Yoshiyuki Ohira

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.

Limitations of using imaging diagnosis for psoas abscess in its early stage.

Objective Patients diagnosed with psoas abscess have a high mortality rate. The major cause of its poor prognosis is delayed treatment. Therefore, making a correct diagnosis rapidly is important. Both computed tomography (CT) and magnetic resonance imaging (MRI) are considered to be the gold standards as imaging modalities that have a high sensitivity for detecting psoas abscess. There have been few reports regarding the limitations of these methods, but psoas abscess in its early stage may go undetected by CT and MRI. Methods Detection of psoas abscess by CT and MRI was investigated in the present study through a retrospective review of 15 patients in whom psoas abscess was diagnosed during a course of ten years at our hospital. Results In all patients, psoas abscess was diagnosed by at least a plain CT, enhanced CT, and/or plain MRI. The interval between the onset of symptoms and diagnosis was 20.9±17.9 days (mean ± standard deviation). In three patients, repeat imaging identified a psoas abscess, whereas initial imaging failed to detect it. The overall sensitivity of plain CT, enhanced CT, and plain MRI for psoas abscess was 78%, 86%, and 88%, respectively. From six days after the onset of symptoms, the sensitivity of each modality was 100%, while the sensitivity from day one to five days was only 33%, 50%, and 50%, respectively. Conclusion Although CT and MRI are considered to be gold standard modalities for diagnosing psoas abscess, both methods can fail to notice this condition in its early stage.

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.

Scrub Typhus (Tsutsugamushi Disease) Presenting as Fever with an Eschar

A 76-year-old Japanese male farmer presented with a 2-day history of high fever, rash, intense headache, and diffuse myalgias. Physical examination revealed a non-pruritic maculopapular rash on his trunk and extremities (Fig. 1). An eschar was located on his right chest, which indicated the site of an infected chigger bite (Fig. 2). Serological tests revealed 1:160 titers of anti-Orientia tsutsugamushi IgM and a fourfold increase in titers between paired samples. Scrub typhus was diagnosed. After

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.

The Effectiveness of Cost Reduction with Charge Displays on Test Ordering under the Health Insurance System in Japan: A Study Using Paper-based Simulated Cases for Residents and Clinical Fellows

Objective To determine whether or not displaying the cost of tests can help reduce charges on test ordering in Japan. Methods This study was conducted under the setting of a simulated first visit of an outpatient for general internal medicine in a secondary medical institution in Japan. We randomly assigned 27 residents and clinical fellows to Team A or B. The first half, without charges displayed on the ordering system, was designated the “non-display group,” and the participants of Team A selected tests for each paper-based simulated case (Q1-Q14), while the participants of Team B selected tests for Q15-Q28. The second half, which had charges displayed, was designated the “display group,” and the participants of Team A selected tests for Q15-Q28, while the participants of Team B selected tests for Q1-Q14. The main outcome measure was the difference in the cost of tests per paper-based simulated case between the non-display and display groups. Results The median (interquartile range) cost of tests per paper-based simulated case was 12,255 yen (5,040-23,695 yen) in the non-display group versus 9,425 yen (2,320-21,700 yen) in the display group, showing a decrease of 2,830 yen with charges being displayed (p=0.002). Conclusion Displaying the charges when ordering tests in paper-based simulated cases resulted in cost reduction. The adoption of this intervention may reduce health insurance costs under the health insurance system in Japan, which has features such as universal health coverage and universal access to care.

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.