Medical migration: A qualitative exploration of the atypical path of Japanese international medical graduates

Background: International Medical Graduates (IMGs) are commonly understood to move from low to high resource countries with motivations including improved financial situations and cultures of emigration. A presumable exception to the above themes would be the Japanese IMG population. The aim of this study was to develop an understanding of the Japanese IMG experience.

Methods: Using a grounded theory approach, we interviewed 19 Japanese IMGs working in the US and 16 Japanese IMGs working in Japan who had completed US clinical training. Questions addressed decision-making to pursue US clinical training, goals for the training, and career decision-making upon completing the training. Data collection and constant comparative analysis were conducted iteratively to identify emerging themes.

Results: The emerging model of the Japanese IMG experience is focused around pivotal experiences that often include dissatisfaction with the quality of Japanese clinical training and personal exposures to US clinical education. Further decision-making in the pursuit of US residency is influenced by educator training quality, and clinical training and career opportunities. The desire to improve Japanese clinical training commonly influences career decision-making after US training.

Conclusions: The Japanese IMG experience contrasts numerous perceptions of international physician migration and, in turn, enhances understanding of this paradigm.     

Percutaneous retrograde recanalization of an occluded celiac artery complicating acute aortic dissection

A 79-year-old woman with a complaint of persistent upper abdominal pain was admitted to our hospital for the treatment of thrombosed acute type B aortic dissection. Computed tomography showed the complete static occlusion of the celiac artery. Because of progressive symptom with elevation of liver enzymes and metabolic acidosis 11?h after admission, endovascular revascularization was attempted on an emergent basis. After a failed catheterization of the celiac ostium in an antegrade fashion due to a hard occlusion, we succeeded in a retrograde recanalization through the pancreaticoduodenal arcade via the superior mesenteric artery with stent placement using a pull-through technique. This technique is useful and safe when an antegrade approach seems difficult.     

Anti-polyribosylribitol phosphate antibody in pediatric patients with <Emphasis Type="Italic">Haemophilus influenzae</Emphasis> type b invasive disease

Haemophilus influenzae type b conjugate vaccine was recently introduced to Japan for voluntary immunizations. H. influenzae type b remains a leading cause of pediatric invasive diseases in Japan. The purposes of this study were to verify the suitability of the H. influenzae type b conjugate vaccine for immunizing children with a history of invasive H. influenzae type b disease and to determine whether H. influenzae type b conjugate vaccine is immunogenic in these children. The subjects comprised 64 children with a history of invasive H. influenzae type b disease. Serum samples from 64 patients with H. influenzae type b systemic infection in the acute and convalescent phases were analyzed. Serum anti-polyribosylribitol phosphate antibody responses of patients <2 years old were poorer than those observed in patients ≥2 years old. Nineteen of the 64 patients received a single dose of H. influenzae serotype b conjugate vaccine, and then follow-up serum was taken and analyzed. Eighteen of 19 patients had ≥1 μg/mL of anti-polyribosylribitol phosphate antibody titer after the first dose of H. influenzae type b conjugate vaccine. H. influenzae type b conjugate vaccine is immunogenic in children with invasive H. influenzae type b disease. Children <4 years old, and particularly <2 years old, with invasive H. influenzae type b disease should receive subsequent immunization with a H. influenzae type b conjugate vaccine.     

The Effect of Lateral Shift of Cricoid Cartilage on Pharyngeal Swallowing

Head rotation is widely used as one of the postural techniques for dysphagic patients. However, it cannot be used for patients with severe limitations to the range of motion of the neck. The purpose of this study was to determine the effect of applying pressure to the cricoid while swallowing and to explore the possibility of this maneuver as an alternative to head rotation. The swallowing function of 12 volunteers was examined with videofluorography under nine conditions: neutral, head rotated to the right, head rotated to the left, applying pressure to the cricoid on the right side at 5, 10, and 15 N, and applying pressure to the cricoid on the left side at 5, 10, and 15 N. To examine the effect of this maneuver on pharyngeal swallowing, the laterality of bolus flow was evaluated using 3 ml barium thin liquid from the posterior-anterior (P-A) view. The “pressing-cricoid” maneuver significantly altered the laterality of the bolus flow; the bolus flow was shifted to the side opposite to which the pressure was applied. The results of these changes were similar to those achieved with head rotation. These results demonstrated that the “pressing-cricoid” maneuver changes the bolus flow. This maneuver may have therapeutic value for the treatment of dysphagic patients as an alternative to head rotation.     

Dysphagia severity scale

A simple, broadly applicable, standardized dysphagia severity scale would be useful to standardize dysphagia evaluations, to monitor recovery and efficacy of treatment and to study the consequences of dysphagia. We developed a global Dysphagia Severity Scale (DSS) from videofluorographic swallowing studies which included subjective clinical ratings of functional swallowing. We rated laryngeal penetration/aspiration (P/A) and pharyngeal retention (PR), and then assessed methods for scoring severity of P/A and PR and for combining them in a global scale. Each method was tested by correlation with overall clinical severity ratings. The highest correlations were found by: 1) scoring P/A based on which foods were aspirated (no aspiration or penetration; penetration only; thin liquid aspiration; thick liquid, pudding, or chewed solid food aspiration; 2) scoring PR based on how much food was retained (none; minimal; moderate; severe); and 3) combining P/A and PR by taking the higher of the two scores as the final DSS rating. The final global DSS score and the clinical severity rating correlated well (r = 0.71). This proposed scale shows promise for rating global dysphagia severity.     

Hemodynamic responses to tracheal intubation with laryngoscope versus lightwand intubating device (Trachlight) in adults with normal airway

Lightwand devices are effective and safe as an aid to tracheal intubation. Theoretically, avoiding direct-vision laryngoscopy could allow for less stimulation by intubation than the conventional laryngoscopic procedure. We designed this prospective randomized study to assess the cardiovascular changes after either lightwand or direct laryngoscopic tracheal intubation in adult patients anesthetized with sevoflurane. Sixty healthy adult patients with normal airways were randomly assigned to one of three groups according to intubating procedure under sevoflurane/nitrous oxide anesthesia (fraction of inspired oxygen = 0.33) (n = 20 each). The lightwand group received tracheal intubation with Trachlight, the laryngoscope-intubation group received tracheal intubation with a direct-vision laryngoscope (Macintosh blade), and the laryngoscopy-alone group received the laryngoscope alone. Heart rate and systolic blood pressure were recorded continuously for 5 min after tracheal intubation or laryngoscopy with enough time to intubate. All procedures were successful on the first attempt. The maximum heart rate and systolic blood pressure values obtained after intubation with Trachlight (114 +/- 20 bpm and 143 +/- 30 mm Hg, respectively) did not differ from those with the Macintosh laryngoscope (114 +/- 20 bpm and 138 +/- 23 mm Hg), but they were significantly larger than those in the laryngoscopy-alone group (94 +/- 19 bpm and 112 +/- 21 mm Hg) (P < 0.05). Direct stimulation of the trachea appears to be a major cause of the hemodynamic changes associated with tracheal intubation. IMPLICATIONS: The magnitude of hemodynamic changes associated with tracheal intubation with the Trachlight is almost the same as that which occurs with the direct laryngoscope. Hemodynamic changes are likely to occur because of direct tracheal irritation rather than direct stimulation of the larynx.     

Skin burn after radiofrequency liver ablation of metastatic tumor

Radiofrequency ablation (RFA) is used to treat unresectable liver tumor. The authors described a case of RFA complicated by skin burn around a ground pad. A 70-year-old female underwent RFA of liver metastatic tumor under general anesthesia. Preoperatively, two ground pads were placed on the patient's right thigh and right calf after left lateral positioning. RFA was performed three times by 90 watts for 15 min each. At the end of surgery we noticed skin burn on the right thigh. It seems that electric current concentrated on the ground pad of the right thigh especially on the proximal side. In conclusion, two ground pads should be placed one on each thigh to distribute electric current.     

The effects of 30% and 60% xenon inhalation on pial vessel diameter and intracranial pressure in rabbits

Xenon may increase cerebral blood flow and intracranial pressure (ICP). To evaluate the effects of xenon on brain circulation, we measured pial vessel diameter changes, CO(2) reactivity, and ICP during xenon inhalation in rabbits. Minimum alveolar anesthetic concentration (MAC) for xenon was established in rabbits (n = 6). By using a cranial window model, pial vessel diameters were measured at 30% and 60% xenon inhalation and in time control groups (n = 15). ICP, mean arterial blood pressure, and heart rate were recorded during 30% and 60% xenon inhalation (n = 5). Pial vessel diameters were measured during hypocapnia and hypercapnia conditions in 60% Xenon and Control groups (n = 14). MAC for xenon was 85%. Xenon (0.35 and 0.7 MAC) dilated the arterioles (10% and 18%, respectively) and venules (2% and 4%, respectively) (P < 0.05). Dilation of arterioles was more prominent than that of venules. ICP, mean arterial blood pressure, and heart rate did not change during xenon inhalation. No difference in CO(2) reactivity was observed between Xenon and Control groups (P = 0.79). Sixty percent xenon (0.7 MAC) dilated brain vessels, but venule changes were small. Xenon did not increase ICP and preserved CO(2) reactivity of the brain vessels. IMPLICATIONS: Xenon might increase cerebral blood flow; however, 0.7 minimum alveolar anesthetic concentration xenon preserved both low intracranial pressure and CO(2) reactivity of the cerebral vessels in the normal rabbit.