Search

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.

Shun Yamashita, Masaki Tago, So Motomura, Satsuki Oie, Hidetoshi Aihara, Naoko E Katsuki, Shu-ichi Yamashita Department of General Medicine, Saga University Hospital, Saga, JapanCorrespondence: Shun YamashitaDepartment of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, JapanTel +81952343238Fax +81952342029Email sy.hospitalist.japan@gmail.comPurpose: 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.Keywords: infective endocarditis, undiagnosed fever, case–control study, prediction model, area under the curve

Background The statistical validities of the official Japanese classifications of activities of daily living (ADLs), including bedriddenness ranks (BR) and cognitive function scores (CFS), have yet to be assessed. To this aim, we evaluated the ability of BR and CFS to assess ADLs using inter-rater reliability and criterion-related validity. Methods New inpatients aged ≥75 years were enrolled in this hospital-based prospective observational study. BR and CFS were assessed once by an attending nurse, and then by a social worker/medical clerk. We evaluated inter-rater reliability between different professions by calculating the concordance rate, kappa coefficient, Cronbach’s α, and intraclass correlation coefficient. We also estimated the relationship of the Barthel Index and Katz Index with the BR and CFS using Spearman’s correlation coefficients. Results For the 271 patients enrolled, BR at the first assessment revealed 66 normal, 10 of J1, 15 of J2, 18 of A1, 31 of A2, 37 of B1, 35 of B2, 22 of C1, and 32 of C2. The concordance rate between the two BR assessments was 68.6%, with a kappa coefficient of 0.61, Cronbach’s α of 0.91, and an intraclass correlation coefficient of 0.83, thus showing good inter-rater reliability. BR was negatively correlated with the Barthel Index (r = − 0.848, p p Meanwhile, CFS at the first assessment revealed 92 normal, 47 of 1, 19 of 2a, 30 of 2b, 60 of 3a, 8 of 3b, 8 of 4, and 0 of M. The concordance rate between the two CFS assessments was 70.1%, with a kappa coefficient of 0.62, Cronbach’s α of 0.87, and an intraclass correlation coefficient 0.78, thus also showing good inter-rater reliability. CFS was negatively correlated with the Barthel Index (r = − 0.667, p p Conclusions BR and CFS could be reliable and easy-to-use grading scales of ADLs in acute clinical practice or large-scale screening, with high inter-rater reliabilities among different professions and significant correlations with well-established, though complicated to use, instruments to assess ADLs. Trial registration UMIN000041051 (2020/7/10).

Shun Yamashita,1 Masaki Tago,1 Midori Tokushima,1 Tomotaro Nakashima,1 Naoko E Katsuki,1 Keizo Anzai,2 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Division of Metabolism and Endocrinology, Faculty of Medicine, Saga University, Saga, JapanCorrespondence: Masaki TagoDepartment of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga 849-8501, JapanTel +81952343238Fax +81952342029Email tagomas@cc.saga-u.ac.jpBackground: Our hospital’s department of general medicine is often involved in the diagnosis and treatment of diseases that are considered by other hospitals or other departments in our hospital to be difficult to diagnose correctly.Objective: The aim of this study was to clarify how patients with infective endocarditis (IE) being admitted to our hospital’s department of general medicine were examined and treated and to elucidate their prognosis compared with patients admitted to other departments.Materials and Methods: Inpatients of Saga University Hospital with definite IE from September 2007 to August 2017 were divided into 2 groups: those admitted to the general medicine department (the GM group) and those admitted to other departments (the non-GM group).Results: Seventy-four patients were included; 17 (23%) were admitted to the general medicine department. In the GM group, the percentage of patients diagnosed with definite or suspected IE was lower (0% vs 32%, p=0.008), as was the rate of patients with echocardiographic findings that fulfilled the major modified Duke’s criteria (71% vs 98%, p≤ 0.001), preadmission. The GM group had higher percentages of patients with back or joint pain (41% vs 9%, p=0.001) and complications, including pyogenic spondylitis (35% vs 2%, p≤ 0.001), deep-seated abscesses (24% vs 5%, p=0.024), pyogenic arthritis (18% vs 0%, p=0.001), and glomerulonephritis (77% vs 37%, p=0.004) than did the non-GM group. Mortality within 30 days of admission to our hospital (12% vs 14%, p=0.753) and overall in-hospital mortality (12% vs 18%, p=0.570) did not significantly differ.Conclusion: The general medicine department could have accurately diagnosed IE, given appropriate treatments, and obtained similar prognoses to those of IE patients treated by other departments, including cardiology and cardiovascular surgery, even in patients for whom diagnosing IE was more difficult or who had less typical echocardiographic findings preadmission.Keywords: infective endocarditis, echocardiographic findings of infective endocarditis, general medicine, cardiology, cardiovascular surgery

Introduction Granulocyte colony-stimulating factor (G-CSF) is widely used as a neutrophil supportive therapy in breast cancer chemotherapy. Common adverse events of G-CSF include bone pain, headache, and fatigue; however, reports of G-CSF-associated vasculitis are few. Case report A 66-year-old woman who had undergone surgery for breast cancer received adjuvant chemotherapy with prophylactic use of pegfilgrastim (peg-G). She developed peg-G-associated vasculitis 11 days after initially receiving peg-G. Management and outcome: Although various blood and culture tests were required to rule out other vasculitis syndromes and infections, her symptoms spontaneously disappeared without any treatment other than discontinuation of the causal drug. Discussion G-CSF-associated vasculitis is occasionally accompanied by severe complications such as aortic dissection and aneurysm formation. This case report is important to draw attention towards this rare and difficult-to-diagnosis adverse event of peg-G.

A 64-year-old Japanese woman developed fatigue, dyspnea, and wheezing in July. Although she had been undergoing treatment for chronic obstructive pulmonary disease for six days, she was transferred to our hospital with delirium and diarrhea. On admission, she had an eschar of 3 mm in diameter on her anterior chest. Polymerase chain reaction of her blood and eschar specimens led to the diagnosis of severe fever with thrombocytopenia syndrome. Chest computed tomography showed ground-glass opacities, suggesting noncardiogenic pulmonary edema or viral pneumonia. This is the first case report of severe fever with thrombocytopenia syndrome beginning with dyspnea and wheezing.

Patient: Male, 50 Final Diagnosis: Proliferative fasciitis/myositis Symptoms: Facial swelling • fever • trismus Medication: — Clinical Procedure: Biopsy Specialty: Pathology Objective: Rare disease Background: Proliferative fasciitis/myositis is a benign disease that can be treated conservatively. However, some patients are mistakenly treated surgically because of a misdiagnosis of the condition as a malignant tumor. Case Report: A 50-year-old Japanese man developed swelling in his left cheek 12 days before admission; he developed a fever and trismus 3 days later. He was admitted to our hospital because of worsening of his condition despite treatment with sitafloxacin for 5 days and needle-aspiration drainage. On admission, he had a fever of 38.1°C, swelling in his left cheek spreading to the lower jaw, and several dental caries. Although ceftriaxone and clindamycin were administered for 7 days because an odontogenic infection was suspected, his condition did not improve. T2-weighted magnetic resonance imaging of the facial muscles on Day 5 of hospitalization showed swelling and high-intensity signals in the left masseter, temporalis, and pterygoid muscles. Macroscopic findings from a biopsy of the left temporalis muscle performed on Day 17 showed white and thickened fascia. Histopathological examination revealed fibrous hyperplasia of the fascia, increased fibrous connective tissue between muscle fibers, and infiltration of inflammatory cells, providing not a definite but a compatible diagnosis of proliferative fasciitis/myositis. Beginning on Day 18, the patient’s fever lessened with gradual improvement of his facial swelling and trismus. Conclusions: It is imperative to include proliferative fasciitis/myositis as a possible diagnosis when patients present with facial swelling and trismus of unknown cause.

Lower gastrointestinal perforation is rare and challenging to diagnose timeously in the 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. This study retrospectively analyzed data on patient factors, symptoms, situational factors, and physician factors across nine institutions between January 1, 2015 and December 31, 2019. Timely diagnosis was defined as diagnosis at the first visit to a computed tomography (CT)-capable facility 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 showed a significant association between examination by a non-generalist and delayed diagnosis. Other factors, such as presence of fever, absence of abdominal tenderness, and unavailability of urgent radiology reports, tended to be associated with delayed diagnosis. The initial misdiagnoses mainly comprised gastroenteritis, constipation, and small bowel obstruction. In conclusion, diagnostic errors occurred in about one-third of lower gastrointestinal perforation cases.

Physicians should be familiar with May‐Thurner syndrome, characterized by the compression of the left common iliac vein by the right common iliac artery and the vertebral body, resulting in pain and swelling of the left lower extremity and DVT. A 64‐year‐old woman presented with unexplained edema in the left lower extremity. Computed tomography with contrast enhancement revealed that the left common iliac vein was compressed and narrowed by the right common iliac artery and the vertebral body, leading to the diagnosis of May‐Thurner syndrome., Physicians should be familiar with May‐Thurner syndrome, characterized by the compression of the left common iliac vein by the right common iliac artery and the vertebral body, resulting in pain and swelling of the left lower extremity and DVT.

Takashi Watari,1,2,* Masaki Tago,3,* Kiyoshi Shikino,4 Shun Yamashita,3 Naoko E Katsuki,3 Motoshi Fujiwara,3 Shu-ichi Yamashita3 1General Medicine Center, Shimane University Hospital, Shimane, Japan; 2Master of Healthcare Quality and Patient Safety, Harvard Medical School, Boston, MA, USA; 3Department of General Medicine, Saga University Hospital, Saga, Japan; 4Department of General Medicine, Chiba University Hospital, Chiba, Japan*These authors contributed equally to this workCorrespondence: Masaki TagoDepartment of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, JapanTel +81 952 34 3238Fax +81 952 34 2029Email tagomas@cc.saga-u.ac.jpPurpose: The training of generalist physicians in university hospitals needs to emphasize development of their research role in order to continue improving their research capacity and their standing in academic hospitals in Japan. This cross-sectional descriptive study aimed to survey departments of general medicine (GM) in university hospitals in Japan to identify the research areas and themes pursued by academic generalist physicians.Patients and Methods: The heads of the departments of GM from 71 university hospitals in Japan were enrolled. The main outcomes studied were the identification of the main research areas and themes in academic departments of GM, based on the classification of the National Grants-in-Aid for Scientific Research (KAKENHI): clinical research, public health, preventive medicine, medical education, basic science, health services and safety and quality.Results: We received 47 of 71 replies (66.2% response rate). Clinical research was the most common area of research (62%), followed by public health and preventive medicine (14%), medical education (11%), and basic sciences (9%). Only one department identified health services and safety and quality as a research area (2%). There was marked variability in research areas across the different departments, with 23% of the research targeting the highest specialties, particularly organ-specific research in the fields of gastroenterology, cardiology, immunology, neurology, metabolic endocrinology, and hematology-oncology.Conclusion: The training of generalist physicians in university hospitals needs to emphasize development of their research role in order to continue improving the research capacity and the standing generalist physicians in academic hospitals in Japan.Keywords: general medicine, research, academic activity

Objective No research on infective endocarditis (IE) concerning populations of more than 40 patients from all departments of the hospitals they may have visited in Japan has been conducted since 2000. The present study clarified the status quo of IE in a university hospital in Japan. Methods Data of inpatients of Saga University Hospital with definite IE from September 2007 to August 2017 were retrospectively analyzed. Patients Records of inpatients with diagnosed IE admitted to any department were scrutinized; those with "definite IE" according to the modified Duke's criteria comprised the study cohort. Results The study cohort was 74 patients with a median age 66.5 years old. Symptoms within 2 months before the first visit to our hospital included a fever (73.0%), general malaise (33.8%), disturbance of consciousness (24.3%), and dyspnea (24.3%). High-frequency causative microorganisms were Staphylococcus aureus (28.4%), followed by Streptococcus viridans (18.9%) and Enterococcus spp. (6.8%). The most frequently involved valves were the mitral valve (48.6%), followed by the aortic valve (25.7%) and multiple valves (14.9%). Patients without cardiac murmurs accounted for 37.8%, and those without or with only mild valvular disease accounted for 32.4%. The incidence of complications was 93.2%, and high-frequency complications were central nervous system disorder (60.8%), followed by glomerulonephritis (45.9%) and extracranial embolism (36.5%). Conclusion The incidences of IE without cardiac murmurs and IE without or with only minor valvular disease were higher than those values previously reported in 2000 in Japan. When IE is suspected clinically, clinicians must check thoroughly for common complications, even in patients without cardiac murmurs or valvular disease.

ObjectivesAbdominal pain is one of the most frequent chief complaints in primary care settings. The aim of the present study was to determine the positive likelihood ratios (PLRs) and negative likelihood ratios (NLRs) of the relationships between the sites of abdominal pain and the organs involved.DesignProspective observational study.SettingA single tertiary centre, a university hospital in Japan.ParticipantsA total of 2591 new outpatients visited the Department of General Medicine at a university hospital from April 2017 to March 2018. Of these, 326 patients aged ≥20 years with abdominal pain were enrolled.ResultsSites of abdominal pain were classified into 11 categories including nine different abdominal sections, ‘generalised abdomen’ and ‘site-indeterminate’. The PLRs between ‘right subcostal’ and ‘liver and biliary tract’; between ‘right subcostal’ and ‘musculoskeletal’ ; between ‘epigastric’ and ‘oesophagus, stomach and duodenum’; between ‘right or left flank’ and ‘urinary tract’; between ‘left flank’ and ‘dermatological’; and between ‘mid-lower’ and ‘intestinal’ ranged from 2.17 to 4.14. The PLRs between ‘epigastric’ and ‘urinary tract’; between ‘mid-lower’ and ‘liver and biliary tract’; between ‘periumbilical’ and ‘urinary tract’; and between ‘generalised abdomen’ and ‘oesophagus, stomach and duodenum’ were low, ranging from 0.17 to 0.25. The NLR ranged from 0.5 to 1.5, excluding the relationship between ‘left flank’ and ‘dermatological’.ConclusionThe presence of pain at right subcostal, epigastric, right or left flank and mid-lower sites might be useful for identifying the organs involved. Additionally, the presence of pain at mid-lower, epigastric, periumbilical and generalised abdominal sites might be helpful for denying the involvement of some organs. Some sites of abdominal pain can be indicative of the organs involved.Trial registration numberUMIN000037686

Patient: Female, 70 Final Diagnosis: Infective endocarditis Symptoms: Dyspnea Medication: — Clinical Procedure: — Specialty: Cradiology Objective: Challenging differential diagnosis Background: Infective endocarditis is prevalent worldwide and the modified Duke criteria have been used universally to diagnose this condition. However, making the correct diagnosis is rather difficult because the clinical presentation and findings of blood tests are non-specific. Case Report: A 70-year-old female complaining of dyspnea for 5 days with acute mitral regurgitation was transferred to our hospital. She had acute heart and respiratory failure and disseminated intravascular coagulation. Although infective endocarditis was suspected, repeated blood cultures and transesophageal echocardiography could not reveal any findings of infective endocarditis. Because the etiology of her condition was not determined by various examinations, mitral annuloplasty was required to treat her mitral regurgitation, and was performed for definitive diagnosis and treatment revealing the presence of vegetation on the mitral valve. Enterococcus faecalis was detected by cultures of the mitral valve and blood after the surgery. Conclusions: It can be very difficult to diagnose infective endocarditis correctly, especially when a case fails to fulfill the modified Duke criteria. In such a case, only cardiac surgery might enable us to make an accurate diagnosis and save a patient’s life.

Patient: Female, 88 Final Diagnosis: Adult onset still’s disease Symptoms: Fever • rash Medication: — Clinical Procedure: — Specialty: Rhaumatology Objective: Unusual clinical course Background: Adult-onset Still’s disease (AOSD) is a rare multi-systemic inflammatory disorder of unknown etiology characterized by spiking fever, characteristic rash, and arthritis. It often associates with high serum ferritin levels. Case Report: An 88-year-old woman had fever of over 39°C without response to extended-spectrum antibiotics for 6 days. She had non-specific erythema with infiltration on her trunk. She had leukocytosis with neutrophilia of 80%, mild hepatic dysfunction, normal level of rheumatoid factor and antinuclear antibody, thrombocytopenia, elevated d-dimer and soluble interleukin2 receptor, extremely high serum ferritin (78 662 ng/mL), and splenomegaly. Although she had no arthritis or specific erythema, we made the diagnosis of AOSD according to Yamaguchi’s criteria with disseminated intravascular coagulation (DIC) and hemophagocytic syndrome (HPS) after ruling out infections, malignancies, or other connective tissue diseases. Twelve percent of AOSD patients have HPS. The mean serum ferritin of AOSD with HPS was reported at 18 179 ng/mL, which supported the diagnosis of AOSD because only a few other diseases could show such extremely high serum ferritin. Although she was treated with prednisolone (30 mg/day), her condition deteriorated and her left pleural effusion increased. Therefore, methylprednisolone 500 mg/day for 3 days was started followed by prednisolone 30 mg/day and immunosuppressive agent (Cyclosporine 50 mg/day), which improved her general condition, elevated C-reactive protein levels, and extremely high serum ferritin levels. Conclusions: We report the case of an elderly patient with severe AOSD, who developed HPS and DIC, whose extremely high serum ferritin level was useful in diagnosis.

An 84-year-old man with type 2 diabetes mellitus (DM) started to show involuntary movement in his left fingers 2 months prior to examination, which gradually spread to his left shoulder a month later. He had a history of cerebral infarction and right haemiparesis remained. His haemoglobin A1c (HbA1c

The serious side effects of aminoglycosides and the spread of aminoglycoside-resistant strains have restricted the clinical application of aminoglycosides. A compound with the identical mode of action with aminoglycosides and with different molecular skeleton would be an alternative drug for aminoglycosides. In this study, we constructed an SPR-based high-throughput screening system for the discovery of such compounds.