Takanori Uehara

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.

Paroxysmal burning pain caused by erythromelalgia

1692 www.thelancet.com Vol 383 May 10, 2014 In October, 2012, an 81-year-old woman presented to our clinic with burning pain in the soles of her feet. She had a 5 year history of paroxysmal burning pain of the soles, accompanied by erythema and swelling, which occurred about twice a week. Symptoms were provoked by a hot bath or arose at night, causing insomnia, but subsided in the daytime. Pain was relieved by cooling the soles. She had a history of hypercholesterolaemia and vasospastic angina, diagnosed 10 years earlier, for which she was taking atorvastatin and diltiazem. At initial examination she had no plantar pain, and neither erythema nor swelling of the soles (fi gure). Dorsalis pedis and posterior tibial pulses were palpable. Thermography showed raised skin temperature in the feet (appendix). On the basis of these clinical features we diagnosed erythromelalgia, and prescribed clonazepam 1 mg daily, with pronounced reduction in the frequency and severity of painful episodes and resolution of her insomnia. Clinical fi ndings and laboratory tests were negative for causes of secondary erythromelalgia such as collagen disorders, including systemic lupus erythematosus or vasculitis. Nerve conduction velocity was normal, ruling out peripheral neuropathy. She had well controlled hypercholesterolaemia, but no other risk factors for atherosclerosis such as hypertension, diabetes, or smoking. Drug-related erythromelalgia has been reported with calcium antagonists, bromocriptine, pergolide, and ticlopidine. We considered primary or calcium-antagonistinduced erythromelalgia due to diltiazem, but could not stop treatment with diltiazem for vasospastic angina for ethical reasons. At follow-up in March, 2014, the patient’s symptoms remained well controlled and there was no evidence of secondary causes of erythromelalgia. Diagnosis of erythromelalgia is based on the clinical triad of paroxysmal burning pain, erythema, and increased skin temperature of the feet. Symptoms are brought on by heat, exertion, and nocturnal sleep, last from a few minutes to several hours, and are improved with cooling. They generally aff ect the legs, but may also aff ect the hands, arms and face, and are bilateral in 98% of patients. Secondary erythromelalgia, associated with myeloproliferative diseases, vascular disorders, collagen diseases, spinal cord disorders, peripheral neuropathy, infectious diseases, and drugs, should be suspected if symptoms are unilateral. Analysis of skin biopsy specimens has suggested small-fi bre neuropathy. In this disorder both the aff erent Aδ fi bres that transmit pain and temperature sensation and sympathetic eff erent C-fi bres are damaged, causing pain distribution that is similar to polyneuropathy, whereas large myelinated fi bres remain intact, so tendon refl exes and nerve conduction velocity are normal. Normally, about 80% of peripheral circulation fl ows through direct anastomoses from arteries to veins, whereas about 20% enters the capillaries. In erythromelalgia pain can arise with nocturnal vasodilation, caused by parasympathetic dominance and leading to increased arteriovenous shunt fl ow with decreased capillary circulation. Neither defi nitive diagnostic criteria nor eff ective treatment have been established for erythromelalgia. Pharmacotherapy for neuropathic pain and nerve block are the usual treatments. Unlike neuropathic pain, which is generally persistent, small-fi bre neuropathy can cause intermittent pain. Erythromelalgia and other types of small fi bre neuropathy should be considered in patients with paroxysmal neuropathic pain.

Recurrent Back Pain of Eosinophilic Esophagitis

A 66-year-old man presented with 5 episodes per week of recurrent severe back pain for 2 weeks. At an emergency clinic, laboratory tests, electrocardiography, contrastenhanced thoracoabdominal computed tomography, and upper gastrointestinal endoscopy had revealed nothing remarkable. His history included aspirin-induced asthma, hypertension, and hyperlipidemia. Current medications were oral candesartan, amlodipine, and simvastatin, as well as inhaled beclomethasone dipropionate. He complained of spontaneous midline back pain at Th 4-7 that worsened over 30 minutes and resolved after 2 hours. It was not aggravated by movement, suggesting referred visceral pain. The pattern of pain and the test results excluded angina pectoris, gallstones, chronic pancreatitis, and peptic ulcer, while the duration, repeatability, and site of pain suggested esophageal spasm. Review of the computed tomography revealed mid to distal esophageal wall thickening (Figure). Endoscopy performed at our hospital identified slight linear furrows at this site, while biopsy revealed epithelial infiltration of eosinophils ( 15 per high power field) in all 4 specimens. The eosinophil count was 605/mL, with no organopathy to suggest hypereosinophilic syndrome. Among diseases associated with eosinophilic infiltration of the esophagus, eosinophilic gastroenteritis and Crohn disease were excluded in this patient, because upper and lower gastrointestinal endoscopy with random biopsy at a total of 10 sites identified no abnormalities outside the esophagus. Pathological examination showed no evidence of esophageal infection, and his symptoms did not suggest celiac disease or vasculitis.

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.

One novel and two uncommon MEFV mutations in Japanese patients with familial Mediterranean fever: a clinicogenetic study

Familial Mediterranean fever (FMF) is an autoinflammatory disease caused by mutations in the MEFV gene and characterized by recurrent episodes of fever and polyserositis. To date, over 317 MEFV mutations have been reported, only nine of which account for almost all Japanese patients with FMF. Therefore, the prevalence of rare MEFV variants and their clinical characteristics remains unclear. This study identified MEFV mutations previously unreported in the Japanese population and described their clinical features. We performed MEFV genetic testing in 488 Japanese patients with clinically suspected FMF. Of these patients, we retrospectively analyzed three patients with novel or very uncommon MEFV mutations. In all patients, the clinical diagnosis of FMF was made according to Tel-Hashomer’s criteria. One novel missense mutation (N679H) and two rare mutations (T681I and R410H) were identified in the MEFV gene. These mutations were found in compound heterozygous or complex genotypes with other known mutations in exons 1 or 2. According to clinical images, all three patients exhibited typical FMF symptoms. A number of patients with FMF caused by novel or uncommon MEFV variants might exist in the Japanese population; therefore, careful genetic testing is required for accurate diagnosis of this curable genetic disorder.

Immunoglobulin G4-related disease with fibroinflammatory lesions in the pleura, bile ducts and pericardium

A 78-year-old man presented with bilateral leg edema, pleural effusions and elevated cholestatic liver enzyme levels that had worsened over two years. Magnetic resonance cholangiopancreatography scans suggested sclerosing cholangitis ([Figure 1A][1]). Positron-emission tomography–computed

Bilateral Trapezius Ridge Pain With Sustained Low-Grade Fever Caused by Aortic Dissection

Aortic dissection generally causes severe chest pain and ischemic symptoms related to branch vessel occlusion, but patients with this disease might present with unexpected symptoms. We report a case of a man with pain extending from the nuchal region to both shoulders and fever for 3 weeks. Bilateral trapezius ridge pain, which is characteristically associated with pericarditis, and persistent fever were the only diagnostic clues to aortic dissection. This case also emphasizes that aortic dissection should be considered as a cause of unexplained persistent fever.

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.

Accuracy of diagnoses predicted from a simple patient questionnaire stratified by the duration of general ambulatory training: an observational study.

Purpose To compare the diagnostic accuracy of diseases predicted from patient responses to a simple questionnaire completed prior to examination by doctors with different levels of ambulatory training in general medicine. Participants and methods Before patient examination, five trained physicians, four short-term-trained residents, and four untrained residents examined patient responses to a simple questionnaire and then indicated, in rank order according to their subjective confidence level, the diseases they predicted. Final diagnosis was subsequently determined from hospital records by mentor physicians 3 months after the first patient visit. Predicted diseases and final diagnoses were codified using the International Classification of Diseases version 10. A “correct” diagnosis was one where the predicted disease matched the final diagnosis code. Results A total of 148 patient questionnaires were evaluated. The Herfindahl index was 0.024, indicating a high degree of diversity in final diagnoses. The proportion of correct diagnoses was high in the trained group (96 of 148, 65%; residual analysis, 4.4) and low in the untrained group (56 of 148, 38%; residual analysis, −3.6) (χ2=22.27, P<0.001). In cases of correct diagnosis, the cumulative number of correct diagnoses showed almost no improvement, even when doctors in the three groups predicted ≥4 diseases. Conclusion Doctors who completed ambulatory training in general medicine while treating a diverse range of diseases accurately predicted diagnosis in 65% of cases from limited written information provided by a simple patient questionnaire, which proved useful for diagnosis. The study also suggests that up to three differential diagnoses are appropriate for diagnostic prediction, while ≥4 differential diagnoses barely improved the diagnostic accuracy, regardless of doctors’ competence in general medicine. If doctors can become able to predict the final diagnosis from limited information, the correct diagnostic outcome may improve and save further consultation hours.