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Abstract Background Internet reviews have become increasingly crucial for both healthcare providers and patients. Electronic word-of-mouth (eWOM) reviews on internet sites often comprise textual content with numerical ratings. In this study, we aimed to identify the evaluation factors of community healthcare institutions regarding eWOM reviews and the impact of each evaluation factor on the institution’s ratings. Methods An observational study was conducted to qualitatively and quantitatively analyse eWOM data posted on Google for randomly selected healthcare institutions in Hirosaki, Japan from September to October 2022. For qualitative data, the authors repeatedly read the eWOM text, coded it, and categorised related sections. For quantitative analysis, a multivariate analysis using a linear regression model was conducted with the categorised factors from the qualitative analysis as explanatory variables and eWOM ratings as response variables. Results Twenty medical institutions (two hospitals and 18 clinics) were randomly extracted from the registry. A total of 147 eWOM texts from each institution were analysed, and coding was performed for 474 segments in the texts. In the qualitative analysis, the evaluated factors in eWOM texts for medical institutions were categorised as communication (evaluation factor for communication with healthcare providers), clinical practice (evaluation factor for the clinical practice of healthcare providers), and medical institution (evaluation factor for the characteristics of medical institutions). According to the multiple regression analysis, the partial regression coefficients for the explanatory variables of positive communication, clinical practice, and medical institution evaluations were 1.04 (95% confidence interval 0.70 to 1.39), 0.65 (95% confidence interval 0.27 to 1.04), and 0.75 (95% confidence interval 0.35 to 1.15), respectively, with the number of ratings as the response variable. Partial regression coefficients for the explanatory variables of negative communication, clinical practice, and medical institution evaluations were − 1.52 (95% confidence interval − 1.88 to -1.16), -0.90 (95% confidence interval − 1.28 to -0.52), and − 0.24 (95% confidence interval − 0.60 to 0.12), respectively. Conclusion We quantitatively and qualitatively analysed the eWOM reviews and ratings of healthcare institutions posted on Google. Three evaluation factors were identified: communication, clinical practice, and medical institution. Our study revealed that communication significantly impacts ratings.

Abstract Unilateral absence of the pulmonary artery (UAPA) is a rare congenital condition. When UAPA occurs without associated congenital heart disease, it is referred to as isolated unilateral absence of the pulmonary artery (IUAPA). IUAPA is frequently not diagnosed until adulthood. A 61‐year‐old female patient presented with right chest pain and a worsening interstitial shadow over 9 years. Contrast‐enhanced computed tomography revealed the absence of blood flow from the pulmonary artery in the right lung, leading to the diagnosis of IUAPA. In this case, the diagnosis of UAPA was established after approximately 40 years. This case underscores the importance of identifying vascular abnormalities to differentiate this condition in patients presenting with nonspecific symptoms and interstitial shadows.

Hemiplegic migraine is a rare form of migraine characterized by aura with unilateral paralysis; however, studies on its treatment are limited. A 39-year-old man with migraine headaches and myofascial pain syndrome was referred to our hospital with transient right hemiplegia, after presenting to an outside emergency department with headache and right hemiplegia 2 days prior. Computed tomography, magnetic resonance imaging, and blood test results revealed no abnormalities. The symptoms resolved spontaneously; he was referred to our hospital. Based on the International Classification of Headache Disorders, Third Edition criteria, he was diagnosed with sporadic hemiplegic migraine. Propranolol was added to his regular regimen as prophylactic treatment, which resulted in reduction in his migraine frequency. Over the next 2 years, no recurrent paralysis occurred. Hemiplegic migraines should be considered in patients with migraine exhibiting transient hemiplegia without obvious intracranial abnormalities. Prophylactic treatment with propranolol could be effective in treatment of hemiplegic migraine.

A 53-year-old otherwise healthy man was referred to our hospital with a fever of unknown origin, headache, and arthralgia. Four days earlier, he had a fever with chills. Treatment with antibiotics and acetaminophen proved ineffective, with the patient subsequently developing headache and joint pain. Blood analysis revealed elevated inflammatory markers, liver impairment, and severe thrombocytopenia (platelet count, 19,000/μL). Subsequent tests revealed elevated levels of anti-cytomegalovirus IgM and IgG. Based on these findings, the patient was diagnosed with severe thrombocytopenia associated with cytomegalovirus infection. Platelet counts increased spontaneously without antiviral therapy. Forty-five days after the initial visit, the symptoms improved, and blood tests revealed resolution of the inflammatory findings, with the platelet count recovering to 155,000/μL. Although the disease may resolve spontaneously, cytomegalovirus infection should be considered as a differential diagnosis in case of severe thrombocytopenia in immunocompetent adults.

Abstract Nintedanib reduces the decline in forced vital capacity and extends the time to the first acute exacerbation of interstitial lung disease (AE-ILD). However, the effect of additional nintedanib administration after AE-ILD onset is unknown. This study aimed to investigate the efficacy and safety of nintedanib administration after AE-ILD development. We retrospectively collected the data of 33 patients who developed AE-ILD between April 2014 and January 2022. Eleven patients who received nintedanib after AE-ILD development and the remaining who did not were classified into the N and No-N groups, respectively. The survival time in the N group tended to be longer than that in the No-N group. The generalized Wilcoxson test revealed that the cumulative mortality at 90 days from AE-ILD onset was significantly lower in the N group. The time to subsequent AE-ILD development was significantly longer in the N group than that in the No-N group. The incidence of adverse gastrointestinal effects and liver dysfunction in the N group was 9–18%. Treatment without nintedanib after AE-ILD development and the ratio of arterial oxygen partial pressure to fractional inspired oxygen were significant independent prognostic factors in the multivariate analysis. Thus, nintedanib administration may be a treatment option for AE-ILD.

A 51-year-old otherwise healthy woman was referred to our hospital with a fever of unknown origin, liver dysfunction, and anemia. One month prior, she had persistent and spontaneous anterior neck pain, with no exacerbation during swallowing or neck movements. Physical examination revealed no pharyngeal or tonsillar abnormalities, heart murmur, arthritis, skin rash, or lymphadenopathy, except for mild bilateral common carotid artery tenderness at the level of the thyroid cartilage. Blood tests showed nonspecific chronic inflammatory findings, anemia, and liver damage, whereas blood cultures, viral antibodies, interferon-γ release assay, and antibodies specific for any collagen disease showed negative results. Echocardiography and computed tomography without contrast of the neck, chest, abdomen, and pelvis showed no apparent abnormalities. She was subsequently diagnosed with Takayasu arteritis using positron emission tomography. Identifying a characteristic history of bilateral carotid artery tenderness and subsequent positron emission tomography can be useful for diagnosing Takayasu arteritis.

Introduction Children’s influenza diagnosis by their guardians has been reported to be highly accurate, but clinical factors that improve the reliability of a guardian’s diagnosis are unclear. Aim To determine the accuracy of guardians’ influenza diagnosis of their children, investigate clinical factors that improve the diagnostic accuracy, and determine the additional clinical value of the guardian’s diagnosis. Methods A prospective observational study was conducted at a primary care clinic in Japan from December 2017 to April 2019. Pre-examination checklists completed by guardians accompanying children aged

Abstract This study aimed to verify the effectiveness of a 48‐h independent power outage system, evaluate the indoor thermal environment under power outage conditions, and improve residential awareness of disasters through a power outage experience. A power outage experiment was conducted in a collective residence with a 48‐h independent power system. The available power for each dwelling unit was limited based on the type of heat source, at 700 and 1200 W for cogeneration (CG) and solid oxide fuel cell (SOFC) heating, respectively. The power supply was halted when the available power limit was exceeded. During the experiment, the thermal environment, temperature, humidity, amount of power generated by the CG and SOFC, and load power of the dwelling units were analyzed. We also conducted a questionnaire survey to evaluate the indoor environment and infrastructure. The results showed that home appliances could be used because all dwelling units were supplied with sufficient power, at 700 and 1200 W. The most important appliances were electric fans, refrigerators, lighting, mobile phones, and computer chargers. Therefore, the experiment demonstrated that a comfortable evacuation living condition can be realized by using CG and SOFC during a power outage in the summer.

Abstract A 30‐year‐old man was referred to our department because of repeated acute‐onset and short‐lasting fatigue attacks, which occurred from 3 months before the referral. He had no abnormal findings in blood tests, electrocardiogram (including 24‐ h monitoring), or head MRI (including angiography). His vital signs were unremarkable, and his physical examination revealed no abnormal findings. Detailed history‐taking with closed‐ended questions revealed the occurrence of tingling sensation from the right fingers as the aura before his attacks. Electroencephalography was performed, which revealed focal epilepsy. Levetiracetam resolved his symptoms. Physicians could consider non‐convulsive epilepsy as a potential cause of repeated acute‐onset and short‐lasting fatigue attacks of unknown etiology after underlying conditions, such as metabolic diseases, have been ruled out.

A 33-year-old man was referred to our hospital with chief complaints of fever, dizziness, and headache. Although he had recurring fever and dizziness for 7 months, neurological examination, magnetic resonance imaging, computed tomography, electrocardiograms, and blood tests were normal. He was diagnosed with functional hyperthermia, cervical vertigo, and tension headache and was treated with oral medication and physical therapy. After treatment, the dizziness and headache resolved; however, the fever and anxiety did not. During follow-up, he noticed differing results from different electronic thermometers. The physician decided to use an accurate analog thermometer, a gallium thermometer, in combination with the other thermometers. The results differed significantly among the thermometers, and the electronic thermometer readings were found to be inappropriately high. The physician made a diagnosis of pseudo-fever, and the patient recognized that the gallium thermometer’s results were the most accurate reflection of his physical condition, resolving his anxiety.

Abstract A 17‐year‐old female patient presented to our hospital with repeated transient loss of consciousness lasting less than 10 min. After regaining consciousness, she experienced no disorientation, confusion, tongue‐biting, or incontinence. Physical findings, blood tests, electrocardiogram, and echocardiogram showed no obvious abnormalities. On being asked whether she had experienced sudden rapid body movements, she answered “yes.” Therefore, we suspected juvenile myoclonic epilepsy (JME) and obtained an electroencephalogram, which showed diffuse bilateral bursts of spike‐and‐wave complexes, confirming the diagnosis. In adolescent patients with transient loss of consciousness, myoclonic jerks should be actively confirmed for the diagnosis of JME.

Abstract Raynaud's phenomenon, induced by cold stimulation and emotional stress, is also induced by whole‐body warm stimulation. A 74‐year‐old man was referred to our department because of nocturnal toe pain from 2 years prior and immediate color change of the toes from 1 year prior when submerging himself into a warm bath. Physical examination and blood tests revealed no abnormal findings suggestive of secondary Raynaud's phenomenon. Two years later, the signs and symptoms persisted. When physicians confirm Reynaud's phenomenon, they should check for the possibility of secondary Reynaud's phenomenon. Additional research on Reynaud's phenomenon induced by warm stimulation is needed.

A 47-year-old farm worker with diabetes mellitus, dyslipidemia, and hyperuricemia was referred to our hospital for a 3-month history of fever and malaise. He had no respiratory tract or abdominal symptoms, skin rashes, or joint pain. There was no change to his regular medication or pesticide exposure. Blood tests and echocardiography revealed no abnormalities. Whole-body computed tomography revealed a fatty liver; however, non-alcoholic steatohepatitis was excluded. We diagnosed the patient with functional hyperthermia. He had a history of snoring and weight gain, and we suspected the obstructive sleep apnea syndrome to be a stressor. Polysomnography revealed severe obstructive sleep apnea syndrome with an apnea–hypopnea index of 44.5. Continuous positive airway pressure was introduced; the axillary temperature decreased gradually and malaise was resolved. Functional hyperthermia should be considered a cause of fever with a negative inflammatory response. Obstructive sleep apnea syndrome can be a stressor for functional hyperthermia, which can be improved by interventions.

Objective To elucidate the diagnostic accuracy of pretest probability of influenza (%) by physicians and the factors affecting the clinical diagnosis.Design Retrospective, single-centre observational study.Setting A community primary care clinic in Japan.Participants The participants were recruited from a database of studies conducted during the influenza season from December 2017 to April 2019.Primary outcome measure Sensitivity and specificity of the physician’s clinical diagnosis of influenza recorded in the medical record as pretest probability.Results A total of 335 patients (median age, 31 years; male, 66.6%) were analysed in this study. The area under the curve (AUC) of the physician’s pretest probability was 0.77. At a cut-off value of 30%, the sensitivity and negative likelihood ratio were 92.0% (95% CI 86.7 to 95.7) and 0.19 (95% CI 0.11 to 0.33), respectively. At a cut-off value of 80%, the specificity and positive likelihood ratio were 90.8% (95% CI 85.4 to 94.6) and 4.01 (95% CI 2.41 to 6.66), respectively. The AUCs of patients who had and had not taken any medications before visiting the clinic were 0.77 (95% CI 0.69 to 0.85) and 0.78 (95% CI 0.71 to 0.84), respectively. The AUCs of patients with type A and B influenza were 0.78 (95% CI 0.72 to 0.84) and 0.76 (95% CI 0.70 to 0.82), respectively. The AUCs of vaccinated and unvaccinated patients were 0.80 (95% CI 0.72 to 0.88) and 0.76 (95% CI 0.63 to 0.89), respectively. The AUC for patients less than 12 hours after onset was 0.69 (95% CI 0.51 to 0.88), and that for patients aged younger than 6 years was 0.69 (95% CI 0.49 to 0.88).Conclusions The physician’s pretest probability of influenza (%) may be useful for both definitive and exclusionary diagnoses within the limits of our study.

Abstract Background Acute hip pain caused by femoral proximal fractures or acute hip arthritis requires imaging for accurate diagnosis. Although pocket-sized ultrasound (PsUS) offers several advantages over other imaging modalities, there is limited information regarding its use in diagnosing femoral proximal fractures or acute hip arthritis. Thus, we aimed to validate the diagnostic accuracy of PsUS for both disorders. Methods In this prospective observational study, outpatients with acute hip pain were diagnosed according to a fixed procedure of the PsUS probe handling. We verified the diagnostic accuracy of PsUS findings (cortical discontinuity and joint fluid retention) and compared it with that of radiography, computed tomography, and magnetic resonance imaging. Results Our study included 52 outpatients (mean age, 78.0 years; female, 88.5%). Of 26 patients diagnosed with femoral proximal fractures, 14 had femoral neck fractures and 12 had femoral trochanteric fractures. The sensitivity and specificity for identifying cortical discontinuity in femoral proximal fractures were 0.96 and 0.92, respectively. The sensitivity for identifying either cortical discontinuity or joint fluid retention in femoral proximal fractures or acute hip arthritis was 0.97. Conclusions Negative PsUS findings of cortical discontinuity and joint fluid retention in the hip are useful for ruling out femoral proximal fractures and acute hip arthritis. PsUS and radiography have comparable diagnostic accuracies, and PsUS could aid in the initial assessment of acute hip pain among the elderly in primary care settings.

A 22-year-old woman was admitted to the hospital with complaints of headache and vomiting. Radiological examinations revealed cerebral sinus venous thromboses, pulmonary thromboembolism, and cavities in the left upper lung. Pulmonary tuberculosis was diagnosed based on sputum and gastric aspirate culture. Heparin followed by warfarin was administered. Anti-tuberculosis agents including rifampicin were also initiated. Since the effect of warfarin did not reach the therapeutic level because of interaction with rifampicin, edoxaban was administered and thromboses were ameliorated. This report illustrates rare thrombotic complications in a TB-induced hypercoagulable state and the potential benefits and safety of edoxaban in combination with rifampicin.

Abstract A 35‐year‐old woman presented with recurrent vertigo without headache, which had persisted for 10 years. Detailed medical history revealed that she experienced hearing loss, tinnitus, nausea, photophobia, phonophobia, and slight discomfort in the head during vertigo attacks, which often led to absence from work. Based on the diagnostic criteria of the International Classification of Headache Disorders, third edition, she was diagnosed with vestibular migraine and was prescribed lomerizine, as prophylaxis. Her symptoms markedly improved, enabling her to go to work. Accurate diagnosis and treatment are important for improving the quality of life of patients, since vestibular migraine is commonly underdiagnosed.

A 54-year-old man was referred to our hospital with painful rashes on the extremities. He also developed polyarthritis and pitting pedal edema. Blood tests showed no specific autoantibodies and were negative for human leukocyte antigens B51, B15, and B27. Lower extremity venous ultrasonography and computed tomography angiography showed no vascular disorders. Skin biopsy showed no evidence of thrombosis or vasculitis. Direct fluorescence antibody analysis showed no antibody or complement deposition. Joint ultrasonography showed mild synovial thickening and/or synovial effusion in the extremities. Non-steroidal anti-inflammatory drugs and topical steroids were administered, followed by oral steroids. However, the signs and symptoms did not improve. Oral steroids were discontinued, and colchicine (0.5 mg/day) was administered. Thereafter, the symptoms of arthritis improved, and no skin rash developed. In potentially inflammatory conditions with skin rash, edema, and polyarthritis that are difficult to diagnose, low-dose colchicine administration may be considered for prompt relief of symptoms.

Introduction. Children’s influenza diagnosis by their guardians has been reported to be highly accurate, but clinical factors that improve the reliability of a guardian’s diagnosis are unclear. Aim. To determine the accuracy of guardians’ influenza diagnosis of their children, investigate clinical factors that improve the diagnostic accuracy, and determine the additional clinical value of the guardian’s diagnosis. Methods. A prospective observational study was conducted at a primary care clinic in Japan from December 2017 to April 2019. Pre-examination checklists completed by guardians accompanying children aged <12 years with clinically suspected influenza were analysed. Receiver-operating characteristic curve analysis was performed to evaluate the diagnostic accuracy at multiple cut-off points and to compare the area under the curve (AUC), using a rapid influenza diagnostic test as the reference standard. Multivariable logistic regression was performed to validate additional contribution of guardians’ diagnosis. Results. A total of 112 patient pairs of child (median age, 6 years) and guardian (mother, 81.2%; father, 16.1%; grandmother, 1.8%; other, 0.9%) were included in the analysis. The AUC for guardians’ influenza diagnosis was higher in mothers (0.72), as well as pairs with children with a history of influenza (0.72), guardians who were aware of the influenza epidemic (0.71), and unvaccinated children (0.76), than in other guardians. After multivariate analysis, the AUC increased significantly from 0.79 to 0.85. Discussion. Guardians’ influenza diagnosis for their children was highly accurate. We identified factors that improve the accuracy of the guardians’ diagnosis and demonstrated that the guardians’ diagnosis can support physicians’ diagnostic accuracy. [ABSTRACT FROM AUTHOR]