Nagoya Journal of Medical Science

The present study aimed to measure the levels of coagulation factors in stored whole blood of pregnant women and to determine their usefulness in treating pregnant women who developed coagulopathy. A prospective study to measure coagulation factors in stored donated whole blood from pregnant and non-pregnant women was conducted. Fibrinogen, FV, FVII, FVIII, FXIII, and von Willebrand factor were measured in blood stored at 4°C for 0, 1, 3, and 5 weeks. All coagulation factors except for factor XIII decreased during storage. Fibrinogen and factor VII in the blood collected from pregnant women gradually decreased over time and their levels were significantly higher after 5 weeks of storage than those of nonpregnant women at week 0. Whole blood donated by pregnant women for autologous blood transfusion and stored at 4°C may be expected being effectively for the prevention of coagulopathy and the treatment of circulatory blood volume loss.

Vulnerable communities in Malaysia have been facing issues of accessibility and availability for pediatric cardiac services for years due to long waiting times, high costs and a lack of pediatric cardiothoracic surgeons. To ease this situation, the government has allocated a certain amount of funds, introduced through the Pediatric Cardiothoracic Program (PCP), in which the patients are transported to the Narayana Health Institute of Cardiac Science (NH) in India to receive a heart operation following an eligibility check at MediAssist4U Sdn Bhd in Selangor, Malaysia, a facility appointed by the NH. This study aimed to determine the demographic incidence of congenital heart diseases of patients in this program and to evaluate the outcome of the program in association with post-operative mortality rate and the beneficial factors of the program. In this study, 241 patients who participated in this program from August 2008 to September 2012 were reviewed. Fisher’s exact tests were applied to calculate p-values of categorical data. Out of 241, 11 patients were rejected because of their poor health condition for flight transportation to India, leaving 230 patients for analysis. The majority of patients were 1 to 4 years of age (57.8%), Malays (61.7%), from families of monthly household income less than RM 1,500 (86.5%) and with primary school-educated parents (86.5%). Patients could apply from any government hospital in Malaysia, but 34.8% of the patients were from the state of Johor. The region (Peninsular Malaysia and East Malaysia) of patients seeking pediatric cardiac services was significantly associated with race (p<0.001), low household income (p<0.001) and low education background of parents (p=0.004). The associations between the age group and diagnosis group (p=0.010) and between duration of hospitalization and outcome of medical management (p=0.013) were significant. Post-operative mortality rate was 1.7% (95% confidence interval, 0.5–4.4). In conclusion, the patients and the government were considered to have benefited from the PCP.

The purpose of this study is to examine the feasibility of single-incision laparoscopic percutaneous extraperitoneal closure (LPEC) for incarcerated inguinal hernia (IIH) repair. 6 single-incision LPEC procedures were performed for IIH repair and 60 procedures were performed for reducible inguinal hernia (RIH) in the same period of time in one hospital. The laparoscope and one pair of grasping forceps were placed through the same umbilical incision. In IIH repair, the herniated organ was gently pulled using the grasping forceps with external manual pressure. If it was difficult to reduce the herniated organ with one pair of forceps, another pair of forceps were inserted through a multi-channel port without extending the umbilical incidion. Using the LPEC needle, the hernia orifice was closed extraperitoneally. We performed a retrospective analysis to compare the outcomes of single-incision LPEC for IIH repair or reducible inguinal hernia. All procedures were completed by single-incision without open conversion. A multi-channel port with another pair of forceps was needed in three cases. The operation time and the length of stay were significantly longer with IIH repair than with RIH repair. There were no major complications and there was no evidence of early recurrence in any patient. In conclusion, single-incision LPEC with a multi-channel port is feasible and safe for IIH repair.

Although lack of human resources for health is becoming a global problem, there are few studies on human resources in Myanmar. This study was conducted to investigate the attrition rates of teaching staff from universities for medical professions in Myanmar from 2009 to 2013. The data were collected from administrative records from Department of Medical Sciences, Ministry of Health, Myanmar. Numbers of staff and those who permanently left work (attrition) from 2009 to 2013 were counted. The reasons were classified into two categories; involuntary attrition (death or retirement) and voluntary attrition (resignation or absenteeism). Official records of the attrited staff were reviewed for identifying demographic characteristics. The annual attrition rate for all kinds of health workers was about 4%. Among 494 attrited staff from 2009 to 2013, 357 staff (72.3%) left their work by involuntary attrition, while 137 staff (27.7%) left voluntarily. Doctors left their work with the highest annual rate (6.7%), while the rate for nurses was the lowest (1.1%). Male staff attrited with a higher rate (4.6%) than female staff (2.7%). Staff aged 46–60 years had the highest attrition rate. PhD degree holders had the highest rate (5.9%), while basic degree holders had the second highest rate (3.5%). Associate professors and above showed the highest attrition rate (8.1%). Teaching staff from non-clinical subjects had the higher rates (8.2%). Among 494 attrited staff, significant differences between involuntary attrition and voluntary attrition were observed in age, marital status, education, overseas degree, position, field of teaching, duration of services and duration of non-residential service. These findings indicated the need to develop appropriate policies such as educational reforms, local recruitment plans, transparent regulatory and administrative measures, and professional incentives to retain the job.

Acute malnutrition affects more than 50 million under-five (U5) children, causing 8.0% of global child deaths annually. The prevalence of acute malnutrition (wasting) among U5 children in Afghanistan was 9.5% nationally and 3.7% in Faryab province in 2013. A cross-sectional study was conducted for 600 households in Faryab to find the prevalence and causes of acute malnutrition. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a logistic model. Demographic results of this study showed that 54.0% of the household heads and 92.3% of the mothers had no education. Three-fourths of households had a monthly income ≤ 250 USD. According to the measurement of weight for height Z-score (WHZ), 35.0% (210/600) of the children had acute malnutrition (wasting, WHZ < −2). In more than half of the households, water, sanitation, and hygiene (WASH) conditions were poor. When adjusted, a significant association of acute malnutrition among U5 children was found with the education level of household heads (OR=1.49; 95% CI, 1.02–2.17), age of household heads (OR=2.01; 95% CI, 1.21–3.35), income (OR=1.66; 95% CI, 1.04–2.27), education level of mothers (OR=2.21; 95% CI, 1.00–4.88), age of children (OR=1.99; 95% CI, 1.32–2.93), history of children with diarrhea in the last two weeks of data collection (OR=1.57; 95% CI, 1.10–2.27), feeding frequency (OR=3.01; 95% CI, 1.21–7.46), water sources (OR=1.89; 95% CI, 1.26–2.83), and iodized salt (OR=0.59; 95% CI, 0.39–0.88). The present study indicated that an increase in education level of parents, household income, and quality of WASH would result in a significant decrease in prevalence of wasting among U5 children.

Amenable mortality (AM) is an indicator of medical care quality. This study aimed to assess the trend and magnitude of AM in Mongolia, with the purpose of providing evidence for decisions on resource allocation. This is the first study on AM trends in Mongolia. Retrospective analysis was done on mortality statistics for the period 2007–2014. Causes of death were coded according to the 10th revision of the International Classification of Diseases (ICD-10). Nolte & McKee’s classification of AM was used for the estimation of amenable mortality rates (AMRs) in Mongolia. During the study period, a total of 130,402 deaths were registered in Mongolia, of which 44,800 (34.4%) deaths were classified as being amenable. The age-standardized AMR per 100,000 population was highest in 2007 (226.6), and declined continuously until the level of 169.2 in 2014. The rate remained consistently higher in males than in females. Cerebrovascular diseases, ischemic heart diseases, perinatal deaths, influenza/pneumonia/asthma and tuberculosis were the leading causes of AM in the past eight years in Mongolia. The AMR was higher in remote western provinces with harsh weather conditions, high poverty rates, lack of human resources for health, and poor infrastructure. In addition, the provinces where Mongolia’s ethnic minorities live tended to have a higher AMR. The government of Mongolia needs to critically look at the regional differences in AM in order to allocate health resources, including human resources, effectively. Further studies are needed to look into the causes of regional disparities in AM, individual-level risk factors to amenable deaths, and validity of death coding in health sector.

In our department, we have attempted to reduce the incidence of complications of conventional esophagectomy. The objective of this retrospective study was to report the short-term outcomes of esophagectomy. We reviewed 138 consecutive patients who had undergone subtotal esophagectomy by combined laparotomy via a 12-cm upper abdominal vertical incision combined with right anterior muscle-sparing thoracotomy from August 2010 to August 2014. Most of the cervical para-esophageal lymph node dissection was completed within the thoracic cavity. We performed three-field dissection in patients with tumors in the upper or middle third of the esophagus with clinical lymph node metastases in the superior mediastinum; the others underwent two-field dissection. We performed neck anastomoses in patients undergoing three-field dissection and thoracic anastomoses in those undergoing two-field dissection. Effective postoperative pain management was achieved with a combination of epidural anesthesia and paravertebral block. Postoperative rehabilitation was instituted for early ambulation and recovery. Enteral nutrition via a duodenal feeding tube was administered from postoperative day 2. Median hospital stay after surgery was 15 days (range, 10–129). Rates for both 30-day and in-hospital mortality were 0%. Morbidity rate for all Clavien–Dindo grades was 41.3%, whereas the morbidity rate for Clavien–Dindo grades III and IV was 7.2%. Anastomotic leakage developed in two patients (1.4%), recurrent laryngeal nerve palsy in 11 (8.0%), and pneumonia in nine (6.5%). Good short-term outcomes, especially regarding anastomotic leaks, were achieved by consistent improvements in surgical techniques, optimization of several operative procedures, and appropriate perioperative management.

A rapid and reliable test for detection of complicated appendicitis would be useful when deciding whether emergency surgery is required. We investigated the clinical usefulness of procalcitonin for identifying acute complicated appendicitis. We retrospectively analyzed 63 patients aged ≥15 years who underwent appendectomy without receiving antibiotics before admission and had preoperative data on the plasma procalcitonin level (PCT), body temperature (BT), white blood cell count (WBC), neutrophil / lymphocyte ratio (N/L ratio), and C-reactive protein level (CRP). Patients were classified into 3 groups: group A (inflammatory cell infiltration of the appendix with intact mural architecture), group B (inflammatory cell infiltration with destruction of mural architecture, but without abscess or perforation), and group C (macroscopic abscess and/or perforation). For identifying destruction of mural architecture, the diagnostic accuracy of PCT was similar to that of BT or CRP. However, the diagnostic accuracy of PCT was highest among the five inflammatory indices for identifying abscess and/or perforation, with the positive predictive value of PCT for abscess and/or perforation being higher than that of CRP (73% vs. 48%). Univariate analysis of the predictors of abscess and/or perforation revealed that a plasma PCT level ≥0.46 ng/mL had the highest odds ratio (30.3 [95% confidence interval: 6.5–140.5] versus PCT >0.46 ng/mL). These findings indicate that procalcitonin is a useful marker of acute appendicitis with abscess and/or perforation.

Curved intertrochanteric varus osteotomy (CVO) is one of the good surgical procedures for avascular necrosis of the femoral head (ANFH) patients. However, some patients with failed CVO are converted to total hip arthroplasty (THA) as a salvage operation. We compared the clinical and radiographic outcomes of 10 hips converted to THA after failed CVO (Group O) (mean age 43.0 years, 8 male and 2 female) with an age and gender matched control group of 20 hips that underwent primary THA for ANFH (Group C). Perioperative blood loss in Group O was significantly higher than that in Group C (535 g vs 282 g (P = 0.002)). Infection and dislocation occurred in 1 and 2 hips in Group O. There were no significant differences in both pre- and post-Harris Hip Score (HHS) between the groups. The stems in the AP radiograph were placed at 2.1° in a valgus position in Group O, whereas those in Group O were inserted at 1.0° in a varus position, a significant difference (P = 0.01). The stem alignment in the Lauenstein view in Group O was 1.2° in the extension position and in Group C was 0.4° in the flexion position, a significantly difference (P = 0.04). THA after failed CVO provides with the stem inserted in a valgus and extension position. Operative bleeding was increased. THA after failed CVO is a technically demanding arthroplasty. We believe that careful preoperative planning and preparation are necessary for this arthroplasty.

Bangladesh is now facing the public health problems of deficiency of iron and iodine, especially for women. The Ministry of Health and Family Welfare of Bangladesh has implemented strong countermeasures to enhance the health condition of the nation. On the other hand, based on the concept of the Declaration of Alma-Ata, complementary and alternative medicine should be used more vigorously to enhance public health in the world. The usage of complementary and alternative medicine such as ayurvedic medicine (AM) should be increased in Bangladesh. Therefore we conducted the study on perceptions of AM by citizens in Dhaka, Bangladesh in order to promote and enhance the effective usage of AM, including herbal medicines as medical resources, from December 2010 to January 2011. This study showed younger citizens (61.1%) did not get more benefit from AM than elder citizens (48.0%). On the other hand, younger citizens (76.8%) did not get more harm from AM than elder citizens (70.1%). We think that in terms of effectiveness of AM, the younger generation in Dhaka seems to be more skeptical to AM than the elder generation in Dhaka, even though the younger generation are more satisfied with AM than the elder generation. With viewpoint of enhancement of usage of AM in Dhaka, we think that scientifically sound information on AM should be collected rigorously and brought to the citizens vigorously to remove the skeptical feeling of AM from younger citizen in Dhaka. In terms of the effective utilization of limited medical resources, AM should be used appropriately in Bangladesh, Asia and the world.

The aims of this study were to describe awareness and knowledge of HIV/AIDS among Bangladeshi married women in rural areas and to examine associations between exposure to mass media and their awareness and comprehensive knowledge of HIV/AIDS where mass media has been suggested to be vital sources of information. From the original dataset of the sixth Bangladesh Demographic Health Survey in 2011, the data of 11,570 rural married women aged 15–49 years old were extracted. Logistic regression analyses were performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs). We found that approximately two-thirds of women (63.0%) aged 15–49 years had heard about HIV/AIDS. Exposure to each type of media was significantly associated with awareness of HIV/AIDS. Comparing to those who were not exposed to each of the investigated media, the adjusted ORs of comprehensive knowledge of HIV/AIDS were significantly high for those exposed to newspapers/magazines less than once a week (1.34, 95% CI 1.09–1.65), newspapers/ magazines at least once a week (1.44, 95% CI 1.07–1.94), television at least once a week (1.41, 95% CI 1.18–1.68). It was suggested that television can be utilized to increase awareness and comprehensive knowledge of HIV/AIDS through effective programs. Although the level of exposure was still low, significant associations between exposure to newspapers/magazines and comprehensive knowledge of HIV/AIDS suggested potential of written messages to promote knowledge of HIV/AIDS.

A 79-year-old man with lymph node recurrence of malignant melanoma received nivolumab, an antiprogrammed death 1 (PD-1) monoclonal antibody. He had pre-existing ocular myasthenia gravis (MG) and a continued small amount of corticosteroid. Grade 3 creatine phosphokinase elevation appeared after two doses of nivolumab, and the treatment was postponed until it improved to grade 1. After three doses of nivolumab, he experienced diplopia and facial muscle weakness which were consistent with an acute exacerbation of MG, and the symptoms relieved without additional treatment for MG. He achieved shrinkage of metastasis after ten doses of nivolumab. Although a case who died due to MG after administration of nivolumab was reported recently, pre-existing MG is considered not to be always a contraindication of nivolumab.