evaluate factors associated with turnover intention among nurses in small and medium-sized medical institutions.

METHODSA self-administered questionaire survey was performed in 293 registered nurses, licensed practical nurses, and assistant nurses working full-time in various medical institutions. Multiple linear regression analysis was conducted, with turnover intention as the dependent variable, and nurses' basic attributes and job satisfaction as independent variables.

RESULTSAs for nurses' basic attributes, turnover intention was significantly associated with registered nurses, younger nurses and those with low satisfaction with sleep. As for nurses' job satisfaction, the number of nurses with turnover intention was significantly higher for those with low satisfaction with salary, low satisfaction with welfare, poor implementation of fair salary raise and poor cooperation among nurses.

CONCLUSIONTurnover intention may be reduced by the enhancement of trust in the organization, giving appropriate advice to young nurses and registered nurses, and developing measures for addressing sleep disorders.