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The aim of this study was to examine whether the distance between the skin and the renal pelvis affects the detection of costovertebral angle (CVA) tenderness in patients with acute focal bacterial nephritis (AFBN).We retrospectively reviewed the charts of our patients between April 2013 and June 2019 who were diagnosed as having AFBN. Diagnosis was based on ultrasound or computed tomography with contrast, revealing at least one wedge-shaped area of decreased vascularity and confirmation of fever not attributable to another condition.We extracted 23 cases, all Japanese (mean age 60.0 years old [range 45-81 years], 7 males, 16 females). CVA tenderness was present in 8 of these 23 patients. Receiver operating characteristic curves were drawn to evaluate the ability to differentiate skin-to-renal pelvis distance (SPD), body mass index, and age. Only SPD was a useful predictor of CVA tenderness, and 66 mm was determined as the optimal cutoff point (area under the receiver operating characteristic curve 0.858, 95% confidence interval 0.70-1.00). Logistic regression analysis was performed with CVA tenderness as a dependent variable, and SPD, body mass index, and age as explanatory variables. SPD was an independent predictive variable of CVA tenderness (CVA tenderness showed low yield in the diagnosis of AFBN in patients with longer SPD. Its use for diagnosis in obese patients may therefore be limited.

Objective This study evaluated the effectiveness of a multidisciplinary team deprescribing intervention to reduce polypharmacy and potentially inappropriate medications (PIMs) in elderly orthopedic inpatients. Methods In this single-center retrospective observational study, orthopedic inpatients ≥75 years old and prescribed ≥6 different medications were enrolled as participants. Interventions comprised multidisciplinary team-led polypharmacy screening and suggestions regarding deprescribing any unnecessary medications during hospital stays. The primary outcome was reduction in the mean number of regular medicines and PIMs. Secondary outcomes included falls, delirium, and other adverse events during hospitalization as well as emergency department visits or unplanned hospital admissions within six months after discharge. Results After propensity score matching, 184 patients (intervention group, n=92; control group, n=92) were included in the analysis. The mean patient age was 83 years old. The mean number of prescribed medications and PIMs at admission were similar in both groups. The mean change in the number of regular medicines was -1.4 [standard deviation (SD), 2.3] in the intervention group and +0.2 (SD, 1.8) in the control group (p0.001). The mean change in the number of PIMs was -0.5 (SD, 0.9) in the intervention group and +0.1 (SD, 0.8) in the control group (p0.001). In-hospital adverse events other than falls and delirium were significantly less common in the deprescribing intervention group than in the control group. Conclusion Deprescribing intervention by our multidisciplinary team seems to have been effective in reducing the number of prescribed medicines and PIMs in elderly orthopedic inpatients, with some accompanying reduction in certain adverse events.

Taiju Miyagami,1 Toru Yamada,2 Yohei Kanzawa,3 Shunsuke Kosugi,4 Kazuya Nagasaki,5 Hiroyuki Nagano,6 Taro Shimizu,7 Kazutoshi Fujibayashi,1 Gautam A Deshpande,1 Toshio Naito1 1Department of General Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan; 2Department of Family Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan; 3Department of General Internal Medicine, Akashi Medical Center, Hyogo, Japan; 4Department of General Internal Medicine, Iizuka Hospital, Iizuka, Fukuoka, Japan; 5Department of Internal Medicine, Mito Kyodo General Hospital, Ibaraki, Japan; 6Emergency Medicine and General Internal Medicine, Rakuwakai Marutamachi Hospital, Kyoto, Japan; 7Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital, Tochigi, JapanCorrespondence: Toru YamadaDepartment of Family Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 1138519, Japan, Tel +81 3 5803 5229, Fax +81 3 5803 0276, Email toru.y.fmed@tmd.ac.jpPurpose: To identify the current ambiguous status of general medicine (GM) and assess current problems and weaknesses for further development of GM.Patients and Methods: This study adopted an observational design. GM practitioners were selected from the mailing lists of two primary professional associations for Japanese GM doctors. We included physicians currently working in a GM department, those self-described as GM doctors, and those board-certified in family medicine or general internal medicine. Respondents replied to survey questions about their sociodemographic data, job descriptions, and the requisite skills for practice. GM doctors’ job description and required skills were categorized into “clinical,” “management,” “education,” and “research.” Participants (n = 971) were compared based on job descriptions and important skills in each category by facility type, size, and position.Results: “Clinical” was indicated as the most important category for both job description and important skills, followed by “management,” “education,” and “research.” For job description details, “follow-up outpatient” (35.6%) ranked first for “clinical,” and “resident education” (57.3%) ranked first for “education.” By facility type and size, job description and important skills decreased for clinical and management categories as facility sizes increased; the opposite was true for “education.” “Research” was generally rated low. By position, no significant difference was found in effort or importance given to research.Conclusion: This study is the first survey on GM physicians across Japan. The results show that while Japanese GM physicians focus on and place importance on clinical practice, they are less involved in research and do not consider research skills to be important. The challenge for the future development of GM lies in research.Keywords: general medicine doctors, job description, observational study, research skills

Hemolytic anemia is a rarely occurring manifestation of native valve infective endocarditis. We herein report an afebrile patient with hemolytic anemia caused by Cardiobacterium hominis endocarditis. A 60-year-old Japanese man had a history of aortic root replacement and the gradual onset of general fatigue. He had hemolytic anemia. Blood cultures detected C. hominis. A transthoracic echocardiogram showed aortic valve vegetation and periannular abscess with perforation of the non-coronary cusp. Intravascular hemolysis recovered after antimicrobial therapy, surgical removal of the vegetation and abscess, and aortic valve replacement. Subacute endocarditis should be considered if patients develop hemolytic anemia with signs of chronic inflammation without a fever.

Background: An increased focus on quality and patient safety led to the evolution of the hospitalist specialty. The number of hospitalists, who cover ward and outpatient care, is on the rise in Japan. However, it is unclear what roles hospitalists themselves consider important in their practice. Therefore, this study aimed to investigate what hospitalists and non-hospitalist generalists in Japan consider important for the practice of their specialty. Methods:This was an observational study that included Japanese hospitalists (1) currently working in a general medicine (GM) or general internal medicine department and (2) working at a hospital. Using originally developed questionnaire items, we surveyed what they think are important to hospitalists and what are important compared to that for non-hospitalist generalists. Results: There were 971 participants (733 hospitalist, 238 non-hospitalist) in the study. The response rate was 26.1％. Both hospitalists and non-hospitalists ranked evidence-based medicine as most important for their practice. Hospitalists ranked diagnosis and patient management as the second and third most important roles for their practice while non-hospitalists ranked patient management and elderly care as second and third. Conclusions: This is the first study investigating what roles Japanese hospitalists consider important and compare those to that of non-hospitalist generalists. Many of the items that hospitalists responded to that they actually consider important were those that hospitalists in Japan are actually working on within and outside of academic societies. We found that diagnostic medicine, and quality and safety are likely to be evolved by hospitalists because they specifically emphasized them, while the care of the elderly is an issue that hospitalists should be more concerned about. Future expected research includes proposals on how to further enhance items that hospitalists emphasize and should focus on, as well as international comparisons regarding the items.

Serotonin syndrome is a potentially life‐threatening adverse reaction from therapeutic drug use, intentional self‐poisoning, or inadvertent interactions between drugs. We report a case of the serotonin syndrome after an overdose of a commonly available over‐the‐counter cough medicine, Shin CONTAC sekidome daburu jizokusei. Over‐the‐counter drugs containing dextromethorphan may, in rare cases, cause health problems requiring hospitalization or worse. An appropriate explanation from the pharmacist at the time of purchase, although not mandatory, is recommended.

Introduction This study aimed to clarify the accuracy of an in‐hospital mortality prediction score for patients with hypothermia. The score consists of five variables (age ≥70 years, mean arterial pressure 1.5 mg/dL, and confusion). In contrast to the previously reported population in southern Israel, a desert climate, we apply the score system to a Japanese humid subtropical climate. Methods The study included patients with a principal diagnosis of hypothermia who were admitted to our community hospital between January 2008 and January 2019. Using the medical records from initial visits, we retrospectively calculated in‐hospital mortality prediction scores along with sensitivity and specificity. Results We recruited 69 patients, 67 of which had analyzable data. Among them, the in‐hospital mortality rate was 25.4%. Hypothermia was defined as mild (32‐35°C) in 34 cases (50.7%), moderate (28‐32°C) in 23 cases (34.3%), and severe (, The in‐hospital mortality prediction scores showed slightly less predictive values compared with those in the previous report. With modifications, the score could however be efficiently applied in such a climate.

Our patient had appendicitis complicated by Chlamydia trachomatis‐induced Fitz‐Hugh‐Curtis syndrome and cervicitis. Differential diagnosis was challenging. A 22‐year‐old Japanese woman was febrile and presented with vomiting and subsequent abdominal pain. She had unprotected sexual intercourse with multiple partners. She had high Alvarado score and lack of cervical motion pain, despite cervical inflammation. Noncontrast CT showed enlarged appendix. Laparoscopic appendectomy revealed acute suppurative appendicitis and perihepatic adhesion. Cervical PCR assay was positive for C. trachomatis. She remained febrile but defervesced after azithromycin therapy. Clinicians should confirm whether females with abdominal pain are sexually active in view of screening for C. trachomatis., Fitz‐Hugh‐Curtis syndrome (FHCS) rarely occurs concurrently with appendicitis, but it can be a differential diagnosis, especially when the clinical course could not be explained by appendicitis alone, as in our patient.

Objective Kikyo-to (KKT) is a fixed combination of glycyrrhiza root and platycodon root extracts. It is an herbal medicine traditionally used in Japan for relieving sore throat associated with acute upper respiratory tract infection (URTI). No controlled studies have yet demonstrated its effect, however. We investigated the efficacy of KKT on sore throat associated with acute URTI. Methods Patients with sore throat who were diagnosed with URTI at the General Medicine Department Office, Akashi Medical Center Hospital, between December 2017 and May 2018 were enrolled. Participants were randomly assigned to two groups at a 1:1 ratio, with stratification by age and sore throat score on a Visual Analogue Scale (VAS), to receive 2.5 g of either KKT or a placebo. Participants and investigators were blinded to group allocation. The primary outcome was the change in sore throat score on VAS 10 minutes after KKT administration. Secondary outcomes were the impact of the sore throat on daily life (none, mild, moderate, and severe) at 10 minutes after administration. Results Thirty-five participants were assigned to each group (n=70, total). The difference in the mean change of sore throat score according to VAS within 10 minutes between the two groups was not statistically significant (KKT 14.40 vs. placebo 17.00; p=0.39). The proportion of patients with a moderate or greater impact of their sore throat on their daily life was also not significantly different between the groups (KKT 22.9% vs. placebo 40.0%; p=0.20). Patients reported no side effects. Conclusion KKT did not significantly relieve sore throat associated with acute URTI compared with placebo.

We herein report a patient with syphilitic cervicitis and cervical cancer presenting as oropharyngeal syphilis. A 31-year-old Japanese woman with a history of unprotected vaginal and oral sex visited our hospital with right submandibular adenomas and erythema in the extremities. The fornix uteri was red, with a nodule noted. The rapid plasma reagin ratio was 1:3. She was diagnosed with syphilitic cervicitis and treated with amoxicillin for four weeks. Initial cervical cytology showed cells with mild nuclear enlargement, which was thought to be metaplasia associated with syphilis. Repeated cytology a month later showed a high-grade squamous intraepithelial lesion. A punch biopsy of the lesion led to the pathological diagnosis of cervical carcinoma in situ. We performed cervical conization, and no recurrence occurred. Human papillomavirus (HPV) immunostaining was positive in the lesion. Mucosal lesions are an infrequently reported symptom of syphilis. When oropharyngeal lesions are found, the sexual history should be ascertained, and the patient should be screened for sexually transmitted diseases. HPV is especially significant because of its association with cervical cancer. Coinfection of HPV with cervical cancer must be ruled out during follow-up for women when oropharyngeal syphilis involves genital lesions.

Scleredema is a rare cutaneous mucinosis characterized by diffuse swelling and non-pitting induration. A 63-year-old man reported a 5-year history of skin thickening of the trunk and a 3-week history of dyspnea. Echocardiography revealed diffuse hypokinesis. Skin biopsies obtained from the waist showed thickened dermis with mucin. Myocardial biopsies showed alcian blue-stained tissue between the muscle fibers. The patient was referred to a dermatologist for phototherapy. Cardiomyopathy should be considered in patients with scleredema. Scleredema usually has a good prognosis; however, the mortality risk could be high when accompanied by cardiomyopathy.

A 65-year-old Japanese man was admitted to our hospital with fever and inflammation of the right ankle. We initiated antibiotics on suspicion of cellulitis. After no clinical improvement, we performed magnetic resonance imaging, which showed a fluid collection in the flexor hallucis longus (FHL) tendon sheath. Synovial fluid analysis revealed monosodium uric crystals. Final diagnosis was FHL tendonitis secondary to gout proven by synovial fluid analysis. To our knowledge, this is the first case report of FHL tendonitis caused by gout. When ankle inflammation is examined in clinical situations, FHL tendonitis caused by gout should be considered.

Aeromonas hydrophila (A. hydrophila) occasionally causes necrotizing fasciitis (NF) and sepsis in immunocompromised hosts. NF is associated with high mortality. In cases of septic shock due to A. hydrophila, mortality is nearly 100%. Our 47-year-old male patient was diagnosed with NF and septic shock due to A. hydrophila. He had not been exposed to fresh or slightly salty water, which is where the bacterium is typically found, so its origin in this case is unclear. This is the first known case in which the patient was able to be completely cured without amputation. NF was suspected from his sepsis, medical history including alcoholic cirrhosis, and a severely poor general condition, but his skin lesions were mild. We promptly made an exploratory incision and debrided his legs. NF could then be diagnosed. At an early stage, A. hydrophila was recognized as a possible pathogen of NF because of the patient's medical background and the Gram stain findings of intraoperative exudate. Minocycline in addition to carbapenem and vancomycin plus clindamycin were administered as empiric therapy. When A. hydrophila was detected in the blood culture, ciprofloxacin was administered as definitive therapy. Successful treatment of NF requires early diagnosis, prompt debridement from onset and adequate empirical antibiotic therapy.

Hyperosmolar hyperglycemic syndrome is a life-threatening diabetic emergency that manifests as altered mental status. An otherwise healthy 40-year-old man presented to our emergency department with headache and severe hypertension. Brain magnetic resonance imaging showed evidence of posterior reversible encephalopathy syndrome, a usually reversible neurological syndrome characterized by subcortical vasogenic oedema. This first reported case details posterior reversible encephalopathy syndrome concurrent with hyperosmolar hyperglycemic syndrome. Prompt diagnosis and management were essential to avoid non-reversible consequences.

Antihistamines are known risk factors for restless legs syndrome (RLS). However, reports on RLS associated with fexofenadine or its combinations are rare. Here, we report a 30‐year‐old woman with RLS that was induced by fexofenadine/pseudoephedrine. She had been taking fexofenadine/pseudoephedrine for three months and felt a strong urge to move her legs at night, which was relieved by movement. Her condition improved by taking pramipexole, which she discontinued subsequently because of dizziness. One month later, she quitted taking fexofenadine/pseudoephedrine, after which her symptoms disappeared a week later. This case study demonstrates that RLS can be induced by fexofenadine/pseudoephedrine and we should always consider the possibility of drug‐induced RLS.

The detection of abnormalities of the cranial arteries on magnetic resonance imaging (MRI) is useful for the diagnosis of giant cell arteritis (GCA). However, reports on the veins of GCA patients are rare. We report the case of an elderly woman with GCA who presented with facial edema. She presented with a one month history of headache and facial edema. After MRI and enhanced computed tomography revealed delayed blood flow in the left jugular vein, a temporal artery biopsy was performed. She was diagnosed with GCA based on the biopsy findings. Following corticosteroid therapy, her symptoms and venous flow improved. The present case indicates that delayed jugular venous flow can occur in GCA patients with facial edema.

Citrobacter koseri is a rare cause of liver abscess with two reported cases in diabetic patients. We report a rare case of C. koseri liver abscess with C. koseri bacteremia in an elderly male with chronic kidney disease. He presented vomiting and weakness without any other signs. He was diagnosed with liver abscess by ultrasound, and blood culture showed C. koseri growth. The patient was treated effectively with a course of antibiotics and drainage. When C. koseri is isolated in patients with comorbidity, such as chronic kidney disease, we should consider the possibility of abscess including liver abscess and utilize a combined treatment of drainage and course of antibiotics for mixed infection.

Testicular vasculitis is a rare condition and little is known about its morphological features. Herein, we report a case of testicular lymphocytic vasculitis, which is rarely documented, in an elderly man. He presented with left testicular swelling and fever, but without any signs of other organ involvement. He was effectively treated with prednisolone and azathioprine. This case report offers information related to the disease course and the importance of biopsy.