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Yoshinori Tokushima,1,2 Masaki Tago,1,2 Midori Tokushima,1,3 Shun Yamashita,1 Yuka Hirakawa,1 Hidetoshi Aihara,1 Naoko E Katsuki,1 Motoshi Fujiwara,1 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Community Medical Support Institute, Faculty of Medicine, Saga University, Saga, Japan; 3Saga Medical Career Support Center, Saga University Hospital, Saga, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jpIntroduction: 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.Keywords: general medicine, hands-on clinical clerkship, medical education, observation-based training

Risa Hirata,1 Masaki Tago,1 Naoko E Katsuki,1 Yoshimasa Oda,2 Midori Tokushima,1 Yoshinori Tokushima,1 Yuka Hirakawa,1 Shun Yamashita,1 Hidetoshi Aihara,1 Motoshi Fujiwara,1 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Department of General Medicine, Yuai-Kai Foundation and Oda Hospital, Saga, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81-952-34-3238, Fax +81-952-34-2029, Email tagomas@cc.saga-u.ac.jpIntroduction: In our former study, we had validated the previously developed predictive model for in-hospital falls (Saga fall risk model) using eight simple factors (age, sex, emergency admission, department of admission, use of hypnotic medications, history of falls, independence of eating, and Bedriddenness ranks [BRs]), proving its high reliability. We found that only admission to the neurosurgery department, history of falls, and BRs had significant relationships with falls. In the present study, we aimed to clarify whether each of these three items had a significant relationship with falls in a different group of patients.Methods: This was a single-center based, retrospective study in an acute care hospital in a rural city of Japan. We enrolled all inpatients aged 20 years or older admitted from April 2015 to March 2018. We randomly selected patients to fulfill the required sample size. We performed multivariable logistic regression analysis using forced entry on the association between falls and each of the eight items in the Saga fall risk model 2.Results: A total of 2932 patients were randomly selected, of whom 95 (3.2%) fell. The median age was 79 years, and 49.9% were men. Multivariable analysis showed that female sex (odds ratio [OR] 0.6, 95% confidence interval [CI] 0.39– 0.93, p = 0.022), having a history of falls (OR 1.9, 95% CI 1.16– 2.99, p = 0.010), requiring help with eating (OR 1.9, 95% CI 1.12– 3.35, p = 0.019), BR of A (OR 6.6, 95% CI 2.82– 15.30, p < 0.001), BR of B (OR 7.5, 95% CI 2.95– 19.06, p < 0.001), and BR of C (OR 4.1, 95% CI 1.53– 11.04, p = 0.005) were significantly associated with falls.Conclusion: History of falls and BRs were independently associated with in-hospital falls.Keywords: bedridden, Bedriddenness ranks, fall, predictive model, validation, Saga fall risk model 2

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.

BACKGROUND In 2019, we developed a predictive formula of in-hospital mortality for inpatients aged ≥65 years transported by ambulance for endogenous diseases. In this study, we aimed to validate this previously developed predictive formula. MATERIAL AND METHODS In this single-center prospective observational study, we enrolled all patients aged ≥65 years who were transported by ambulance and admitted to an acute care hospital in Japan for endogenous diseases. We calculated the score according to our developed formula using age, disturbance of consciousness, the shock index, and amount of oxygen administered, with each item scoring 1 point and then totaling them. We subsequently evaluated the in-hospital mortality rate, stratum-specific likelihood ratio, and area under the receiver operating characteristic curve (AUC) of the formula, using in-hospital mortality as the primary outcome. RESULTS In total, 325 patients were included in this study. Forty-two patients died during hospitalization. Multivariable logistic regression analysis (forced-entry method) revealed that disturbance of consciousness and oxygen administration 5 L/min or more were significantly associated with mortality during hospitalization. In contrast, aged ≥90 years and shock index of 1 or higher were not significant. The mortality and stratum-specific likelihood ratios for scores in the predictive formula of 3 and 4 were 40.9% and 4.66, and 66.7% and 13.48, respectively. The AUC of the predictive formula for in-hospital mortality was 0.670 (95% confidence interval: 0.574-0.767). CONCLUSIONS This study showed that our predictive formula, consisting of factors available immediately after ambulance transport in older patients, is feasible with sufficient discrimination ability and reliability.

An 80‐year‐old man who presented with only lower anterior chest pain was diagnosed as sigmoid colon diverticulitis. His chest pain was considered to be referred pain from a disease at sigmoid colon, which should be suspected when other major causes of chest pain are excluded., Lower chest pain due to referred pain can rarely occur as the only symptom in patients with sigmoid colon diverticulitis. When evaluating patients with lower chest pain, try to examine abdomen carefully after ruling out major causes of chest pain.

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.

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

A 40‐year‐old man with bilateral hilar lymphadenopathy in chest X‐ray and the λ‐sign in gallium‐67 scintigraphy was subsequently diagnosed with systemic sarcoidosis according to the findings of bronchoalveolar lavage and histopathological examinations of transbronchial lung biopsies. Identifying the λ‐sign could be a valuable clue to the early diagnosis of sarcoidosis., The λ‐sign strongly suggests the diagnosis of sarcoidosis because all reported patients with the λ‐sign were subsequently diagnosed as having sarcoidosis. Identifying the λ‐sign with gallium‐67 scintigraphy could be a valuable clue to the early diagnosis of sarcoidosis.

A 67-year-old man visited our hospital for fever lasting 1 week, sore throat and appetite loss. He was a current smoker (50 pack-years), had no other particular medical history and was taking no medications. On the first visit, he had no fever, abnormalities in vital signs or physical examination

Objective This study was designed to compare the association between the body mass index (BMI) and symptoms of gastroesophageal reflux disease (GERD) in allegedly normal subjects undergoing regular medical checkups and subjects diagnosed with non-alcoholic fatty liver disease (NAFLD). Additionally, the correlation between the BMI and GERD symptoms was evaluated in subjects with NAFLD. Methods This study included 50 patients with NAFLD and 228 normal subjects evaluated during regular medical checkups. The height, weight, BMI, frequency scale for the symptoms of GERD (FSSG), and serum concentrations of triglycerides and γ-GTP were compared between the two groups. In the NAFLD group, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) concentrations were measured and insulin resistance was calculated using the quantitative insulin sensitivity check index (QUICKI). Results The total FSSG score moderately correlated with the BMI in the NAFLD group (r=0.342, p=0.015), but correlated negatively in the control group (r=-0.014, p=0.831). The FSSG score in the NAFLD group also negatively correlated with the AST/ALT ratio (r=-0.319) and insulin resistance calculated using the QUICKI score (r=-0.288). The BMI in the NAFLD group moderately correlated with the acid-reflux related score on the FSSG (r=0.389), and both the AST/ALT ratio (r=-0.344) and QUICKI score (r=-0.330) negatively correlated with the dyspepsia score on the FSSG. Conclusion Obesity evaluated by the BMI was a significant risk factor for the exacerbation of GERD symptoms in subjects with NAFLD.