Spinal Deformity Manifested by Urinary Tract Infection: A Case of Acute-on-Chronic Mobility Dysfunction

A 53-year-old man with diabetes mellitus presented to the emergency department with a fever and impaired mobility. A preliminary diagnosis of urinary tract infection was made based on dysuria and pyuria. History-taking revealed a history of gait disturbance and difficult urination. A thorough physical examination suggested a spinal abnormality. MRI scan revealed a narrow spinal canal due to ossification of the posterior longitudinal ligament and diffuse idiopathic skeletal hyperostosis. Throughout the diagnostic process, we employed both vertical tracing to investigate the causes of urinary tract infection and horizontal tracing to explore comorbidities such as diabetes. Additionally, we introduced appropriate social security and support systems under the name of diagnostic excellence.

Epidemic Myalgia Presenting as Cervical Pain: A Case Report

A 53-year-old female visited our hospital because of cervical and abdominal pain preceding fever and upper respiratory symptoms. Severe tenderness was noted over the bilateral sternocleidomastoid muscles, the superior portion of the trapezius muscle, and the umbilical region of the abdomen. The patient reported exacerbation of posterior neck pain in the supine position and during the transition from sitting to the supine position. The diagnosis of epidemic myalgia was finally made. This case highlights the presence of the cervical variant of epidemic myalgia.

The Usage of the Term "Social" in Japanese Primary Care Literature

INTRODUCTION

There has been a growing recognition of the importance of incorporating a "social" perspective in primary care practice. However, the specific meaning of the term "social" in the context of primary care is often not clearly defined or explained in the literature. This study aims to explore the usage and interpretation of the term "social" in primary care discourse in Japan.

METHODS

We collected papers containing the term "social" ("shakai-teki" in Japanese) from 810 papers published between 2010 and 2022 in the Official Journal of the Japan Primary Care Association. Through abductive coding, we examined how the term was employed and the different meanings attributed to it.

RESULTS

The instances of using the term "social" were classified into five distinct categories: (i) non-medical, (ii) emphasizing the importance of topics, (iii) public as an object, (iv) connections with people who support health and well-being, and (v) structural inequities that are detrimental to health.  Conclusion: The analysis revealed that the term "social" in the context of primary care discourse was multifaceted and characterized by ambiguity. To ensure effective communication and clarity in discussions, it is crucial for primary care professionals to have a clear understanding of the intended meaning and implications of the term "social."

Identifying Unmet Social Needs in a Patient Living in Isolation: A Case Report

Loneliness and social isolation are common among older adults. To deliver high-quality care to older patients, healthcare professionals should know the social conditions of their patients. Addressing social determinants of health (SDH) in daily practice is beneficial to both patients and healthcare professionals. We illustrate a patient with congestive heart failure and cognitive decline whose social conditions improved through an SDH assessment. An SDH assessment has some potential advantages, which include facilitating a comprehensive understanding of patients' social conditions, visualizing how patients' social conditions have changed, deepening interprofessional collaboration, and ameliorating unnecessary negative emotions toward patients. This case report conveys two key messages. Firstly, healthcare professionals have the capability to evaluate patients' social backgrounds and enhance their health and social conditions through routine care. Secondly, the utilization of an SDH screening toolkit can support and enhance this initiative.

Acute Calcific Tendinitis of the Longus Colli Muscle

A man in his 40s complained of posterior neck pain and headache after a local festival. The patient also developed mild fever, odynophagia, and difficulty opening his mouth widely. Physical examination revealed mild rightward torticollis and limited ranges of neck motion. A neck computed tomography (CT) revealed calcification on the tendon of the lingus colli muscle. The pain decreased rapidly after acetaminophen and loxoprofen administration. Physicians should recognize the clinical characteristics of acute calcific tendinitis of the longus colli muscle (ACTLC) and conduct thorough follow-ups to exclude infection.

51-year-old woman • History of Graves disease • General fatigue, palpitations, and hand tremors • Dx?

► history of Graves disease ► general fatigue, palpitations, and hand tremors.

The impact of patients' social backgrounds assessment on nursing care: Qualitative research

Background

Although nurses are expected to address the social determinants of health (SDH) in clinical settings, the perspectives of front-line nurses on the integration of SDH into their clinical practice remain unclear. Understanding the dynamism of this integration and its outcomes can yield crucial insights into effective nursing care. This study aims to elucidate the integration and adoption of tool-based SDH assessment nursing programs and their impacts on daily nursing care.

Methods

We conducted qualitative research at a small community-based hospital in Japan, where a tool-based program characterized by social background interviews and documentation was implemented. Nurses at the hospital were recruited via purposive and snowball sampling. After hypothesis generation, semi-constructed in-depth online interviews were conducted. Each interview lasted between 30 and 50 min. The data were analyzed via thematic analysis using the framework approach.

Results

A total of 16 nurses participated. Participants' incorporation of the novel SDH assessment program was bolstered by prior learning and their recognition of its practical value. Institutional support and collaborative teamwork further facilitated the adoption of this innovation. Enhanced knowledge about the social contexts of their patients contributed to increased respect, empathy, and self-affirmation among participants, consequently enhancing the quality of nursing care.

Conclusion

Through team-based learning, reflection, and support, nurses can integrate a tool-based SDH assessment program into their daily nursing practice. This program has the potential to empower nurses to deliver more holistic care and redefine their professional identity. Further research is warranted to assess patient-reported outcomes.

Tirzepatide-Induced Injection Site Reaction

A male in his 70s developed a rash on his lower abdomen after changing his subcutaneous injection drug from dulaglutide to tirzepatide. The rash diminished after stopping tirzepatide injection. This case illustrated that tirzepatide can potentially lead to an injection site rash, despite another glucagon-like peptide-1 (GLP-1) receptor agonist (RA) being used without adverse reactions. Injection site reactions are one of the potential adverse events associated with GLP-1 RA use. To the best of our knowledge, this is the first reported case of tirzepatide-induced injection site reaction.

Coronavirus or Cholangitis? An Acute Necrotizing Encephalopathy Caused by COVID-19

A 63-year-old Japanese woman presented to the emergency room with a fever and altered mental status. She was diagnosed as acute cholangitis and coronavirus disease 2019 (COVID-19). On the second day, her consciousness level deteriorated. The patient was finally diagnosed with acute necrotizing encephalopathy (ANE). This case illustrated ANE caused by COVID-19 that co-occurred with acute cholangitis. ANE is a subtype of acute encephalitis/encephalopathy, sometimes related to COVID-19. ANE shares some clinical features with acute cholangitis. COVID-19 and bacterial infections may coexist, thus complicating an accurate diagnosis. Physicians should avoid overlooking life-threatening febrile conditions even if the diagnosis of COVID-19 is confirmed.

Primary care physicians' perceptions of social determinants of health recommendations: a qualitative study

BACKGROUND

Several organisations have called for primary care professionals to address social determinants of health (SDoH) in clinical settings. For primary care physicians to fulfill their community health responsibilities, the implications of the SDoH recommendations need to be clarified.

AIM

To describe primary care physicians' views about being asked to address SDoH in clinical settings, from both positive and negative perspectives.

DESIGN & SETTING

A qualitative study in Japan. Twenty-one physicians were purposively recruited.

METHOD

'Love and breakup letter' methodology was used to collect qualitative data that contained both positive and negative feelings. Participants wrote love and breakup letters about being asked to address SDoH in a clinical setting, then undertook an in-depth online interview. Data were analysed via thematic analysis using the framework approach.

RESULTS

The following themes were identified: (i) primary care physicians take pride in being expected to address SDoH; (ii) primary care physicians rely on the recommendations as a partner, even in difficult situations; (iii) primary care physicians consider the recommendations to be bothersome, with unreasonable demands and challenges, especially when supportive surroundings are lacking; and (iv) primary care physicians reconstruct the recommendations on the basis of their experience.

CONCLUSION

Primary care physicians felt both sympathy and antipathy towards recommendations asking them to address SDoH in their clinical practice. The recommendations were not followed literally, instead contributing to physicians' clinical mindlines. Professional organisations that plan to develop and publish recommendations about SDoH should consider how their recommendations might be perceived by their target audience.

Assessing Social Circumstances in Primary Care: Expert Consensus via Delphi Technique

Background and Objective

In the Japanese primary care setting, a set of questions to screen patients' social circumstances has never been developed in a scientific manner. This project aimed to reach a consensus among diverse experts to develop a set of such questions, to meet the need for assessing patients' health-related social circumstances.

Methods

We used a Delphi technique to generate expert consensus. The expert panel was composed of various clinical professionals, medical trainees, researchers, support members for marginalized people, and patients. We conducted multiple rounds of communication online. In round 1, the participants provided their opinions about what health care professionals should ask to assess patients' social circumstances in primary care settings. These data were analyzed into several themes. In round 2, all themes were confirmed by consensus.

Results

Sixty-one people participated in the panel. All participants completed the rounds. Six themes were generated and confirmed: economic condition and employment, access to health care and other services, living in everyday life and leisure time, total physiological needs, tools and technology, and history of the patient's life. In addition, the panelists emphasized the importance of respecting the patient's preferences and values.

Conclusion

A questionnaire, abbreviated by the acronym of HEALTH+P, was developed. Further research about its clinical feasibility and impact on patient outcomes is warranted.

Defining the observable processes of patient care related to social determinants of health

INTRODUCTION

An understanding of social determinants of health (SDH) and patients' social circumstances is recommended to deliver contextualised care. However, the processes of patient care related to SDH in clinical settings have not been described in detail. Observable practice activities (OPAs) are a collection of learning objectives and activities that must be observed in daily practice and can be used to describe the precise processes for professionals to follow in specific situations (process OPA.) METHODS: We used a modified Delphi technique to generate expert consensus about the process OPA for patient care related to SDH in primary care settings. To reflect the opinions of various stakeholders, the expert panel comprised clinical professionals (physicians, nurses, public health nurses, social workers, pharmacists and medical clerks), residents, medical students, researchers (medical education, health care, sociology of marginalised people), support members for marginalised people and patients. The Delphi rounds were conducted online. In Round 1, a list of potentially important steps in the processes of care was distributed to panellists. The list was modified, and one new step was added. In Round 2, all steps were acknowledged with few modifications.

RESULTS

Of 63 experts recruited, 61 participated, and all participants completed the Delphi rounds. A total of 14 observable steps were identified, which were divided into four components: communication, practice, maintenance and advocacy. The importance of ongoing patient-physician relationships and collaboration with professionals and stakeholders was emphasised for the whole process of care.

DISCUSSION

This study presents the consensus of a variety of experts on the process OPA for patient care related to SDHs. Further research is warranted to investigate how this Communication-Practice-Maintenance-Advocacy framework could affect medical education, quality of patient care, and patient outcomes.

Primary care nurses during the coronavirus disaster and their struggle: Qualitative research

Background

Coronavirus disease 2019 (COVID‐19) has substantially affected the health and lives of medical professionals. However, the experiences of nurses engaged in primary care remain unclear. We explored how nurses working in primary care were psychologically and socially affected by the COVID‐19 disaster and how they overcame the difficulties experienced.

Methods

We conducted a qualitative study of seven Japanese nurses working in primary care. Data collection was performed before, during, and after a workshop based on the Tojisha‐Kenkyu (user‐led research) framework to explore how the COVID‐19 disaster affected the nurses and how they coped. Data were analyzed using inductive thematic analysis.

Results

Three themes emerged from the analysis: effects of the COVID‐19 disaster on nurses, nurses' newly found strength during the pandemic, and their changes and achievements through the Tojisha‐Kenkyu framework. The first theme comprised four subthemes: fear of the unknown; difficulty in adaptation; dysfunction in patient care; and defilement and oppression. The second theme involved feeling in control and professionalism. The third theme, which was based on participants' discovery of “same and different” fellowships, showed work reconstruction and self‐understanding, which alleviated their difficulties.

Conclusions

The effect of the pandemic on nurses working in primary care ranges from work‐related frustration to daily life issues. The Tojisha‐Kenkyu method can help nurses to alleviate difficulties. Further research should be conducted to elucidate the constant burden on primary care professionals and establish appropriate occupational and daily life support during pandemics.

A report of the social determinants of health workshop: Muddle cleared up in a polylogue

This letter illustrated our online workshop about clinical practice and postgraduate education about social determinants of health (SDH) to family medicine residents and attending physicians in Japan. The participants were encouraged not only by acquiring knowledge and skills but by sharing their experience and talking reflectively. The opportunities for family physicians in Japan to learn about SDH and reflect on their practices should be warranted.

Experience of residents learning about social determinants of health and an assessment tool: Mixed‐methods research

Background

Educating healthcare professionals about the social determinants of health is important in improving health outcomes of marginalized patients. Residents' experience of learning about the social determinants of health and a clinical assessment tool remains unclear.

Methods

Residents participated in an online session about the social determinants of health and the assessment tool. Using the New World Kirkpatrick Model, we obtained data about participants' experience from various perspectives. The data were analyzed using a concurrent triangulation mixed‐methods design.

Results

The study included 20 out of 30 residents. Their response was good, and self‐reported learning scores were increased by the session. They learned when to ask about patients' social conditions, what to ask, and how to coordinate medical care appropriately. Participants reported reflecting on their role as medical professionals and implementing new practices based on their learning, as well as concerns about addressing patients' social conditions.

Conclusion

Through learning about the social determinants of health, and assessment tools, residents both acquired knowledge and skills, and reflected on their previous practice, accepted patients as they are, understood difficult patients better, and developed interprofessional collaboration. Medical education about the social determinants of health can trigger changes in residents' views.

Diagnosing Bacterial Infection in the era of Pandemic: A Case Report

In the coronavirus disease 2019 (COVID-19) pandemic era, physicians’ clinical decision-making is often distorted. A man in his 60s presented with an already-subsided cough and anxiety about COVID-19. The physician was influenced by the patient’s anxiety and stuck to exclusion of COVID-19. The patient was finally diagnosed with sepsis caused by obstructive pyelonephritis. The key point for diagnosis was physicians’ awareness that the patient took slow and heavy steps. To confront the challenge of making an appropriate diagnosis of bacterial infection in the era of COVID-19, physicians should be aware of diagnostic biases and watch patients’ general appearance closely.

Superior cluneal nerve entrapment syndrome: a common but often overlooked cause of low back pain

An 81‐year‐old woman complained of low back pain (LBP) on her regular check‐up. Physical examination revealed tenderness at the middle point of the posterior iliac crest and burning dysesthesias around the tenderness point, without any other neurological findings. An injection of local anesthetics diminished the pain. The diagnosis of superior cluneal nerve entrapment syndrome (SCNES) was made. SCNES is relatively common, as high as 14% in patients with LBP, but frequently overlooked. Primary care physicians should be aware of the typical findings of SCNES for correct diagnosis and treatment.

Two Feet-One Hand Syndrome

Ringworm infection is a common but frequently misdiagnosed skin disease. An 81-year-old woman presented with a complaint of mild itch of the third and fourth fingers of her right hand and the toes of both feet. A crusted rash was seen on the right hand and both feet. The results of potassium hydroxide testing were positive for filamentous fungi. The diagnosis of two feet-one hand syndrome was made. The rash was treated successfully by topical ketoconazole. Recognition of this typical distribution of the rash may help make a prompt diagnosis of ringworm infection.

Pneumothorax presenting as epigastric pain

A male patient who smoked heavily complained of severe epigastric pain. He also had mild chest pain for the last 4 weeks. Imaging tests revealed pneumothorax secondary to cystic changes probably as a result of chronic obstructive pulmonary disease. Pneumothorax, particularly slowly progressive one, may present as abdominal pain. In addition to cardiovascular and gastrointestinal diseases, pneumothorax should be considered as a differentiasl diagnosis of epigastric pain with preceding pain or other symptoms in a heavy smoker.

Why-not-doing-high-tech-test Syndrome

A 69-year-old man presented with fever, chill, and malaise. A thorough physical examination brought the correct diagnosis of psoas abscess to light. In this case, a physical examination is the only way to correct diagnosis.

A case of laryngopharyngeal reflux-associated chronic cough: Misinterpretation of treatment efficacy causes diagnostic delay

A 62-year-old woman presented with a dry cough lasting 18 months. She had previously been examined by multiple doctors, but no abnormalities were observed. Several medications such as rabeprazole and inhaled corticosteroids were administered as test treatments without any improvement. Therefore, the possibility of biological disease, including acid reflux, had been mistakenly ruled out. We examined the sputum gram stain. The result showed phagocyted normal bacterial flora, suggesting aspiration. Laryngoscopy revealed edema of the arytenoid cartilage. The patient was finally diagnosed with laryngopharyngeal reflux and silent aspiration. This case suggested that the ineffectiveness of proton-pump inhibitors cannot always exclude the presence of reflux disease and the usefulness of gram stain examination to detect silent aspiration.

The crescent sign of ruptured baker's cyst

Ruptured Baker's cyst is easily misdiagnosed as deep vein thrombosis. Recognizing the crescent sign is important to make a rapid and correct diagnosis.

All that glitters is not gold

A 79-year-old Japanese woman presented with acute and diffuse abdominal pain, which turned out to be an unusual diagnosis. This article highlights a hint in physicians' diagnostic process, thereby avoiding the obstacles in making a correct diagnosis.

Social vital signs for improving awareness about social determinants of health

We, Team SAIL, have held sessions introducing social vital signs (SVS). SVS is a useful tool for evaluating patient’s social determinants of health (SDH).

Intestinal myiasis in a very elderly patient with inappropriate home care

An 83-year-old Japanese woman with dementia presented with multiple pressure ulcers and cellulitis. At presentation, numerous white maggots were wriggling in the stool on the diaper. Interview to the family revealed that the patient received inappropriate home care due to her dementia and her primary caregiver's developmental disability. No further maggots were omitted after admission, and she was diagnosed with intestinal myiasis. Intestinal myiasis has become rare in developed countries especially in adults. However, elderly bedridden patients living in poor hygiene conditions are at a greater risk of developing intestinal myiasis.

A case of lupus meningitis treated successfully with methylprednisolone pulse therapy

A 46-year-old female had suffered from systemic lupus erythematosus (SLE) for 8 years. Headache, vomiting and stiff neck appeared in the active phase of SLE. Findings in the cerebrospinal fluid were consistent with those of lupus meningitis. No pathogenic microbes were detected by microbiological or immunological examinations. She was diagnosed as having lupus meningitis. The method discussed herein which elucidates the cause of fever in SLE using white blood cell count (WBC) and alpha-2 globulin appeared to be useful for examining this case of meningitis. Lupus meningitis seems to preferentially occur in SLE patients with positive anti-ribonucleoprotein (RNP) antibody. Pulse therapy with methylprednisolone appeared to work well in this lupus meningitis patient who had had a long course of corticosteroid therapy.

Endocrine studies on ovarian androblastomas (Sertoli-Leydig tumors)

Endocrine studies were made on 4 women with ovarian Sertoli-Leydig cell tumors of varying degrees of differentiation. Clinically, all 4 patients showed evidence of increased androgen production, manifested by either hirsutism or virilization. The calculated ratios of steroid hormones between the affected ovarian venous values and peripheral values for testosterone (T), androstenedione (A), and dehydroepiandrosterone (DHEA) in 3 patients, were 1.4-18.6, 4.2-24.4, and 3.7-10.0, respectively. The peripheral levels of the hormones before salpingo-oophorectomy in all the patients were T: 0.97-45.0 ng/ml; A: 2.92-114.0 ng/ml; and DHEA: 13.0-20.9 ng/ml. In the 3 juvenile patients, elevated basal levels of LH and normal or subnormal levels of FSH (high LH:FSH ratio) were found. In a 12-year-old patient with 1,900 g tumor composed predominantly of Sertoli cells with lipid storage, the peripheral serum levels of T and estradiol (E2) were 114 ng/ml and 1890 pg/ml, respectively. The present data suggest that: 1) androblastomas have a biosynthetic capacity for androgen, estrogen, or both in which both the delta 5 and delta 4 pathways are involved, and 2) little correlation exists between the endocrine function and cellular composition of the tumors or their degree of differentiation.