Yusuke Hirota

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.

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.

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.

M-protein-negative Myeloma Mimicking Lumbar Disc Herniation

A 60-year-old man was referred to us with high levels of aspartate aminotransferase and lactate dehydrogenase (LDH). He did not complain of any symptoms; however, he had been diagnosed with lumbar disc herniation, even though his back pain improved only to half of its previous level with pregabalin. Thus, we asked about the red flag of back pain and confirmed that he had involuntary body weight loss, which led us to diagnose truly non-secretory multiple myeloma, a variant of multiple myeloma that is associated with M-protein negativity and a normal serum free light chain level.

Super bone scan: bone metastases of prostate cancer

A 75-year-old man presented with a 2-month history of worsening chest and back pain. Physical examination revealed generalised bone tenderness with associated indirect pain; digital rectal examination indicated asymmetric prostatic induration. Laboratory examination revealed high serum alkaline phosphatase (1348 U/L (bone type, 73.2%)), high C reactive protein (4.5 mg/dL), high serum ferritin (2952 ng/mL) and high prostate-specific antigen (1346 ng/mL). A whole-body technetium-99m methyldiphosphonate (Tc-99m MDP) scan revealed increase in bone …