Kazutaka Noda

Predictors for benign paroxysmal positional vertigo with positive Dix–Hallpike test

Objective Patient medical history is important for making a diagnosis of causes of dizziness, but there have been no studies on the diagnostic value of individual items in the history. This study was performed to identify and validate useful questions for suspecting a diagnosis of benign paroxysmal positional vertigo (BPPV). Methods Construction and validation of a disease prediction model was performed at the outpatient clinic in the Department of General Medicine of Chiba University Hospital. Patients with dizziness were enrolled (145 patients for construction of the disease prediction model and 61 patients for its validation). This study targeted BPPV of the posterior semicircular canals only with a positive Dix–Hallpike test (DHT + BPPV) to avoid diagnostic ambiguity. Binomial logistic regression analysis was performed to identify the items that were useful for diagnosis or exclusion of DHT + BPPV. Results Twelve patients from the derivation set and six patients from the validation set had DHT + BPPV. Binomial logistic regression analysis selected a “duration of dizziness ≤15 seconds” and “onset when turning over in bed” as independent predictors of DHT + BPPV with an odds ratio (95% confidence interval) of 4.36 (1.18–16.19) and 10.17 (2.49–41.63), respectively. Affirmative answers to both questions yielded a likelihood ratio of 6.81 (5.11–9.10) for diagnosis of DHT + BPPV, while negative answers to both had a likelihood ratio of 0.19 (0.08–0.47). Conclusion A “duration of dizziness ≤15 seconds” and “onset when turning over in bed” were the two most important questions among various historical features of BPPV.

Problem-based learning using patient-simulated videos showing daily life for a comprehensive clinical approach.

Objectives We examined whether problem-based learning tutorials using patient-simulated videos showing daily life are more practical for clinical learning, compared with traditional paper-based problem-based learning, for the consideration rate of psychosocial issues and the recall rate for experienced learning. Methods Twenty-two groups with 120 fifth-year students were each assigned paper-based problem-based learning and video-based problem-based learning using patient-simulated videos. We compared target achievement rates in questionnaires using the Wilcoxon signed-rank test and discussion contents diversity using the Mann-Whitney U test. A follow-up survey used a chi-square test to measure students’ recall of cases in three categories: video, paper, and non-experienced. Results Video-based problem-based learning displayed significantly higher achievement rates for imagining authentic patients (p=0.001), incorporating a comprehensive approach including psychosocial aspects (p<0.001), and satisfaction with sessions (p=0.001). No significant differences existed in the discussion contents diversity regarding the International Classification of Primary Care Second Edition codes and chapter types or in the rate of psychological codes. In a follow-up survey comparing video and paper groups to non-experienced groups, the rates were higher for video (χ2=24.319, p<0.001) and paper (χ2=11.134, p=0.001). Although the video rate tended to be higher than the paper rate, no significant difference was found between the two. Conclusions Patient-simulated videos showing daily life facilitate imagining true patients and support a comprehensive approach that fosters better memory. The clinical patient-simulated video method is more practical and clinical problem-based tutorials can be implemented if we create patient-simulated videos for each symptom as teaching materials.

Finger stiffness or edema as presenting symptoms of eosinophilic fasciitis

Abstract To investigate the clinical features and finger symptoms of eosinophilic fasciitis (EF), we reviewed five patients with EF. The chief complaint was pain, edema and/or stiffness of the extremities. The distal extremities were affected in all patients, and there was also proximal involvement in one patient. One patient had asymmetrical symptoms. All four patients with upper limb involvement had limited range of motion of the wrist joints, and three of them complained of finger symptoms. Two of these three patients showed slight non-pitting edema of the hands, and the other one had subcutaneous induration of the forearm. All four patients with lower limb symptoms had limited range of motion of the ankle joints, and two showed edema or induration of the legs. Inflammatory changes in the joints were not detected in any of the patients. Two patients displayed neither objective induration nor edema, and two patients had muscle tenderness. In conclusion, finger symptoms of patients with EF might be caused by fasciitis of the forearms, which leads to dysfunction of the long finger flexors and extensors as well as slight edema of hands. Limited range of motion of wrist and/or ankle joints indicates sensitively distal muscle dysfunction caused by fasciitis.

Paroxysmal hip pain.

In January, 2007, a 58-year-old woman presented to our department with a 2-year history of severe paroxysmal hip pain. She had a 30-year history of anorexia nervosa. The pain originated near the pubis and radiated to the right or left hip, with right-sided pain being more frequent. The pain often occurred after urination or defecation, and lasted from several minutes to several hours. She could not walk because of the severity of the pain, and had to lie supine with the aff ected thigh fl exed to obtain some relief. Our patient had presented to emergency departments several times, receiving a diagnosis of psychogenic pain or osteoarthritis because of degenerative changes shown on hip radiographs. On examination, she was asymptomatic but severely emaciated with a height of 159 cm and weight of 32 kg (body-mass index 12·7 kg/m2). There was no tenderness, swelling, or restricted movement of her hip joints, making the diagnosis of degenerative arthritis unlikely. Just after examination, left-sided pain occurred on urination. Emergency CT of the pelvis showed intrusion of the bowel into the left obturator canal (fi gure). Her pain soon subsided, and elective surgery was scheduled. After 1 month, severe right-sided pain occurred and she had an emergency laparotomy. Bilateral obturator hernia was diagnosed and mesh repair surgery done. In August, 2009, at 32-month follow-up she had not experienced any pain since the operation. Obturator hernia is most common in emaciated elderly women between 70 and 90 years old. Women are aff ected six times more frequently than men because they have a wider pelvis with a larger obturator canal. Emaciation is an important risk factor because the loss of preperitoneal fat overlying the obturator canal increases the risk of herniation. Obturator hernia is relatively rare, with a reported incidence of 0·073% of all abdominal hernias and bilateral obturator hernia has an incidence of only 0·013%. The hernia is more common in multiparous women and Asians, and occurs less frequently on the left side because the sigmoid colon can cover the left obturator foramen, preventing herniation. The usual presention is with the clinical features of acute small bowel obstruction, but obstruction can also be partial and resolve spontaneously. Approximately one third of the patients have a history of intermittent previous attacks. Patients can present with groin, thigh, knee, or hip pain due to compression of the obturator nerve by the hernia (Howship-Romberg sign), which is seen in 15–50% of patients. The pain is exacerbated by extension, abduction, or medial rotation of the thigh, while fl exion usually relieves it. Our patient with bilateral hernia was relatively young, but she had severe emaciation due to anorexia nervosa. Bowel herniation induced the HowshipRomberg sign, resulting in her curious paroxysmal hip pain. Diagnosis of obturator hernia is challenging, although CT or ultrasonography can be useful, the correct diagnosis is made preoperatively in only 21·5% to 31·3% of cases. Diffi culty in establishing the diagnosis leads to a high mortality rate of up to 25%, so early accurate diagnosis is crucial. Although obturator hernia is a rare disease, it must be considered when any underweight woman, not only the elderly, complains of unexplained pain in the groin, thigh, knee, or hip.

Influence of predicting the diagnosis from history on the accuracy of physical examination

Background This study aimed to clarify the influence of predicting a correct diagnosis from the history on physical examination by comparing the diagnostic accuracy of auscultation with and without clinical information. Methods The participants were 102 medical students from the 2013 clinical clerkship course. Auscultation was performed with a cardiology patient simulator. Participants were randomly assigned to two groups. Each group listened to a different simulated heart murmur and then made a diagnosis without clinical information. Next, a history suggesting a different murmur was provided to each group and they predicted the diagnosis. Finally, the students listened to a murmur corresponding to the history provided and again made a diagnosis. Correct and incorrect diagnosis rates of auscultation were compared between students with and without clinical information, between students predicting a correct or incorrect diagnosis from the history (correct and incorrect prediction groups, respectively), and between students without clinical information and those making an incorrect prediction. Results For auscultation with or without clinical information, the correct diagnosis rate was 62.7% (128/204 participants) versus 54.4% (111/204 participants), showing no significant difference (P=0.09). After receiving clinical information, a correct diagnosis was made by 102/117 students (87.2%) in the correct prediction group versus 26/87 students (29.9%) in the incorrect prediction group, showing a significant difference (P=0.006). The correct diagnosis rate was also significantly lower in the incorrect prediction group than when the students performed auscultation without clinical information (54.4% versus 29.9%, P<0.001). Conclusion Obtaining a history alone does not improve the diagnostic accuracy of physical examination. However, accurately predicting the diagnosis from the history is associated with higher diagnostic accuracy of physical examination, while incorrect prediction is associated with lower diagnostic accuracy of examination.

Unilateral lower abdominal wall protrusion and umbilical deviation

Postherpetic pseudohernia must be suspected when a patient develops motor dysfunction coincident with or following a herpes zoster eruption.

Anxiety and depression in general practice outpatients: the long-term change process

Background and objectives Patients who come for a consultation at a general practice clinic as outpatients often suffer from background anxiety and depression. The psychological state of such patients can alleviate naturally; however, there are cases when these symptoms persist. This study investigated the realities and factors behind anxiety/depression becoming prolonged. Methods Participants were 678 adult patients, who came to Department of General Medicine at Chiba University Hospital within a 1-year period starting from April 2012 and who completed the Hospital Anxiety and Depression Scale (HADS) during their initial consultation. Participants whose Anxiety or Depression scores in the HADS, or both, were 8 points or higher were defined as being within the anxiety/depression group, with all other participants making up the control group. A telephone interview was also conducted with participants. Furthermore, age, sex, the period from the onset of symptoms to the initial consultation at our department, the period from the initial department consultation to the telephone survey, and the existence of mental illness at the final department diagnosis were investigated. Results A total of 121 patients (17.8% response rate) agreed to the phone survey. The HADS score during the phone survey showed that the anxiety/depression group had a significantly higher score than the control group. The HADS scores obtained between the initial consultation and telephone survey showed a positive correlation. Logistic regression analysis extracted “age” and the “continuation of the symptoms during the initial consultation” as factors that prolonged anxiety/depression. Conclusion Anxiety and depression in general practice outpatients have the possibility of becoming prolonged for an extended period of time. Being aged 65 years or over and showing a continuation of symptoms past the initial consultation are the strongest factors associated with these prolonged conditions. When patients with anxiety and depression exhibit these risk factors, they should be further evaluated for treatment.

Prolonged Dry Cough without Pulmonary Changes on Radiological Imaging

A 16-year-old boy who was a non-smoker presented with a prolonged severe dry cough and malaise of 3 months in duration. Despite an increase in the patients inflammatory marker levels, no respiratory lesions were radiologically or serologically detected. We suspected that the cough reflex pathway had been stimulated by large vessel vasculitis (LVV, a non-respiratory inflammatory condition) and diagnosed the patient with Takayasu arteritis. While inflammation of either the ascending pharyngeal or pulmonary artery have been reported to cause cough in patients with LVV, the present case shows that intense inflammation of the aortic arch and the starting portion of its main branches may stimulate a vagus nerve branch as a novel mechanism causing cough.

A-MUPS score to differentiate patients with somatic symptom disorder from those with medical disease for complaints of non-acute pain

Purpose To develop a clinical score to discriminate patients with somatic symptom disorder (SSD) from those with medical disease (MD) for complaints of non-acute pain. Methods We retrospectively examined the clinical records of consecutive patients with pain for a duration of ≥1 month in our department from April 2003 to March 2015. We divided the subjects according to the diagnoses of definite SSD (as diagnosed and tracked by psychiatrists in our hospital), probable SSD (without evaluation by psychiatrists in our hospital), matched MD (randomly matched two patients by age, sex, and pain location for each definite SSD patient), unmatched MD, other mental disease, or functional somatic syndrome (FSS). We investigated eight clinical factors for definite SSD and matched MD, and developed a diagnostic score to identify SSD. We subsequently validated the model with cases of probable SSD and unmatched MD. Results The number of patients with definite SSD, probable SSD, matched MD, unmatched MD, other mental disease, and FSS was 104 (3.5%), 214 (7.3%), 197 (6.7%), 742 (25%), 708 (24%), and 978 (33%), respectively. In a conditional logistic regression analysis, the following five factors were included as independent predictors of SSD: Analgesics ineffective, Mental disorder history, Unclear provocative/palliative factors, Persistence without cessation, and Stress feelings/episodes (A-MUPS). The area under the receiver operating characteristic curve (AUC) of the model was 0.900 (95% CI: 0.864–0.937, p<0.001), and the McFadden’s pseudo-R-squared was 0.709. For internal validation, the AUC between probable SSD and unmatched MD was 0.930 (95% CI: 0.910–0.950, p<0.001). The prevalence and the likelihood ratio of SSD increased as the score increased. Conclusion The A-MUPS score was useful for discriminating patients with SSD from those with MD for complaints of non-acute pain, although external validation and refinement should be needed.

Abnormal Paroxysmal Nocturnal Behavior Due to Insulinoma

A 74-year-old woman presented with abnormal paroxysmal nocturnal behavior during sleep, such as frequent turning and groaning, occurring twice or thrice per week for the past 2 months. The abnormal behavior usually appeared around 2:00 AM and resolved spontaneously in 1-2 hours, after which the patient would fall back to sleep. During an episode, a family member would slap the patient in an attempt to wake her up, but the patient was never completely awakened and could not remember much about what had happened during the episode. Autonomic nervous symptoms, such as excessive sweating, tremor, and palpitations, had not been observed, and the patient’s weight had not changed. The patient had been taking beta-blockers for hypertension. At the initial visit the patient showed no symptoms. A physical examination found no abnormalities in the patient, who was 150 cm tall and weighed 50 kg. However, around 2:00 PM, the patient exhibited the same abnormal behavior, when she was in the waiting room, as previously observed. The patient had not eaten anything since the night before, assuming she would undergo blood sampling. Laboratory studies revealed hypoglycemia, with blood glucose of 25 mmol/L, immunoreactive insulin of 15.2 mU/L, and C-peptide of 6.5 mg/L when measured simultaneously. She recovered immediately after intravenous infusion of 50% glucose. Abdominal computed tomography revealed a 14-mm diameter hypervascular mass in the body of the pancreas (Figure). Insulinoma was diagnosed, and the mass removed by enucleation. She had not experienced abnormal nocturnal behavior since the operation. Patients with insulinomas show various hypoglycemic symptoms, commonly including neurogenic and neuroglycopenic symptoms. The neurogenic symptoms include tremor, palpitations, diaphoresis, and hunger. The neuroglycopenic symptoms include cognitive impairment,