How to Overcome the Barriers Behind Writing Case Reports for Beginners and Young General Physicians

Background

Case reports are fundamental to clinical medicine that trace back to ancient Egypt preceding Hippocrates in the history of medicine. Case reports contribute to academic development and new clinical research. However, among cases presented at an annual academic conference for Japanese generalists, only a few cases were later published in peer-reviewed journals, highlighting potential barriers regarding the writing of case reports, such as mentorship absence. This paper aimed to offer guidance and strategies to novice and young general physicians in overcoming barriers and effectively composing case reports for international peer-reviewed journals.

Methods

This paper focuses on case reports for general physicians with extensive experience in writing case reports for international peer-reviewed journals. We conducted a narrative review to help beginners and young general physicians in writing case reports and discussed strategies for overcoming these barriers.

Results

We propose the following three tips as important processes for writing case reports: recognize the types of suitable cases for case reports; select a journal for submission using a list of candidate journals for general physicians; and organize the discussion section with one theme per paragraph. In addition, we provide a list of journals that specifically focus on case reports, along with important pointers for beginners and young general physicians that will assist authors in the field of general medicine in choosing appropriate journals for submission.

Conclusion

We hope that understanding and applying these tips will aid beginners and young general physicians in writing case reports.

Influence of Different Undercut Depths of Clasp Fabricated by Selective Laser Melting on Retentive Force

INTRODUCTION

The purpose of this study was to investigate the influence of undercut depths on abutment teeth regarding the retentive force of clasps fabricated through selective laser melting (SLM), and to compare them with conventional cast clasps.

METHODS

Akers clasps made of cobalt chromium alloy were fabricated using the SLM method (SLM), and the retentive forces were compared with clasps made with the conventional cast method (Cast). Three undercut amounts (0.25 mm, 0.15 mm, and 0 mm) were applied on the abutment tooth. The specimens were subjected to 10,000 repetitive insertion/removal cycles.

RESULTS

SLM-0.15 showed slightly lower initial retentive force than the Cast specimens, it remained within an acceptable range. During insertion/removal test, the SLM-0.15 specimen showed a significant difference between the initial retentive force and the retentive force after 5,000 cycles, indicating that SLM-0.15 was the least likely to change in retentive force within the parameters established in this study. The inner clasp surface on the SLM groups had higher surface roughness before testing compared to the Cast specimen.

CONCLUSIONS

Akers clasps fabricated by SLM demonstrated optimal initial retentive forces with smaller undercuts than conventional Cast clasps, and the retentive forces changed less with repetitive insertion/removal.

Writing Case Reports Can Improve Seven Components in Clinical Reasoning

Case reports provide scientific knowledge and opportunities for new clinical research. However, it is estimated that less than 5% of cases presented by Japanese generalists at academic conferences are published due to various barriers such as the complex process of writing articles, conducting literature searches, the significant time required, the reluctance to write in English, and the challenge of selecting appropriate journals for publication. Therefore, the purpose of this opinion paper is to provide clinicians with practical tips for writing case reports that promote diagnostic excellence. In recent years, clinical practitioners have been striving for diagnostic excellence and optimal methods to accurately and comprehensively understand the patient's condition. To write a case report, it is essential to be mindful of the elements of diagnostic excellence and consider the quality of the diagnostic reasoning process. We (the authors) are seven academic generalists who are members of the Japanese Society of Hospital General Medicine (JSHGM) - Junior Doctors Association, with a median of 7 years after graduation and extensive experience publishing case reports in international peer-reviewed journals. We conducted a narrative review and discussed ways to write case reports to promote diagnostic excellence, leveraging our unique perspectives as academic generalists. Our review did not identify any reports addressing the critical points in writing case reports that embody diagnostic excellence. Therefore, this report proposes a methodology that describes the process involved in writing diagnostic excellence-promoting case reports and provides an overview of the lessons learned. Based on our review and discussion, we explain the essential points for promoting diagnostic excellence through case reports categorized into seven components of clinical reasoning. These strategies are useful in daily clinical practice and instrumental in promoting diagnostic excellence through case reports.

Effects of a 60-Minute Lecture About Diagnostic Errors for Medical Students: A Single-Center Interventional Study

INTRODUCTION

The danger of diagnostic errors exists in daily medical practice, and doctors are required to avoid such errors as much as possible. Although various factors, including cognitive, system-related, and patient-related factors, are involved in the occurrence of diagnostic errors, the percentage of doctors with insufficient medical knowledge among those factors is extremely low. Therefore, lectures on diagnostic errors might also be useful for medical students without experience working as doctors. This study investigated whether a 60-minute lecture on diagnostic errors would enable Japanese medical students to consider the factors involved in diagnostic errors and how their perceptions of diagnostic errors change.

METHODS AND MATERIALS

This single-center interventional study was conducted in October 2022 among fourth-year medical students at the Faculty of Medicine, Saga University. A questionnaire survey was conducted before and immediately after the lecture to investigate changes in the perceptions of medical students regarding diagnostic errors. One mock case question was given on an exam the day after the lecture, and the number of responses to cognitive biases and system-related and patient-related factors involved in diagnostic errors were calculated.

RESULTS

A total of 83 students were analyzed. After the lecture, medical students were significantly more aware of the existence of the concept of diagnostic error, the importance of learning about it, their willingness to continue learning about it, and their perception that learning about diagnostic errors improves their clinical skills. They were also significantly less likely to feel blame or shame over diagnostic errors. The mean numbers of responses per student for cognitive bias, system-related factors, and patient-related factors were 1.9, 3.4, and 0.9, respectively. The mean number of responses per student for all factors was 5.6.

CONCLUSION

A 60-minute lecture on diagnostic errors among medical students is beneficial because it significantly changes their perception of diagnostic errors. The results of the present study also suggest that lectures may enable Japanese medical students to consider the factors involved in diagnostic errors.

How Do We Establish the Utility and Evidence of General Medicine in Japan?

Hospital Medicine in the United States has achieved significant progress in the accumulation of evidence. This development has influenced the increasing societal demand for General Medicine in Japan. Generalists in Japan actively engage in a wide range of interdisciplinary clinical practices, education, and management. Furthermore, Generalists have also contributed to advances in research. However, there is limited evidence regarding the benefits of General Medicine in Japan in all these areas, with most of the evidence derived from single-center studies. In Japan, the roles of Generalists are diverse, and the comprehensive definition of General Medicine makes it difficult to clearly delineate its scope. This results in an inadequate accumulation of evidence regarding the benefits of General Medicine, potentially making it less attractive to the public and younger physicians. Therefore, it is necessary to categorize General Medicine and collect clear evidence regarding its benefits.

Validation and Improvement of the Saga Fall Risk Model: A Multicenter Retrospective Observational Study

Purpose

We conducted a pilot study in an acute care hospital and developed the Saga Fall Risk Model 2 (SFRM2), a fall prediction model comprising eight items: Bedriddenness rank, age, sex, emergency admission, admission to the neurosurgery department, history of falls, independence of eating, and use of hypnotics. The external validation results from the two hospitals showed that the area under the curve (AUC) of SFRM2 may be lower in other facilities. This study aimed to validate the accuracy of SFRM2 using data from eight hospitals, including chronic care hospitals, and adjust the coefficients to improve the accuracy of SFRM2 and validate it.

Patients and Methods

This study included all patients aged ≥20 years admitted to eight hospitals, including chronic care, acute care, and tertiary hospitals, from April 1, 2018, to March 31, 2021. In-hospital falls were used as the outcome, and the AUC and shrinkage coefficient of SFRM2 were calculated. Additionally, SFRM2.1, which was modified from the coefficients of SFRM2 using logistic regression with the eight items comprising SFRM2, was developed using two-thirds of the data randomly selected from the entire population, and its accuracy was validated using the remaining one-third portion of the data.

Results

Of the 124,521 inpatients analyzed, 2,986 (2.4%) experienced falls during hospitalization. The median age of all inpatients was 71 years, and 53.2% were men. The AUC of SFRM2 was 0.687 (95% confidence interval [CI]:0.678-0.697), and the shrinkage coefficient was 0.996. SFRM2.1 was created using 81,790 patients, and its accuracy was validated using the remaining 42,731 patients. The AUC of SFRM2.1 was 0.745 (95% CI: 0.731-0.758).

Conclusion

SFRM2 showed good accuracy in predicting falls even on validating in diverse populations with significantly different backgrounds. Furthermore, the accuracy can be improved by adjusting the coefficients while keeping the model's parameters fixed.

Polybacterial Iliopsoas Muscle Abscess as an Indication for Early Diagnosis of Crohn's Disease

BACKGROUND Crohn disease (CD) is a chronic, relapsing inflammatory bowel disease characterized by penetrations or fistulae in the gastrointestinal tract and abscesses in the surrounding tissues. Diagnosis of CD is difficult with an iliopsoas muscle abscess (IMA) as an initial presentation. CASE REPORT A 22-year-old Japanese man had right hip pain 17 days prior to admission. Because of worsening pain, he was admitted to our hospital. Physical examination revealed limitation of his right hip motion and a positive right psoas sign. Abdominal contrast-enhanced computed tomography (CT) revealed a large right IMA. Continuous drainage, which revealed polymicrobial pus, with intravenous administration of antibiotics dramatically decreased the size of the IMA. The drainage tube was removed on hospitalization day 9 because barium enema and contrast radiography of the abscess through the drainage tube showed no fistula. However, on day 19 of hospitalization, the IMA was redetected by abdominal CT. Continuous abscess drainage was resumed, and the third contrast radiograph of the abscess revealed contrast medium flow into the small intestine. Colonoscopy detected stenoses and circumferential ulceration of the terminal ileum. Histopathological examination of the ileum biopsy showed histocyte aggregation with lymphocyte or plasmacyte infiltration of the lamina propria, compatible with a CD diagnosis. Laparoscopic ileocecal resection was performed on day 64 of hospitalization. CONCLUSIONS Penetration of the intestinal tract caused by CD should be suspected in a patient with a polymicrobial IMA. It is essential to identify the fistula and subsequently perform surgical resection of the affected intestinal area.

Helicobacter cinaedi Infection Presenting with Myalgia and Cellulitis

BACKGROUND Helicobacter cinaedi is a rare bacterium, accounting for only 0.2% of the positive isolates in blood cultures. Previous reports note that patients with H. cinaedi infection often have underlying diseases. H. cinaedi infection is diagnosed by blood culture. However, because of the slow growth of this bacterium in blood culture, the diagnosis can be missed. CASE REPORT A 78-year-old man gradually developed erythema and pain in his left arm, then left shoulder and both lower legs. The patient presented to our hospital on day 17. He was afebrile, but the examination was remarkable for tenderness in both gastrocnemius muscles and erythema from the distal left lower leg to the ankle. We suspected pyomyositis and cellulitis and started oral administration of amoxicillin-clavulanate. On day 22, H. cinaedi was detected in blood cultures. Based on these findings, we diagnosed pyogenic myositis and cellulitis caused by H. cinaedi bacteremia. On day 24, antibiotic therapy was changed to intravenous ampicillin, and symptoms improved. Additional examination did not reveal any underlying immunodeficiency disorder, such as malignancy or HIV infection. CONCLUSIONS H. cinaedi infection can occur in healthy patients. Myalgia can be caused by pyogenic myositis because of bacteremia. In cases of myalgia or cellulitis of unknown etiology, blood cultures can be useful when bacteremia is suspected; blood samples should be monitored over an extended period.

Listeria meningitis diagnosed by blood culture with fever, neurological symptoms, and no meningeal irritation signs

Key Clinical Message

Listeria can cause neurological symptoms in immunocompromised and older patients. Additionally, it is impossible to rule out meningitis by the absence of typical meningeal irritation signs. Therefore, patients with fever and neurological impairments should be rapidly examined for blood and cerebrospinal fluid cultures to rule out Listeria meningitis.

Abstract

A woman in her 90s developed fever, dysarthria, and transient disturbance of consciousness. Physical examination revealed no meningeal irritation signs. Listeria monocytogenes were detected in her blood culture the following day. Because of an increased number of cells in cerebrospinal fluid, she was diagnosed with Listeria meningitis.

Acute abdominal pain due to atypical bilateral adrenal infarction in acute myeloid leukemia with alterations related to myelodysplasia: A case report

Key Clinical Message

Acute myeloid leukemia (AML) can cause acute abdomen following adrenal insufficiency or adrenal infarction. Therefore, when diffusely enlarged adrenal glands and adrenal insufficiency of unknown cause are seen in a patient presenting with acute abdomen, adrenal infarction due to AML, or other hematologic diseases should be ruled out.

Abstract

A 49-year-old man developed acute abdominal pain following adrenal insufficiency and was diagnosed with acute myeloid leukemia (AML) with myelodysplasia-related changes. Because AML can cause acute abdominal pain due to adrenal infarction following adrenal insufficiency, a patient with these conditions should be ruled out adrenal infarction due to AML or other hematologic diseases.

Difficulty in diagnosing peritonitis caused by multidrug-resistant tuberculosis

Key Clinical Message

The low sensitivity of ascites culture for acid-fast bacilli necessitates a peritoneal biopsy when tuberculous peritonitis is suspected. Findings in the peritoneum on computed tomography may prompt suspicion of tuberculous peritonitis.

Abstract

A 47-year-old Nigerian man presented with fever, abdominal distention, and weight loss. Abdominal computed tomography revealed massive ascites and peritoneal thickening. Despite failing to culture acid-fast bacilli from ascites, histological examination and culture of peritoneum revealed multidrug-resistant tuberculosis peritonitis. Peritoneal biopsy is mandatory when tuberculosis peritonitis is suspected.

A Simple and Accurate Model for Predicting Fall Injuries in Hospitalized Patients: Insights from a Retrospective Observational Study in Japan

BACKGROUND While several predictive models for falls have been reported such as we reported in 2020, those for fall "injury" have been unreported. This study was designed to develop a model to predict fall injuries in adult inpatients using simple predictors available immediately after hospitalization. MATERIAL AND METHODS This was a single-center, retrospective cohort study. We enrolled inpatients aged ≥20 years admitted to an acute care hospital from April 2012 to March 2018. The variables routinely obtained in clinical practice were compared between the patients with fall injury and the patients without fall itself or fall injury. Multivariable analysis was performed using covariables available on admission. A predictive model was constructed using only variables showing significant association in prior multivariable analysis. RESULTS During hospitalization of 17 062 patients, 646 (3.8%) had falls and 113 (0.7%) had fall injuries. Multivariable analysis showed 6 variables that were significantly associated with fall injuries during hospitalization: age (P=0.001), sex (P=0.001), emergency transport (P<0.001), medical referral letter (P=0.041), history of falls (P=0.012), and abnormal bedriddenness ranks (all P≤0.001). The area under the curve of this predictive model was 0.794 and the shrinkage coefficient was 0.955 using the same data set given above. CONCLUSIONS We developed a predictive model for fall injuries during hospitalization using 6 predictors, including bedriddenness ranks from official Activities of Daily Living indicators in Japan, which were all easily available on admission. The model showed good discrimination by internal validation and promises to be a useful tool to assess the risk of fall injuries.

Evaluation of a Previously Developed Predictive Model for Infective Endocarditis in 320 Patients Presenting with Fever at 4 Centers in Japan Between January 2018 and December 2020

BACKGROUND In our previous single-center study, we developed an infective endocarditis (IE) prediction model among patients with undiagnosed fever (UF) based on 5 factors that can be obtained on admission: ambulance transfer, presence of cardiac murmur or pleural effusion, blood neutrophil percentage, and platelet count. The present study aimed to retrospectively evaluate the prediction model for IE in 320 patients presenting with fever at 4 university hospitals in Japan from January 2018 to December 2020. MATERIAL AND METHODS Patients aged ≥20 years admitted to 4 hospitals with I-330 (IE) or R-50-9 (UF) according to the International Statistical Classification of Diseases and Related Health Problems-10 were enrolled. More than 2 physicians at each hospital reviewed the patient diagnoses using the modified Duke criteria, allocating "definite IE" to IE group (n=119) and "non-definite IE" to UF group (n=201). Five factors on admission were analyzed by multivariate logistic regression. The discriminative ability and calibration of the model were evaluated using the area under the curve (AUC) and the shrinkage coefficient, respectively. RESULTS A total of 320 patients were enrolled. The odds ratios (95% confidence intervals) were as follows: ambulance transfer 1.81 (0.91-3.55); cardiac murmur 13.13 (6.69-27.36); pleural effusion 2.34 (0.62-2.42); blood neutrophil percentage 1.09 (1.06-1.14); and platelet count 0.96 (0.93-0.99). The AUC was 0.783 (0.732-0.834) with a shrinkage coefficient of 0.961. CONCLUSIONS The IE prediction model is useful to estimate the probability of IE immediately after admission for fever in patients aged ≥20 years.

Heidenhain Variant of Sporadic Creutzfeldt-Jakob Disease with a Variety of Visual Symptoms: A Case Report with Autopsy Study

BACKGROUND Sporadic Creutzfeldt-Jakob disease (sCJD) is a fatal disease caused by the change of prion protein (PrP). Affected patients present with rapidly progressive cognitive dysfunction, myoclonus, or akinetic mutism. Diagnosing the Heidenhain variant of sCJD, which initially causes various visual symptoms, can be particularly difficult. CASE REPORT A 72-year-old woman presented with a 2- to 3-month history of photophobia, blurring vision in both eyes. Seven days previously, she showed visual impairment of 20/2000 in both eyes. Left homonymous hemianopia and restricted downward movement of the left eye were observed with an intact pupillary light reflex and normal fundoscopy. On admission, her visual acuity was light perception. Cranial magnetic resonance imaging revealed no abnormality, and electroencephalography showed no periodic synchronous discharges. Cerebrospinal fluid examination on the sixth hospital day revealed tau and 14-3-3 protein with a positive result of real-time quaking-induced conversion. She thereafter developed myoclonus and akinetic mutism and died. Autopsy revealed thinning and spongiform change of the cerebral cortex of the right occipital lobe. Immunostaining showed synaptic-type deposits of abnormal PrP and hypertrophic astrocytes. Consequently, she was diagnosed with the Heidenhain variant of sCJD with both methionine/methionine type 1 and type 2 cortical form based on the western blot of cerebral tissue and PrP gene codon 129 polymorphism. CONCLUSIONS When a patient presents with various progressive visual symptoms, even without typical findings of electroencephalography or cranial magnetic resonance imaging, it is essential to suspect the Heidenhain variant of sCJD and perform appropriate cerebrospinal fluid tests.

Clinical Clerkships in General Medicine Enable Students to Acquire Basic Medical Competencies and Experience in Community-Based Integrated Care: A Descriptive Questionnaire-Based Study

Background No previous research has targeted educators regarding educational practice and the achievements of students in terms of the learning objectives of clinical clerkships in university general medicine departments of Japan. We aimed to clarify the characteristics of clinical clerkships in Japanese general medicine departments using a questionnaire administered to chairpersons of university general medicine departments. Methods This was a descriptive questionnaire-based study using Google Forms (Google, Inc., Mountain View, CA, USA). We asked the chairpersons of general medicine departments in Japanese universities the following questions, with responses given on a 5-point Likert scale: Question 1: How well are primary symptoms in the national model core curriculum for undergraduate medical education taught in clinical clerkships in university general medicine departments? Question 2: How successfully can students achieve the learning objectives of the national model core curriculum for undergraduate medical education through clinical clerkships in general medicine departments of university hospitals? Question 3: How successfully can students achieve the learning objectives of the national model core curriculum for undergraduate medical education through clinical clerkships in other community clinics or hospitals? The results of the questionnaire responses are described as mean±standard deviation. Results Of the 71 Japanese universities with general medicine departments, 43 were included in the analysis. For Question 1, the symptoms and pathophysiologies with a mean score of 4 points or higher were fever, general malaise, anorexia, weight loss or gain, edema, abdominal pain, lymphadenopathy, and headache. All those symptoms require basic medical competencies. For Questions 2 and 3, the intramural clinical clerkship of general medicine departments had a higher mean score than the extramural clinical clerkship for diagnostic reasoning that emphasizes medical history and physical examination and a comprehensive approach to patients with multiple health problems. In contrast, the extramural clinical clerkship, in which medical students can build experience with community-integrated care, had a mean score of 3 points or higher for all items. Conclusions The clinical clerkship in general medicine departments of Japanese universities provides students with chances to acquire clinical competencies regarding primary symptoms and pathophysiologies. Additionally, the extramural clinical clerkship provides experience in community-based integrated care, including home medical care, collaboration, health and welfare, and long-term care.

Five strategies on writing research papers for beginners and young general medicine doctors

We propose five important strategies for young generalists to write original research and papers. We hope that even beginners will understand and practice these five strategies, and help young generalist to write research papers based on clinical questions that arise in their daily practice.

Formation and evolution of carbonaceous asteroid Ryugu: Direct evidence from returned samples

Samples of the carbonaceous asteroid Ryugu were brought to Earth by the Hayabusa2 spacecraft. We analyzed 17 Ryugu samples measuring 1 to 8 millimeters. Carbon dioxide-bearing water inclusions are present within a pyrrhotite crystal, indicating that Ryugu's parent asteroid formed in the outer Solar System. The samples contain low abundances of materials that formed at high temperatures, such as chondrules and calcium- and aluminum-rich inclusions. The samples are rich in phyllosilicates and carbonates, which formed through aqueous alteration reactions at low temperature, high pH, and water/rock ratios of <1 (by mass). Less altered fragments contain olivine, pyroxene, amorphous silicates, calcite, and phosphide. Numerical simulations, based on the mineralogical and physical properties of the samples, indicate that Ryugu's parent body formed ~2 million years after the beginning of Solar System formation.

Hands-on Clinical Clerkship at the Department of General Medicine in a University Hospital Improves Medical Students' Self-Evaluation of Skills of Performing Physical Examinations and Informed Consent: A Questionnaire-Based Prospective Study

Introduction

The educational effects of a hands-on clinical clerkship on medical students at the Department of General medicine of Japanese university hospitals remain to be clarified. This study aimed to determine how such education affects medical students' self-evaluation of their clinical skills.

Methods

We enrolled 5th-year-grade students at the Department of General Medicine, Saga University Hospital, Japan in 2017. The students were divided into those who were going to have Japanese traditional-style observation-based training mainly in the outpatient clinic (Group O) and those in the 2018, new-style, hands-on clinical clerkship as one of the group practice members in outpatient and inpatient clinics (Group H). A questionnaire survey using the 4-point Likert scale for self-evaluation of the students' clinical skills at the beginning and the end of their training was conducted in both groups. The pre- and post-training scores of each item in both groups were compared and analyzed using the Mann-Whitney test.

Results

All 99 students in Group O and 121 of 123 students in Group H answered the questionnaires. The response rate was 99%. Two items regarding the abilities of "can perform a systemic physical examination quickly and efficiently" and "can clearly explain the current medical condition, therapeutic options, or risks associated with treatment, and discuss the process for obtaining informed consent" showed higher scores in the post-training survey in Group H than in Group O. There were no differences in these scores in the pre-training survey between the two groups.

Conclusion

A hands-on clinical clerkship at the Department of General medicine in a university hospital in Japan provided medical students with higher self-confidence in their skills of performing a physical examination and better understanding of patients' treatment options and the process of informed consent than observation-based training.

Criterion-related validity of Bedriddenness Rank with other established objective scales of ADLs, and Cognitive Function Score with those of cognitive impairment, both are easy-to-use official Japanese scales: A prospective observational study

Aim

Bedriddenness Rank (BR) and Cognitive Function Score (CFS), issued by the Ministry of Health, Labour and Welfare, Japan, are easy-to-use and widely used in the medical and long-term care insurance systems in Japan. This study aims to clarify the criterion-related validity of the CFS with the Mini-Mental State Examination (MMSE) and ABC Dementia Scale (ABC-DS), and to re-evaluate the criterion-related validity of BR with the Barthel Index (BI) or Katz Index (KI) in more appropriate settings and a larger population compared with the previous study.

Methods

A single-center prospective observational study was conducted in an acute care hospital in a suburban city in Japan. All inpatients aged 20 years or older admitted from October 1, 2018 to September 30, 2019. The relationship between BR and the BI and KI, and the relationship between CFS and the MMSE and ABC-DS were analyzed using Spearman’s correlation coefficients.

Results

We enrolled 3,003 patients. Of these, 1,664 (56%) patients exhibited normal BR. The median (interquartile range) values of the BI and KI were 100 (65–100) and 6 (2–6), respectively. Spearman’s rank correlation coefficients between BR and the BI and KI were −0.891 (p < 0.001) and −0.877 (p < 0.001), respectively.

Of the patients, 1,967 (65.5%) showed normal CFS. The median (interquartile range) MMSE of 951 patients with abnormal CFS and ABC-DS of all patients were 15 (2–21) and 117 (102–117), respectively. Spearman’s rank correlation coefficients between CFS and MMSE and ABC-DS were −0.546 (p < 0.001) and −0.862 (p < 0.001), respectively.

Conclusions

BR and CFS showed significant criterion-related validity with well-established but complicated objective scales for assessing activities of daily living and cognitive functions, respectively. These two scales, which are easy to assess, are reliable and useful in busy clinical practice or large-scale screening settings.

Relation of lymphopenia to comorbidity burden and its prognostic value in patients with acute decompensated heart failure with preserved left ventricular ejection fraction: a multicentre study

Background

Systemic inflammation resulting from comorbidities is postulated to play a central role in the pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF). Lymphopenia is a common manifestation of systemic inflammation and a prognostic factor in patients with HF. However, the association of lymphopenia with the comorbidity burden is unknown, and its prognostic value in patients with HFpEF admitted due to acute decompensated heart failure (ADHF) also remains elusive.

Purpose

We sought to clarify the relation of lymphopenia with the comorbidity burden, as well as its prognostic value and complementarity with the Get with the Guidelines-Heart Failure (GWTG-HF) risk score in ADHF patients with HFpEF.

Methods

Patients' data were extracted from the Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT-HFpEF), which is a prospective multicentre registry for patients with ADHF with a LVEF ≥50%. We analysed data of patients admitted between June 2016 and December 2020 who survived to discharge. The total lymphocyte count (per μL) and GWTG-HF risk score were obtained on admission, as previously reported. Comorbidity burden was defined as the number of comorbidities from the following: atrial fibrillation, hypertension, diabetes mellitus, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, anaemia, and obesity. The study endpoint was all-cause death.

Results

Over a median follow-up of 417 days, 181 of the 1013 included patients died. The proportion of patients with a total lymphocyte count in the lowest tertile was increasing with the increase in comorbidity burden (Figure 1). In the multivariate Cox analysis, a total lymphocyte count in the intermediate (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.00–2.41, p=0.0486) and lowest tertile (HR 2.23, 95% CI 1.47–3.38, p=0.0002) was independently associated with all-cause death. There was a significant difference in the all-cause death rate among the groups stratified by total lymphocyte count tertile (Figure 2). The total lymphocyte count had a higher C-statistic value (0.627) for the prediction of all-cause death than the GWTG-HF risk score, and the C-statistic value of the GWTG-HF risk score was improved when the total lymphocyte count was added (0.613 to 0.636, p=0.0260).

Conclusions

Lymphopenia was significantly associated with comorbidity burden. Furthermore, it was a useful marker of poor prognosis in hospitalised patients with acute HFpEF and was shown to be complementary to the contemporary HF prognostic score.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Roche Diagnostics K.K.Fuji Film Toyama Chemical Co. Ltd.

Willingness to Select Initial Clinical Training Hospitals Among Medical Students at a Rural University in Japan: A Single-Center Cross-Sectional Study

PURPOSE

Many countries will be aged societies by 2060. As a super-aged society, Japan may offer a valuable reference point. The number of medical residents and doctors working at university hospitals in Japan has halved since 2004, resulting in serious shortages of doctors in rural areas. This study clarified factors influencing medical students to choose university hospitals as facilities for their initial training or to only choose community hospitals.

METHODS

This single-center cross-sectional study was conducted in a typical rural city in Japan from February to March 2021. Data were collected using a questionnaire developed from a narrative review and discussion among four researchers. The participants were divided into those who chose university hospitals and those chose only community hospitals for logistic regression analysis.

RESULTS

Of the 300 students who answered the questionnaire (46.4% response rate), 291 agreed to participate in the study. At the time, 93 students had not decided where to undertake initial training, and were excluded. Of the 198 analyzed students, 113 (57.1%) had chosen university hospitals. Significant factors affecting students' choices were "good salary or fringe benefits" (odds ratio [OR] 2.6, 95% confidence interval [CI]: 1.3-5.2) in the community hospital group, and "desire to have contact with doctors practicing in a medical setting before starting hospital training in the fifth and sixth grade" (OR 0.4, 95% CI: 0.2-0.8) and "prefer Saga Prefecture for initial training" (OR 0.2, 95% CI: 0.1-0.4) among the university hospital group.

CONCLUSION

University hospitals could offer a good salary or fringe benefits to secure residents. Other useful measures include preferential admission of students who pledge to work in the prefecture of their medical school after graduation and facilitating contact between motivated students and senior doctors before starting hospital training.

Increasing the Status of Hospital General Medicine Departments with Emphasis on Outpatient Care in Japan

Demand is increasing for general medicine services in Japan, a super-aged society. The new medical specialty system introduced in 2019 obligates physicians to obtain a qualified specialty from among 19 basic specialty fields, including general medicine, before obtaining more advanced qualified subspecialties. The role of the department of general medicine in Japan varies in each hospital. Remuneration for medical services obtained by general medicine departments that mainly provide outpatient care is relatively low, making it difficult to fill positions in this department within a hospital. We conducted a narrative review and discussed ways to increase the status of hospital general medicine departments that mainly provide outpatient care. We consider the following four points to be important: improvement of diagnostic capabilities in the outpatient setting; playing a central role in education for medical students and residents; active involvement with patients who have diagnostic difficulties or social problems; and branding and promotion of the general medicine department. We envision that adopting an active approach to these points will increase the status of general medicine departments that mainly provide outpatient care within the hospital, allowing such newly established departments to start easily in Japanese hospitals in the future.

Absence of the Anterior Communicating Artery on Selective MRA is Associated with New Ischemic Lesions on MRI after Carotid Revascularization

BACKGROUND AND PURPOSE

ICA-selective MRA using a pencil beam presaturation pulse can accurately visualize anterior communicating artery flow. We evaluated the impact of anterior communicating artery flow on the perioperative hemodynamic status and new ischemic lesions after carotid revascularization.

MATERIALS AND METHODS

Eighty-three patients with carotid artery stenosis were included. We assessed anterior communicating artery flow using ICA-selective MRA. The preoperative hemodynamic status was measured using SPECT. We also measured the change in regional cerebral oxygen saturation after temporary ICA occlusion. New ischemic lesions were evaluated by DWI on the day after treatment.

RESULTS

Anterior communicating artery flow was detected in 61 patients, but it was not detected in 22 patients. Preoperative cerebrovascular reactivity was significantly higher in patients with (versus without) anterior communicating artery flow with a mean peak systolic velocity of ≥200 cm/s (39.6% [SD, 23.8%] versus 25.2% [SD, 16.4%]; P = .030). The decrease in mean regional cerebral oxygen saturation was significantly greater in patients without (versus with) anterior communicating artery flow (8.5% [SD, 5.6%] versus 3.7% [SD, 3.8%]; P = .002). New ischemic lesions after the procedure were observed in 23 patients. The multivariate logistic regression analysis revealed that anterior communicating artery flow (OR, 0.07; 95% CI, 0.012-0.45; P = .005) was associated with new ischemic lesions.

CONCLUSIONS

The absence of anterior communicating artery flow influenced the perioperative hemodynamic status in patients with carotid stenosis and was associated with an increased incidence of new ischemic lesions after carotid revascularization.

Reasons for medical students selecting a rural prefecture in Japan for initial clinical training: a single-center-based cross-sectional study

Objective: Securing a sufficient number of medical residents to work in rural areas is an urgent issue. This study sought to clarify the factors that cause medical students at a rural university in Japan to select a particular place for their initial clinical training. Materials and Methods: A questionnaire was administered to all medical students at Saga University between February and March 2021. Participants were divided into two groups based on their training location choice: those who chose Saga Prefecture (Saga group) and those who selected other prefectures (non-Saga group). Then, logistic regression analysis was performed. Results: The questionnaire was answered by 300 students (46.3% response rate), of whom 291 agreed to participate in the study; 122 (41.9%) and 169 (58.1%) students were allocated to the Saga and non-Saga groups. Within the Saga group, the following factors were statistically significant: being admitted to Saga University's medical school through the system of special allotment of admission to applicants pledging to work in Saga Prefecture following graduation (or regional quota programs for admission) (odds ratio [OR], 19.18; 95% confidence interval [CI], 6.99-52.60); and being from Saga Prefecture (OR, 6.05; 95% CI, 2.24-16.35). With the non-Saga group, the desire to work in an urban area (OR, 0.03; 95% CI, 0.00-0.37) was statistically significant. Conclusion: To encourage medical residents to choose this prefecture for their initial clinical training, the focus should be on medical students who are from Saga Prefecture or admitted through the regional quota program.

Pitfall of isolated superior mesenteric artery dissection with normal D‐dimer level

A 51‐year‐old man with untreated hypertension developed sudden‐onset epigastric pain. Despite a normal D‐dimer level, abdominal contrast‐enhanced computed tomography revealed superior mesenteric artery dissection. Abdominal contrast‐enhanced computed tomography is mandatory when examining patients with sudden‐onset abdominal pain, even those with a normal D‐dimer level.

An Infected Massive Persistent Sciatic Artery Aneurysm Treated by an Aneurysmal Incision and Drainage after Angiographic Embolization

A man in his 80s undergoing chronic hemodialysis presented with a high fever. A 10-cm soft mass was palpable in his right buttock. Abdominal computed tomography and angiography showed an incomplete-type unilateral persistent sciatic artery aneurysm (PSAA) with gas patterns and a blood flow through the aneurysm. Incision drainage was performed after arterial embolization. Gram staining of the hematoma showed gram-positive cocci that had formed chains, thus leading to a diagnosis of an infected PSAA. Drainage by incision after arterial embolization was used as the therapeutic method of choice for a massive infected PSAA with a sustained blood flow in order to prevent sciatic nerve injury and bleeding associated with PSAA resection.

Unilateral syphilitic optic neuritis without meningitis or uveitis

A 69‐year‐old man with left eye pain and visual impairment was diagnosed with syphilitic optic neuritis, who was successfully treated by penicillin. Although it is difficult to decide syphilis as the direct cause of optic neuritis, it is essential to diagnose syphilis in every patient with optic neuritis.

External validation of a new predictive model for falls among inpatients using the official Japanese ADL scale, Bedriddenness ranks: a double-centered prospective cohort study

Background

Several reliable predictive models for falls have been reported, but are too complicated and time-consuming to evaluate. We recently developed a new predictive model using just eight easily-available parameters including the official Japanese activities of daily living scale, Bedriddenness ranks, from the Ministry of Health, Labour and Welfare. This model has not yet been prospectively validated. This study aims to prospectively validate our new predictive model for falls among inpatients admitted to two different hospitals.

Methods

A double-centered prospective cohort study was performed from October 1, 2018, to September 30, 2019 in an acute care hospital and a chronic care hospital. We analyzed data from all adult inpatients, for whom all data required by the predictive model were evaluated and recorded. The eight items required by the predictive model were age, gender, emergency admission, department of admission, use of hypnotic medications, previous falls, independence of eating, and Bedriddenness ranks. The main outcome is in-hospital falls among adult inpatients, and the model was assessed by area under the curve.

Results

A total of 3,551 adult participants were available, who experienced 125 falls (3.5%). The median age (interquartile range) was 78 (66–87) years, 1,701 (47.9%) were men, and the incidence of falls was 2.25 per 1,000 patient-days and 2.06 per 1,000 occupied bed days. The area under the curve of the model was 0.793 (95% confidence interval: 0.761–0.825). The cutoff value was set as − 2.18, making the specificity 90% with the positive predictive value and negative predictive value at 11.4% and 97%.

Conclusions

This double-centered prospective cohort external validation study showed that the new predictive model had excellent validity for falls among inpatients. This reliable and easy-to-use model is therefore recommended for prediction of falls among inpatients, to improve preventive interventions.

Trial registration

UMIN000040103 (2020/04/08)

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02871-5.

Evaluating educational performance and achievements of faculty in general medicine departments of Japanese universities

A cross‐sectional questionnaire‐based study was conducted to examine whether the educational performance and achievements are appropriately recognized and contribute to their promotion in university hospitals. We found that the chairpersons of those general medicine departments believed that educational performance had not been appropriately evaluated; educational achievements did not receive sufficient consideration for promotion compared with the performance and achievements related to clinical and research activities.

Diagnostic error rates and associated factors for lower gastrointestinal perforation

Lower gastrointestinal perforation is rare and challenging to diagnose in patients presenting with an acute abdomen. However, no study has examined the frequency and associated factors of diagnostic errors related to lower gastrointestinal perforation. This large-scale multicenter retrospective study investigated the frequency of diagnostic errors and identified the associated factors. Factors at the level of the patient, symptoms, situation, and physician were included in the analysis. Data were collected from nine institutions, between January 1, 2015 and December 31, 2019. Timely diagnosis was defined as diagnosis at the first visit in computed tomography (CT)-capable facilities or referral to an appropriate medical institution immediately following the first visit to a non-CT-capable facility. Cases not meeting this definition were defined as diagnostic errors that resulted in delayed diagnosis. Of the 439 cases of lower gastrointestinal perforation identified, delayed diagnosis occurred in 138 cases (31.4%). Multivariate logistic regression analysis revealed a significant association between examination by a non-generalist and delayed diagnosis. Other factors showing a tendency with delayed diagnosis included presence of fever, absence of abdominal tenderness, and unavailability of urgent radiology reports. Initial misdiagnoses were mainly gastroenteritis, constipation, and small bowel obstruction. In conclusion, diagnostic errors occurred in about one-third of patients with a lower gastrointestinal perforation.

A survey of the research practice in general medicine departments of Japanese universities: A cross-sectional study

BACKGROUND

Few studies have focused on research practice in Japanese university general medicine (GM) departments.

METHODS

This is a questionnaire-based cross-sectional study to clarify the research achievement and associated factors of Japanese university GM department. Univariate analysis was performed to compare the number of English-language research publications and explanatory variables.

RESULTS

Forty-seven universities responded. Over a 3 years period, the median number of English-language research publications was 6. Perceived degree of research necessity, staff numbers, collaborative research, conference presentations, and obtaining research grants were significantly associated with a higher number of English-language research publications.

CONCLUSIONS

While GM research output was found to be limited, numerous associated factors can potentially change Japanese GM departments' research environments.

Avoiding invasive surgical procedures for a slow-growing asymptomatic huge anterior mediastinal lipoma under watchful waiting

A mass shadow in the right lower lung field was detected by chest X-ray in a 79-year-old woman, which was eventually diagnosed as anterior mediastinal lipoma. She remained under watchful waiting without surgery for 9 years without developing symptoms, even though the lipoma had grown to an extremely large size.

Bone-destructive osseous arteriovenous fistula at the jugular bulb mimicking a glomus jugular tumor

BACKGROUND

Some reports have described intraosseous arteriovenous fistulas showing osteolytic changes, but an osseous arteriovenous fistula (AVF) at the jugular bulb showing extensive bone destruction is a very rare disease.

CASE DESCRIPTION

A 60-year-old man presented with pulsatile tinnitus and right facial nerve palsy. Radiological imaging showed a large homogenously enhanced osteolytic lesion at the right jugular foramen. A cerebral angiogram showed a high-flow vascular lesion of the jugular bulb associated with retrograde sinus reflux, resulting in venous congestion of the deep venous system. These findings led us to misdiagnose this lesion as a glomus jugular tumor. However, combined arterial and venous angiography after transarterial embolization revealed the precise angioarchitecture, and we finally diagnosed this lesion as a high-flow osseous AVF at the jugular bulb. We performed transvenous embolization using a triple catheter technique. The lesion was successfully obliterated, and the 6-months angiogram showed no recurrence.

CONCLUSION

A rare case of high flow osseous AVF at the jugular bulb associated with osteolytic changes in the surrounding bony structure is reported. Although many hypervascular lesions at the jugular bulb are glomus tumors, bone destructive osseous AVF at the jugular bulb should be considered.

Development of a Clinical Prediction Model for Infective Endocarditis Among Patients with Undiagnosed Fever: A Pilot Case-Control Study

Purpose

Infective endocarditis (IE) may be diagnosed as fever of unknown origin due to its delusively non-descriptive clinical features, especially in outpatient clinics. Our objective is to develop a prediction model to discriminate patients to be diagnosed as “definite” IE from “non-definite” by modified Duke criteria among patients with undiagnosed fever, using only history and results of physical examinations and common laboratory examinations.

Patients and Methods

The study was a single-center case–control study. Inpatients at Saga University Hospital diagnosed with IE from 2007 to 2017 and patients with undiagnosed fever from 2015 to 2017 were enrolled. Patients diagnosed with definite IE according to the modified Duke criteria, except those definitely diagnosed with other disorders responsible for fever, were allocated to the IE group. Patients without IE among those defined as non-definite according to the modified Duke criteria were allocated to the undiagnosed fever group. We developed a prediction model to pick up patients who would be “definite” by modified Duke criteria, which was subsequently assessed by area under the curve (AUC).

Results

A total of 144 adult patients were included. Of these, 59 patients comprised the IE group. We developed the prediction model using five indicators, including transfer by ambulance, cardiac murmur, pleural effusion, neutrophil count, and platelet count, with a sensitivity 84.7%, a specificity 84.7%, an AUC 0.893 (95% confidence interval 0.828–0.959), a shrinkage coefficient 0.635, and a stratum-specific likelihood ratio 0.2–50.4.

Conclusion

Our prediction model, which uses only indicators easy to gain, facilitates prediction of patients with IE. These indicators can be acquired even at common hospitals and clinics, without requiring advanced medical equipment or invasive examinations.

Trial Registration Number

UMIN000041344.

Radiomics analysis of myocardial perfusion SPECT images in patients with cardiomyopathy and heart failure

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): JSPS KAKENHI Grants

Background

Although myocardial perfusion heterogeneity due to focally damaged cardiomyocytes is observed in single−photon emission computed tomography (SPECT) imaging, a current perfusion defect scoring system does not allow us to provide sufficient diagnostic information for heterogeneity.

Purpose

The aim of this study was to perform radiomics analysis of myocardial perfusion SPECT (MPS) images to investigate the potential to detect myocardial perfusion heterogeneity.

Methods

Patients with hypertrophic cardiomyopathy (n = 3), heart failure (n = 9), and with a low likelihood of coronary artery disease (n =15) (Figure 1), who underwent a rest 99mTc-MIBI myocardial perfusion SPECT, were assessed using a LIFEx software. Four shape−based features, 6 histogram−based features, and 32 textural features were computed. The relevant features for the classification of the patients were selected using the Boruta algorithm, and hierarchical clustering of the selected features using the Spearman correlation coefficient was also performed for the feature reduction. The receiver operating characteristics (ROC) analysis was performed by the support vector machine to calculate the area under the ROC curve (AUC) for the selected features.

Results

Of 40 features, 17 were selected by the classification analysis, and these features were classified into 7 classes by the correlation analysis (Figure 2). The ROC AUCs for 7 features extracted from each class were 0.99, 0.97, 0.96, 0.92, 0.90, 0.86, and 0.83 for the contrast of NDGLDM, the entropy of histogram, ZLNU of GLZLM, the energy of GLCM, the energy of histogram, SZLGE of GLZLM, and the correlation of GLCM, respectively, as compared to 0.39 for a summed rest score.

Conclusions

Radiomics analysis successfully determined the myocardial perfusion heterogeneity in patients with cardiomyopathy and heart failure. It might be promising for the evaluation of myocardial damages that cannot be analyzed by the conventional scoring method.