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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 Ornithine transcarbamylase deficiency (OTCD) is an X-linked semi-dominant disorder, causing possible fatal hyperammonemia. Late-onset OTCD can develop at any time from 2 months after birth to adulthood, accounting for 70% of all OTCDs. CASE REPORT A 35-year-old man with chronic headaches stated that since childhood he felt sick after eating meat. Fourteen days before hospital admission, he began receiving 60 mg/day of intravenous prednisolone for sudden deafness. The prednisolone was stopped 5 days before hospital admission. Four days later, he was transferred to our hospital because of confusion. On admission, he had hyperammonemia of 393 µmol/L. Because he became comatose 7 hours after admission, and his serum ammonia increased to 1071 µmol/L, we promptly started hemodialysis. Because his family history included 2 deceased infant boys, we suspected late-onset OTCD. On day 2 of hospitalization, we began administering ammonia-scavenging medications. Because he gradually regained consciousness, we stopped his hemodialysis on day 6. After his general condition improved, he was transferred to the previous hospital for rehabilitation on day 32. We definitively diagnosed him with late-onset OTCD due to the low plasma citrulline and high urinary orotic acid levels found during his hospitalization. CONCLUSIONS Clinicians should suspect urea cycle disorders, such as OTCD, when adult patients present with marked hyperammonemia without liver cirrhosis. Adult patients with marked hyperammonemia should immediately undergo hemodialysis to remove ammonia, regardless of causative diseases.

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.

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 Hiroyuki Nagano,2 Taku Harada,3 Taiju Miyagami,4 Kosuke Ishizuka,5 Masatomi Ikusaka5 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan; 3Division of General Medicine, Showa University Koto Toyosu Hospital, Tokyo, Japan; 4Department of General Medicine, Faculty of Medicine, Juntendo University, Tokyo, Japan; 5Department of General Medicine, Chiba University Hospital, Chiba, JapanCorrespondence: Shun Yamashita, Department of General Medicine, Saga University Hospital, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81952343238, Fax +81952342029, Email sy.hospitalist.japan@gmail.comAbstract: 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.Keywords: general medicine, outpatient, diagnostic capability, education, difficult diagnosis, branding

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.

Shun Yamashita,1 Masaki Tago,1 Midori Tokushima,2 Sei Emura,2 Shu-Ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Saga Medical Career Support Center, Saga University Hospital, Saga, JapanCorrespondence: Shun Yamashita, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81952343238, Fax +81952342029, Email sy.hospitalist.japan@gmail.comPurpose: 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.Keywords: medical student, initial clinical training, university hospital, community hospital, questionnaire, cross-sectional study

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.

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