Correction: Comparison of professionalism between emergency medicine resident physicians and faculty physicians: A multicenter cross-sectional study.

[This corrects the article DOI: 10.1371/journal.pone.0230186.].

Comparison of professionalism between emergency medicine resident physicians and faculty physicians: A multicenter cross-sectional study.

Professionalism is a critical competency for emergency medicine (EM) physicians, and professional behavior affects patient satisfaction. However, the findings of various studies indicate that there are differences in the interpretation of professionalism among EM resident physicians and faculty physicians. Using a cross-sectional survey, we aimed to analyze common challenges to medical professionalism for Japanese EM physicians and survey the extent of professionalism coursework completed during undergraduate medical education. We conducted a multicenter cross-sectional survey of EM resident physicians and faculty physicians at academic conferences and eight teaching hospitals in Japan using the questionnaire by Barry and colleagues. We analyzed the frequency of providing either the best or second-best answers to each scenario as the main outcome measure and compared the frequencies between EM resident physicians and EM faculty physicians. Fisher's exact test and the Wilcoxon rank sum test were used to analyze data. A total of 176 physicians (86 EM resident physicians and 90 EM faculty physicians) completed the survey. The response rate was 92.6%. The most challenging scenario presented to participants dealt with sexual harassment, and only 44.5% chose the best or second-best answers, followed by poor responses to the confidentiality scenario (69.9%). The frequency of either the best or second-best responses to the confidentiality scenario was significantly greater for EM resident physicians than for EM faculty physicians (77.1% versus 62.9%, p = 0.048). More participants in the EM resident physician group completed formal courses in medical professionalism than those in the EM faculty physician group (25.8% versus 5.5%, p < 0.01). Further, EM faculty physicians were less likely than EM resident physicians to provide acceptable responses in terms of confidentiality, and few of both had received professionalism training through school curricula. Continuous professionalism education focused on the prevention of sexual harassment and gender gap is needed for both EM resident physicians and faculty physicians in Japan.

Unique characteristics of frequent presenters to the emergency department in a Japanese population: a retrospective analysis.

AIM: Little evidence on Japanese frequent presenters (FPs) is available. Therefore, this retrospective cohort study compared characteristics between FPs and non-frequent presenters (NFPs) in emergency departments (EDs) in Japan. METHODS: Frequent presenters included those who presented to an ED ≥4 times during the study period from August 1, 2012 to July 21, 2013. The primary outcomes were triage level and disposition. Secondary outcomes were ED length of stay, method of arrival, and discharge diagnosis. RESULTS: During the study period, 195 FPs had 1,154 visits to the ED, compared to 15,953 visits by 13,838 NFPs. The sex distribution between FPs and NFPs was comparable (107 men [54.9%] versus 7,070 men [51.1%], respectively; P = 0.29), but the mean age was significantly higher in the FP group (57.3 versus 46.5 years, respectively; P < 0.0001). Among the FPs, the rate of free governmental health insurance was higher than that of those who pay 30% of health costs (35 patients paid 0% [79.5%] versus 109 patients paid 30% [42.6%], respectively). Condition severity (FP, 84 severe cases [7.28%]; NFP, 1,320 severe cases [8.27%], respectively) and rate of admission (FP, 207 admissions [17.9%]; NFP, 2,987 admissions [18.7%], respectively) were comparable between the groups, although the rate of ambulance use was lower for the FP group. The most frequent diagnostic codes (International Classification of Diseases, 10th Revision) in the FP group were "symptoms and signs". CONCLUSION: Triage levels and hospital admission rates were not significantly different between FPs and NFPs in this single-center study in Japan.

The diagnostic accuracy of the mediastinal width on supine anteroposterior chest radiographs with nontraumatic Stanford type A acute aortic dissection.

Background: Nontraumatic Stanford type A acute aortic dissection is a life-threatening condition; thus, the ability to make a precise diagnosis of nontraumatic Stanford type A acute aortic dissection is essential for the emergency physician. Several reports have shown that the mediastinal widening on a chest radiograph is useful for the diagnosis of nontraumatic Stanford type A acute aortic dissection; however, the exact cutoff value of the mediastinal width on plain radiographs is rarely defined. Methods: A single-center retrospective case-control study was conducted between October 1, 2013, and March 31, 2015. We evaluated the maximal mediastinal width of the anteroposterior chest X-ray at the level of the aortic knob in the supine position between patient groups with and without nontraumatic Stanford type A acute aortic dissection. Results: We enrolled 72 patients (36 patients with nontraumatic Stanford type A acute aortic dissection and 36 patients without nontraumatic Stanford type A acute aortic dissection). The median mediastinal width of patients with nontraumatic Stanford type A acute aortic dissection was significantly larger than that of patients without nontraumatic Stanford type A acute aortic dissection (100.7 mm vs 77.7 mm, P < .01). The optimal cutoff level was 87 mm (sensitivity, 81%; specificity, 89%). Using multivariable logistic regression, the odds ratio of a mediastinal width of >87 mm for a diagnosis nontraumatic Stanford type A acute aortic dissection was 57.1 (95% confidence interval, 11.2-290.2). Conclusion: A mediastinal width of >87 mm showed high sensitivity in the diagnosis of probable nontraumatic Stanford type A acute aortic dissection.

IV crystalloid fluid for acute alcoholic intoxication prolongs ED length of stay.

OBJECTIVES: Acute alcohol intoxication is often treated in emergency departments by intravenous crystalloid fluid (IVF), but it is not clear that this shortens the time to achieving sobriety. The study aim was to investigate the association of IVF infusion and length of stay in the ED. METHODS: This single-center retrospective cohort study was conducted in Japan and included patients aged ≥20years of age and treated for acute alcohol intoxication without or with IVF. The primary outcome was the length of the ED stay and the treatments were compared by time-to-event analysis. RESULTS: A total of 106 patients, 42 treated without IVF and 64 with IVF. The baseline characteristics of the two groups were similar. Kaplan-Meier analysis and the generalized Wilcoxon test found no significant difference between the two treatments in the time to ED discharge. The median time was 189 (IQR 160-230) minutes without IVF and 254.5 (203-267 minutes with IVF; p=0.052). A Cox proportional hazards regression model adjusted for potential confounding variables found that patients treated with IVF were less likely to be discharged earlier than those treated without IVF (HR 0.54, 95% CI: 0.35-0.84, p=0.006). CONCLUSIONS: IVF for treatment of acute alcoholic intoxication prolonged ED length of stay even after adjustment for potential confounders. Patients given IVF for acute alcohol intoxication should be selected with care.

Emergency department outpatient treatment of alcohol-intoxicated bicyclists increases the cost of medical care in Japan.

Riding a bicycle under the influence of alcohol is illegal in Japan. Nevertheless, intoxicated bicyclists are frequently treated at hospital emergency departments for bicycle-related injuries. This patient population usually requires more hospital resources, even for relatively minor injuries. Therefore, we hypothesized that bicycle-related crashes involving bicyclists under the influence of alcohol cost more to treat than those that do not involve alcohol intoxication. The aim of the present study was to examine the costs associated with bicycle-related minor injuries and alcohol intoxication of the bicyclist. The study was conducted at the Tokyo Bay Urayasu Ichikawa Medical Center Emergency Department, Japan. All minor bicycle crashes involving 217 individuals aged ≥20 years treated from September 1, 2012 to August 31, 2013 were included in the analysis of data obtained from medical records. Variables included alcohol intoxication, sex, age, collision with a motor vehicle, Glasgow Coma Scale, injury severity score (ISS), laboratory tests, treatment of wounds, number of X-ray images, number of computed tomography scans, and medical costs. Multiple linear regression analysis was performed to evaluate the association between alcohol intoxication and medical costs. Seventy (32%) patients consumed alcohol, and the median medical cost was 253 USD (interquartile range [IQR], 164-330). Multivariable analysis showed that alcohol intoxication was independently associated with higher medical costs (p = 0.030, adjusted R-square value = 0.55). These findings support our hypothesis and should encourage authorities to implement comprehensive measures to prohibit bicycling under the influence of alcohol to prevent injuries and to reduce medical costs.

Validation of the modified Japanese Triage and Acuity Scale-based triage system emphasizing the physiologic variables or mechanism of injuries.

BACKGROUND: The Canadian Triage and Acuity Scale is a valid triage system. The system was translated and implemented in the Japanese emergency departments (EDs) from 2012. This system was named the Japanese Triage and Acuity Scale; however, the validation studies of the Japanese Triage and Acuity Scale have been limited. In addition, for a patient with multiple complaints, it could become challenging, due to its requirement of a single complaint. Therefore, we hypothesized that a modified version of the Japanese Triage and Acuity Scale using first-order modifiers without chief complaint detection is accurate. METHODS: A retrospective cohort study evaluated a correlation between the modified triage scale level and outcomes of all adult emergency department patients at a Japanese hospital. Construct validity of the modified triage scale level was assessed based on comparisons of total admission rate (including hospitalizations, emergency department deaths) and length of stay between triage levels. RESULTS: The distributions of five levels of the triage scale (level 1 is the most urgent) among the 17,121 cases are as follows: 1:451, 2:1148, 3:7703, 4:7652, and 5:167. Total admission rates by each level were 1:89.8, 2:68.2, 3:26.4, 4:6.6, and 5:0.6 %, which progressively increased from level 5 to 1 and were significant (p < 0.01). Compared with patients in level 3, the odds of total admission rates were 14.4, 5.1, 0.27, and 0.030 for the patients in levels 1, 2, 4, and 5. The length of stay was longer in the patients with the more urgent levels except for those with level 1. CONCLUSIONS: The modified version of the Japanese Triage and Acuity Scale is a valid predictor of total admission and length of stay and may enable the nurses to triage patients without detecting the chief complaints.

Tracheobronchitis in a patient with Crohn's disease.

A 19-year-old Japanese man who had been diagnosed with Crohn's disease (CD) suffered from dry cough and fever over 38 degrees C for three days prior to hospitalization. On admission, his colonic CD condition was stable, neither active nor in remission. Computed tomography of the chest showed small elevated tracheobronchial lesions. Bronchoscopy showed diffuse whitish granular lesions in the trachea and bronchi. The pathological findings in the biopsy showed inflammatory infiltration suggesting Crohn's tracheobronchitis. Thereafter, he was treated with inhaled Fluticasone propionate 400 microg/day. After one week his dry cough improved, and after two weeks bronchoscopic findings were improved.

Severe myelosuppression following alopecia shortly after the initiation of 6-mercaptopurine in a patient with Crohn's disease.

A 15-year-old, woman, Crohn's disease patient, who carried the TPMT *3C heterozygous mutant, complained of alopecia 3 days after starting 6-mercaptopurine (6-MP) and then developed severe myelosuppression 6 weeks after starting 6-MP. The alopecia involved scalp hair only (body hair preserved) and was dominant in the temporal region. Following these side effects, transient remission of Crohn's disease occurred. Myelosuppression due to 6-MP is a rare but life-threatening side effect that is difficult to predict despite continuous monitoring of complete blood cell counts. In the present case, 6-MP-induced alopecia preceded myelosuppression and progressed rapidly as the myelosuppression worsened.

Polymerase chain reaction detection of bacterial 16S rRNA gene in human blood.

Bacterial 16S ribosomal RNA genes (rDNA) were detected in blood samples from two healthy individuals by PCR under conditions involving 30 cycles that did not produce any visible products from negative control saline. Even from control samples, PCR involving 35-40 cycles yielded visible bands. Major clones detected in the blood samples, but not in control, were the Aquabacterium subgroup, Stenotrophomonas subgroup, Budvicia subgroup, Serratia subgroup, Bacillus subgroup and Flavobacteria subgroup. No clone was located within the bacteroides-clostridium-lactobacillus cluster, which is indigenous to gastrointestinal flora.

Ventricular fibrillation during colonoscopy: a case report--colonoscopy in high-risk patients should be performed with ECG monitoring.

While ventricular premature contractions have been noted during colonoscopy (CS), ventricular fibrillation (VF) is rare. We recently had a patient who developed VF during CS and recovered without any sequelae despite severe complications after cardiopulmonary resuscitation (CPR). If electrocardiogram (ECG) monitoring had been done during CS, a direct current shock defibrillation could have been accomplished and prevented complications. CS in high-risk patients should be done with ECG monitoring.

Hepatocellular carcinoma with direct invasion to the stomach.

A 71-year-old man was admitted to our hospital with abdominal pain. Hepatocellular carcinoma (HCC) had been diagnosed 2 years earlier and he had undergone 7 courses of intra-hepato-arterial chemotherapy (IHAC). We performed gastrointestinal fiberscopy and identified a massive protrusion on the lesser curvature. Abdominal contrast-enhanced computed tomography revealed multiple hepatic masses and an extrahepatic enlarged mass with invasion to the pancreas and stomach. A specimen for endoscopic biopsy revealed adenocarcinoma that stained positive for alpha-fetoprotein. Gastrointestinal bleeding resulting from direct invasion of HCC is unusual.

Valsartan, an angiotensin II type-I receptor blocker, and left ventricular diastolic function--a case report.

Impaired diastolic function is related to subjective symptoms, reduced exercise capacity, and poor prognosis in patients with congestive heart failure, and an angiotensin II type-I receptor blocker might have a beneficial effect on diastolic function in such patients with heart failure. A 53-year-old woman underwent valvuloplasty of the mitral valve and later presented with heart failure symptoms, including exertional dyspnea and easy fatigue. Although no pathological changes could be identified by radiography of the chest, electrocardiography, or routine echocardiography, the assessment of diastolic function with Doppler echocardiography revealed left ventricular diastolic dysfunction. Her neurohumoral parameters and left ventricular diastolic dysfunction improved after 1 month of treatment with Valsartan, an angiotensin II type-I receptor blocker, accompanied by improvement of her subjective symptoms. This case implies that angiotensin II type-I receptor blocker could improve left ventricular diastolic dysfunction and that Doppler echocardiography might be useful for detecting diastolic dysfunction in high-risk patients undergoing cardiac surgery.

Extremely low frequency magnetic fields originating from equipment used for assisted reproduction, umbilical cord and peripheral blood stem cell transplantation, transfusion, and hemodialysis.

The extremely low-frequency (ELF) magnetic fields (MFs) originating from equipment used for assisted reproduction, umbilical cord-blood and peripheral-blood stem cell transplantation, transfusion, and hemodialysis were measured. The ELF-MF values were 0.1-1.2 microT on clean benches, <0.1-8.0 microT on inverted microscopes, <0.1-13.6 mmicroT in CO2 incubators, 4.3-11.5 microT in centrifuges, 0.4-18.8 microT in programmed freezers, <0.1-0.3 microT in deep freezers, 0.3-3.1 microT on cell separators, and 0.2-0.9 microT in hemodialysers. Frequencies of MFs were nominally 60 Hz, but some devices showed non-sinusoidal 120 Hz. Such MFs can be reduced by shielding the sources or altering the protocols employed.

Diagnostic evaluation of acute pancreatitis in two patients with hypertriglyceridemia.

We present two diagnostically challenging cases of acute pancreatitis with hypertriglyceridemia accompanied with chylomicronemia caused with a deficiency of lipoprotein lipase and with the presence of type V hyperlipidemia. Both cases suffered from acute abdomen following the ingestion of fatty food and revealed the increase in parameters of inflammation without significant elevation of serum amylase levels. The imaging examination of ultrasonography could not detect significant findings of acute pancreatitis and a computer tomography scan eventually confirmed the findings of acute pancreatitis. Both cases responded to a low fat diet and administration of a cholecystokinin receptor antagonist, exhibiting a relief of abdominal symptoms. As in the present cases with acute abdomen following the ingestion of fatty food, the identification of serum hypertriglyceridemia and an abdominal computer tomography scan might be useful in establishing the diagnosis of acute pancreatitis and in developing the therapeutic regimen, when hypertriglyceridemia interferes with the evaluation of pancreatic enzyme activities and ultrasound examination provides poor pancreatic visualization.

Cardiovascular risk factor profiles and endothelial function in coronary artery disease patients treated with statins.

Although endothelial dysfunction is associated with cardiovascular risk factors and is improved by cholesterol-lowering therapy, the relationship between endothelial function and cardiovascular risk factor profiles has not been fully investigated in coronary artery disease patients who have been treated with statins. We investigated endothelial function in male hypercholesterolemic patients (n=53) who underwent statin therapy over 6 months in a cross-sectional study. Patients were classified into three groups based on the results of coronary angiography: a normal coronary artery group (n=15), an angina pectoris group (n=20) and a myocardial infarction group (n=18). Endothelial function was assessed by measuring flow-mediated dilatation after reactive hyperemia in the brachial artery, and serum lipid, lipoprotein (a), glucose and insulin levels were measured. Significant associations were observed between the status of coronary disease and systolic blood pressure, lipoprotein (a), glucose and insulin levels (p <0.05, respectively), and the levels of these risk factors in the myocardial infarction group were higher than those in the other groups. Flow-mediated dilatation was also associated with the status of coronary disease (p <0.05), and the myocardial infarction group showed the lowest levels of flow-mediated dilatation (p <0.05). Flow-mediated dilatation was negatively correlated with systolic and diastolic blood pressures, serum levels of lipoprotein (a), glucose and insulin, and the status of coronary disease. Stepwise multiple regression analysis also revealed that lipoprotein (a), diastolic blood pressure and the status of myocardial infarction were significantly correlated with impaired vasodilatation. Serum lipids, age and smoking habit were independent of flow-mediated dilatation. In conclusion, even after cholesterol-lowering treatment, male patients with myocardial infarction still had endothelial dysfunction, and higher levels of lipoprotein (a) may be associated with endothelial dysfunction in such patients.

Unstable hemoglobinemia, Hb Buenos Aires, Bryn Mawr, followed up for eighteen years.

A 20-year-old man has been under observation for 18 years because of unstable hemoglobinemia, Hb Buenos Aires, Bryn Mawr (beta-globin, Phe85Ser). At the age of 19 years, he was hospitalized because of fever and hemolytic crisis, and the symptoms resolved after infusion of antibiotics. Nucleotide sequencing of the beta-globin gene confirmed that the patient was heterozygous for the mutation. The patient's erythrocytes showed an increased affinity for oxygen and a prolonged glycerol lysis time. We review a previously reported single family and 5 other cases, and discuss the clinical significance of splenectomy and plasma-derived haptoglobin.

Antisense RNAs transcribed from the upstream region of the precore/core promoter of hepatitis B virus.

The bidirectional activity of the precore/core promoter of hepatitis B virus (HBV) has been demonstrated in cultured cell lines. However, HBV antisense transcripts (asRNAs) have not been demonstrated in vivo. In the present study using liver tissue from patients with chronic hepatitis, an anchored 5'RACE mapping the 5' ends at position 1680/1681, 1655 or 1609/1602 was carried out. In limited cases, RLM-3'RACE detected asRNAs to terminate at four or five consecutive dT residues in the 0.7 kb downstream region. PCR of oligo(dT)-primed cDNA did not amplify a typical polyadenylated asRNA. RT-PCR using various primers did not detect any spliced forms. Competitive RT-PCR estimated the copy numbers of the asRNAs to be 0.05-0.4 % of total sense RNAs. All sequenced asRNAs had ORF6 but, in one patient, the asRNA initiating at position 1680/1681 had additional initiation and termination codons in front of ORF6. Therefore, asRNAs are transcribed by RNA polymerase III at a low level, encompass a dispensable ORF6 gene and might be retained in the nucleus. The endogenous asRNAs complementary to the common ends of all sense RNAs suggest antisense-mediated self-regulation of hepadnavirus.