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.

Purpose: Patients with head and neck cancer (HNC) who undergo dental procedures during radiotherapy (RT) face an increased risk of developing osteoradionecrosis (ORN). Accordingly, new tools must be developed to extract critical information regarding the dose delivered to the teeth and mandible. This article proposes a novel approach for visualizing 3-dimensional planned dose distributions on panoramic reconstruction computed tomography (pCT) images. Materials and Methods: Four patients with HNC who underwent volumetric modulated arc therapy were included. One patient experienced ORN and required the extraction of teeth after RT. In the study approach, the dental arch curve (DAC) was defined using an open-source platform. Subsequently, pCT images and dose distributions were generated based on the new coordinate system. All teeth and mandibles were delineated on both the original CT and pCT images. To evaluate the consistency of dose metrics, the Mann-Whitney U test and Student t-test were employed. Results: A total of 61 teeth and 4 mandibles were evaluated. The correlation coefficient between the 2 methods was 0.999, and no statistically significant difference was observed (P>0.05). This method facilitated a straightforward and intuitive understanding of the delivered dose. In 1 patient, ORN corresponded to the region of the root and the gum receiving a high dosage (approximately 70 Gy). Conclusion The proposed method particularly benefits dentists involved in the management of patients with HNC. It enables the visualization of a 3-dimensional dose distribution in the teeth and mandible on pCT, enhancing the understanding of the dose delivered during RT.

Objective: The initial and operational costs of telemedicine are major barriers to its adoption. We aimed to investigate and identify the barriers to adopting a telemedicine system in a Japanese rural general hospital without incurring setup and operational costs.Materials and Methods: Our study was conducted between May and August 2018, and included six general practitioners working at a rural general hospital. We extracted data collected from messages (date and time, sender and recipient, and counts and contents of messages) and conducted semi-structured interviews, which were then analyzed using quantitative and qualitative methods.Results: We quantitatively analyzed the total counted of the 179 messages. The total counts recorded for each physician were 56 (A), 20 (B), 3 (C), 74 (D), 5 (E), and 21 (F). The mean monthly counts were 2.17 (May), 8.50 (June), 11.50 (July), and 7.67 (August). Interview data from the six physicians yielded 13 codes that included various points of dissatisfaction acting as barriers to using our system, which we grouped into mental and physical barriers. Mental barriers included suspicion of carrying, feelings of isolation, and loss, whereas physical barriers included portability, user authentication, internet speed, group chat system, notice, search image, typing, chat system, print facility, and limited function.Conclusion: The representative barriers to introducing a telemedicine system at a rural general hospital in Japan without initial and running costs could be classified as feelings of isolation and suspicion of carrying (mental barriers); and notice, portability, and user authentication (physical barriers). Continued investigation in this area is warranted, and solutions to these barriers could improve the shortage of medical staff in the context of declining birth rates and aging populations in Japan.

Decreased kidney function is associated with increased risk of cardiovascular events and mortality, and heart failure (HF) is a wellknown risk factor for renal dysfunction. Acute kidney injury (AKI) in patients with HF often is attributed to prerenal factors, such as renal hypoperfusion and ischemia as a result of decreased cardiac output. Another such factor is reduction of absolute or relative circulating blood volume, with the decrease in renal blood flow leading to renal hypoxia followed by a decrease in the glomerular filtration rate. However, renal congestion is increasingly being recognized as a potential cause of AKI in patients with HF. Increased central venous pressure and renal venous pressure lead to increased renal interstitial hydrostatic pressure and a reduction of the glomerular filtration rate. Both decreased kidney function and renal congestion have been shown to be important prognostic factors of HF, and adequate control of congestion is important for improving kidney function. Loop and thiazide diuretics are recommended as standard therapies to reduce volume overload. However, these agents are associated with worsening renal function even though they are effective for improving congestive symptoms. There is growing interest in tolvaptan, which can improve renal congestion by increasing excretion of free water and decreasing the required dose of loop diuretic, thereby improving kidney function. This review summarizes renal hemodynamics, the pathogenesis of AKI due to renal ischemia and renal congestion, and diagnosis and treatment options for renal congestion.

This study aimed to validate the usefulness of parent artery complex coil protection for the treatment of wide-neck, side-branched, and ruptured aneurysms. A microcatheter was first introduced into the aneurysmal sac, and another microcatheter was introduced into the parent artery or near the orifice of the branch artery. A framing coil was deployed partially from the first microcatheter, and a protection coil was deployed from the second microcatheter to prevent protrusion of the first framing coil to the parent artery and side branches. After the first framing coil insertion, the protection coil was withdrawn to confirm the stability of the framing coil and blood flow. The procedures with this technique were successful for 3 patients. Parent artery complex coil protection can be an effective and safe coil embolization technique for the preservation of parent and side branch arteries and an alternative method for emergent ruptured cases.

Objectives: Cytomegalovirus (CMV) colitis is generally diagnosed in immunocompromised patients. It is rare for patients who are not immunocompromised to develop CMV colitis. Cases of CMV colitis in patients with inflammatory bowel disease have also been reported. We encountered a case of CMV colitis with a new diagnosis of severe ulcerative colitis and demonstrated the importance of suspecting ulcerative colitis in immunocompetent patients with CMV colitis.Patient: A 78-year-old woman was hospitalized with fever and diarrhea that had lasted for a month. Colonoscopy revealed continuous diffuse edema, mucosal redness, and multiple punched-out ulcers with bleeding, suggesting cytomegalovirus (CMV) colitis, although she was not immunocompromised. Immunohistochemical staining revealed CMV-positive cells, and CMV colitis was diagnosed. One month later, a colonoscopy was conducted owing to persistent symptoms despite initiating the prescribed antiviral drug. A complete loss of vascular pattern, easy bleeding of the crude mucosa, and exacerbation of multiple punched-out ulcers were observed. She was diagnosed with severe ulcerative colitis. The symptoms of ulcerative colitis disappeared with prednisolone and 5-amino salicylic acid treatment.Conclusion: Ulcerative colitis should be suspected in immunocompetent patients with CMV colitis.

Purpose: Gastric neoplasia is a common manifestation of familial adenomatous polyposis (FAP). This study aimed to elucidate the clinical characteristics, endoscopic features including fundic gland polyposis (FGPsis), and treatment outcomes of gastric neoplasms (GNs) in patients with FAP. Materials and Methods: A total of 35 patients diagnosed with FAP, including nine patients from four pedigrees who underwent esophagogastroduodenoscopy (EGD), were investigated regarding patient characteristics, GN morphology, and treatment outcomes. Results: Twenty-one patients (60.0%) had 38 GNs; 33 (86.8%) and 5 (13.2%) were histologically diagnosed with adenocarcinoma and adenoma, respectively. There were no specific patient characteristics related to GNs.Nodule-type GNs were more prevalent in patients with FGP than without (52.2% vs. 0.0%, P=0.002) in the upper body of the stomach. Conversely, depressed-type GNs were fewer in patients with FGPsis than in those without (13.0% vs. 73.3%, P<0.001). Slightly elevated-type GNs were observed in both groups (34.8% vs. 20.0%, P=0.538). Even within pedigrees, the background gastric mucosa and types of GNs varied. In total, 24 GNs were treated with endoscopic submucosal dissection (ESD) and eight with endoscopic mucosal resection (EMR). EMR was selected for GNs with FGPsis because of the technical difficulty of ESD, resulting in a lower en bloc resection rate (62.5% vs. 100%, P=0.014). Conclusions Our study indicates the necessity of routine EGD surveillance in patients diagnosed with FAP. Notably, the morphology and location of GNs differed between patients with and without FGPsis. Endoscopic treatment and outcomes require more attention in cases of FGPsis.

Adrenal venous sampling (AVS) is the key procedure for lateralization of primary hyperaldosteronism (PA) before surgery. Identification of the adrenal veins using computed tomography (CT) and intraoperative cortisol assay facilitates the success of catheterization. Although administration of adrenocorticotropic hormone (ACTH) has benefits such as improving the success rate, some unilateral cases could be falsely diagnosed as bilateral. Selectivity index of 5 with ACTH stimulation to assess the selectivity of catheterization and lateralization index (LI) >4 with ACTH stimulation for unilateral diagnosis is used in many centers. Co-secretion of cortisol from the tumor potentially affects the lateralization by the LI. Patients aged <35 years with hypokalemia, marked aldosterone excess, and unilateral adrenal nodule on CT have a higher probability of unilateral disease. Patients with normokalemia, mild aldosterone excess, and no adrenal tumor on CT have a higher probability of bilateral disease. Although no methods have 100% specificity for subtype diagnosis that would allow bypassing AVS, prediction of the subtype should be considered when recommending AVS to patients. Methodological standardization and strict indication improve diagnostic quality of AVS. Development of non-invasive imaging and biochemical markers will drive a paradigm shift in the clinical practice of PA.

Gastric adenocarcinoma of the fundic gland mucosa type (GA-FGM) was proposed as a new variant of gastric adenocarcinoma of the fundic gland type (GA-FG). However, at present, the influence of Helicobacter pylori and the speed of progression and degree of malignancy in GA-FGM remain unclear. Herein, we report the first case of intramucosal GA-FGM that was endoscopically observed before and after H. pylori eradication over 15 years. The lesion showed the same tumor size with no submucosal invasion and a low MIB-1 labeling index 15 years after its detection using endoscopy. The endoscopic morphology changed from 0-IIa before H. pylori eradication to 0-IIa+IIc and then 0-I after H. pylori eradication. These findings suggest that the unaltered tumor size reflects low-grade malignancy and slow growth, and that the endoscopic morphology is influenced by H. pylori eradication.

Methods: The subjects were 473 volunteers. They were divided into two groups (activity and non-activity) according to participation or non-participation in sporting activities using a self-filled questionnaire. The evaluation items were height, weight, grip strength, bone density, Hospital Anxiety and Depression Scale (HADS) score, standing radiographic parameters, PRO (evaluated by EuroQol-5 dimension [EQ-5D], Oswestry Disability Index [ODI]), and NDI. Results: There were 101 males in the non-activity group and 69 in the activity group and 178 females in the non-activity group and 125 in the activity group. For the males, the evaluation items with significant influence were cervical lordosis (non-activity group:activity group, 17°:22°) and T1 slope minus cervical lordosis (10°:6°, p <0.05). For the females, the evaluation items with significant influence were sagittal vertical axis (28:14 mm), HADS (10.4:8.4), EQ-5D (0.79:0.86), ODI (17:12), and NDI (12:9, p <0.01). HADS and PRO in the females were significantly correlated with the EQ-5D (−0.40), ODI (0.43), and NDI (0.55). Conclusions Males who participated in sporting activities had better cervical spine alignment but no effect on PRO. Females with sporting activities had better spinal global alignment and less mental stress. It is suggested that sporting activity in females might be associated with PRO because HADS highly correlates with PRO.