Training items for trainee residents in community medicine in rural areas.

OBJECTIVE: To examine the significant events experienced by initial trainees during community medicine training, evaluate their impact on community medicine practice, and support improvements in rural community medicine training. RESULTS: Three faculty teachers independently evaluated the reports of 25 residents who had completed a four-week community medicine training in a rural area to analyze major events. The reports were analyzed using topics from the Model Core Curriculum for Medical Education that relate to rural medicine. The most frequently reported items were identified as follows: Primary care: 9 (36.0%); integrated community care systems: 8 (32.0%); medical care in the local community: 7 (28.0%); home health care and systems, patient-physician relationship, and end-of-life medical treatment and care: 6 each (24.0%). Reports from residents describing events related to home health care and systems and end-of-life medical treatment and care were related to more than one item.

A Case of Milk-Alkali Syndrome Caused by Diuretic-Induced Alkalosis and Polypharmacy.

Milk-alkali syndrome, which is characterized by hypercalcemia, metabolic alkalosis, and renal dysfunction, typically results from the ingestion of large amounts of calcium and absorbable alkaline products. However, these symptoms can also manifest when alkalosis and calcium loading occur simultaneously, owing to other factors. We report a case of milk-alkali syndrome caused by loop-diuretic-induced alkaline load and polypharmacy in an 85-year-old Japanese woman with multiple comorbidities, including osteoporosis, hypertension, type 2 diabetes, dyslipidemia, and Parkinson's disease. The patient regularly took 14 drugs, including calcium L-aspartate, eldecalcitol, celecoxib, and a fixed-dose combination of losartan and hydrochlorothiazide. Immediately before admission, furosemide was administered for the treatment of edema. The patient presented with chest discomfort, general malaise, and clinical signs of dehydration, hypercalcemia, hypophosphatemia, hypokalemia, and hypomagnesemia, accompanied by electrocardiogram abnormalities, renal dysfunction, and chloride-resistant metabolic alkalosis. The hypercalcemia was specifically induced by calcium L-aspartate and eldecalcitol. The hypomagnesaemia and hypophosphatemia were caused by diuretics and hypercalcemia. Thus, all the oral medications were discontinued, and rehydration and electrolyte correction therapy were administered. The final diagnosis was milk-alkali syndrome caused by the concomitant use of loop diuretics and other medications, without absorbable alkaline preparation use. This case underscores the importance of considering drug-related factors, checking concomitant medications, and being aware of the benefits, harmful effects, and side effects of polypharmacy in older adults with multimorbidity.

Pulmonary syphilis with a cicatricial variant of organizing pneumonia: a case report.

BACKGROUND: Syphilis is a chronic disease that progresses in the primary, secondary, latent, and tertiary stages. Pulmonary manifestations of syphilis are rare, and their histological features have not been well-described. CASE PRESENTATION: A 78-year-old man was referred to our hospital because of a solitary nodular shadow in the right middle lung field on a chest radiograph. Five years prior, a rash appeared on both legs. He was tested for syphilis at a public health center, and the non-treponemal test result was negative. When he was approximately 35 years old, he had unspecified sexual intercourse. Chest computed tomography showed a 13-mm nodule with a cavity in S6 of the right lower lobe of the lung. Robot-assisted resection of the right lower lobe was performed because of suspected localized right lower lobe lung cancer. A cicatricial variant of organizing pneumonia (CiOP) was observed, and immunohistochemistry identified Treponema pallidum inside the macrophages in the nodule cavity. The rapid plasma regain (RPR) value was negative, and the Treponema pallidum hemagglutination assay was positive. The patient was diagnosed as having secondary syphilis with pulmonary involvement. Insidious progression of secondary syphilis may result in CiOP and a negative RPR test result. CONCLUSIONS: We report the first case of pulmonary syphilis with a histological pattern of CiOP. It may be asymptomatic and difficult to diagnose because the RPR test may be negative for a long period of time. When either non-treponemal or treponemal test results are positive, the possibility of pulmonary syphilis should be considered along with appropriate medical treatment.

Evaluation of Adverse Reactions to Influenza Vaccination: A Prospective Cohort Study.

This study aimed to investigate the influence of sex, age, and quadrivalent vaccination history on adverse reactions (ARs) to influenza vaccines and the relationship between the occurrence of ARs and the risk of influenza infection. Study participants were employees of three hospitals in the Hyogo Prefecture, Japan, who received the influenza vaccine in 2019. Data were collected using questionnaires. The main factors were age, sex, and history of influenza vaccination as a control. The primary outcomes were the incidence of local and systemic ARs attributable to the vaccine and positive influenza cases among the participants during the influenza season. Logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (CI). Among the 1493 participants, 80% experienced either local or systemic ARs. ARs were less common among men than among women (OR: 0.28, 95% CI: 0.21-0.37) and less common among those aged ≥60 years (OR: 0.48, 95% CI: 0.26-0.89). ARs were significantly more likely to occur in those with a history of influenza vaccination (OR: 1.96, 95% CI: 1.15-3.33). Those who had ARs, notably localized ones, were significantly more likely to incur influenza infection. Individuals who report ARs to influenza vaccination should strictly adopt non-pharmaceutical preventive measures in the hospital, community settings, and at home.

Association between Adverse Reactions to the First and Second Doses of COVID-19 Vaccine.

This study investigated the frequency of adverse reactions to COVID-19 vaccines in Japan and the impact of first-dose adverse reactions on second-dose adverse reactions. Individuals who received an mRNA COVID-19 vaccine at our center in March or April 2021 were included. Data were collected using questionnaires. The main factors were age (<40, 40−59, and >60 years), sex, underlying disease, and first-dose adverse reaction. The primary outcomes were incidence of local and systemic adverse reactions (ARs) attributable to the vaccine. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Among 671 participants, 90% experienced local or systemic ARs. An AR to the first dose was associated with a significantly increased risk of an AR to the second dose (OR: 49.63, 95% CI: 21.96−112.16). ARs were less common among men than among women (OR: 0.36, 95% CI: 0.17−0.76). Local ARs were less common among those aged 60 years or older (OR: 0.35, 95% CI: 0.18−0.66), whereas systemic ARs were more common among those aged under 40 years. Information on ARs to the first dose is important for healthcare providers and recipients when making vaccination decisions.

A Comparison of the Learning Effects of Face-to-Face Versus Online Formats of a Clinical Reasoning Lecture.

Objective This study investigated the different learning effects achieved through a clinical reasoning lecture that was simultaneously conducted via two formats: one format involved in-person face-to-face instruction, whereas the other provided remotely conducted online instruction. The lecture was based on a case presentation held at a participating university in 2015. Methods We compared the learning outcomes between the abovementioned formats based on participants' responses. Data were obtained using questionnaires distributed to eligible lecture attendees, including medical students and physicians who had graduated during the preceding 10 years. The questions were about the following aspects: the time duration of the lecture, degree of satisfaction with the online system (online attendees), and degree of satisfaction with the lecture content. The participants then completed a five-question mini-test related to the disease from the presented lecture case to assess their overall degree of understanding. Results Online participants gave significantly higher scores for images in the online system (degrees of satisfaction: online 72.7 ± 18.0 vs. in-person 55.6 ± 24.9), audio in the online system (66.1 ± 20.5 vs. 57.5 ± 25.8), the usefulness of multiple venues (82.1 ± 19.3 vs. 60.5 ± 25.0), intention to attend the next lecture (82.3 ± 19.0 vs. 65.8 ± 21.4), and overall meaningfulness of the lecture in the online interactive format (83.6 ± 16.3 vs. 72.6 ± 19.6) compared with the in-person group. However, similar mini-test scores were documented between the two groups (4.2 ± 0.7 for the in-person group and 4.3 ± 0.7 for the online group; no significant differences were noted). Conclusions The results show similar learning effects, degrees of satisfaction, and degrees of comprehension between online and in-person lecture attendees. Our findings demonstrate that the online format is a suitable pedagogical intervention in the study context. Continued implementation and further studies are thus warranted to gain deeper insights into the topic.

Efficient open recruitment and perspectives of host families on medical student homestays in rural Japan.

We devised and assessed open recruitment of host families for medical student homestays in a rural area of Hyogo Prefecture, Japan, so that program organizers would not have to depend on professional and personal connections. The duration of the homestays was one night and two days, and they were conducted in August 2016, 2017, and 2018. The purpose of this community-based medical education program was to promote interactions between medical students and residents of Tamba area. The study asked one family member from each host family to complete a questionnaire after the homestay, and their experiences were evaluated in the study. The questionnaire results were analyzed using a visual analog scale (VAS; 0-100 mm). Thirty-three host families participated in the homestay program over three years. Results showed that VAS scores were high for enjoyment of homestays (VAS; 92.4 ± 13.0), continuation of the homestay program (91.7 ± 12.7), continuation of participation in the homestay program (89.2 ± 16.2), and desire for the homestay students to work in the area in the future (95.4 ± 6.3). The recruitment of host families through advertising was an efficient method for this community-based medical education homestay program. The results indicate that it is possible to attract more host families through open recruitment, which will contribute to the sustainability of the homestay program. Further research, including a follow-up of the students who participated and whether they chose a rural area or Tamba to practice is needed in the future. Since this is an ongoing program, further research in a similar format can be conducted in the future.

Meningitis retention syndrome caused by varicella zoster virus in a patient without a rash: a case report.

BACKGROUND: Meningitis retention syndrome (MRS) is a rare condition that presents with acute urinary retention as a complication of aseptic meningitis. Cases of MRS due to varicella zoster virus (VZV) infection without a rash are rare. We report the case of a patient who had no signs of meningitis or VZV infection, including a rash. CASE PRESENTATION: A 58-year-old man presented with dysesthesia of the lower limbs and acute urinary retention. He had fever but no rash and no signs of meningitis. He was diagnosed to have VZV infection based on the detection of VZV DNA in the cerebrospinal fluid. He responded satisfactorily to a course of intravenous acyclovir and experienced no sequelae during a 2-year follow-up period. CONCLUSION: MRS due to aseptic meningitis of viral origin should be considered in the differential diagnosis of acute urinary retention even in the absence of specific signs and symptoms of meningitis or a suggestive rash.

Concerns and Anxieties of Patients During Hospitalization for COVID-19.

Objective The objective of this study was to evaluate the concerns and anxieties of hospitalized coronavirus disease (COVID-19) patients. Methods A questionnaire was distributed to patients on discharge. The responses were analyzed once they were returned by mail. Results Responses were received from 27 of 39 patients (average age, 50 ± 17 years). Among the participants, 16 were male (59.3%), 19 were symptomatic (70.4%), and two required a ventilator (7.4%). Anxiety about symptom exacerbation was reported by 36.0% of participants. Quarantine-associated stress was experienced by 60.0% of participants, and 72.0% of participants supported the change in federal policy that allows asymptomatic patients and patients with mild conditions to isolate themselves at a hotel or their home. Following discharge, 44.0% of participants experienced anxieties regarding their lives after discharge, and 56.0% were anxious regarding discrimination and rumors. During hospitalization, 68.0% of participants re-evaluated their attitude toward health, 44.0% regretted the preventative measures they took before contracting COVID-19, and 44.0% felt guilty for becoming infected. Conclusions Participants experienced various kinds of stress related to hospitalization for COVID-19. There was a trend of people being more concerned about their relationships than their own health. Therefore, as asymptomatic participants and participants with mild symptoms also experienced psychological stresses, it is also necessary to consider the psychological and social effects of the disease.

Changes in patients' outlook, behaviors, and attitudes toward COVID-19 after hospitalization and their experiences of discrimination and harassment.

OBJECTIVE: This study aims to examine changes in patients' perspectives and outlooks regarding the disease and their health after hospitalization for COVID-19 and investigate their discrimination and harassment experiences. This prospective observational study surveyed discharged patients who had been admitted to Hyogo Prefectural Tamba Medical Center in Japan for COVID-19. Patient characteristics, changes in outlook and behaviors after discharge, and incidents of discrimination and harassment were examined. The study was conducted in two waves: March-June 2020 and July-September 2020. RESULTS: Responses were obtained from 27 patients aged 50 ± 17 years, including 16 men (59.3%). We found most patients feared infection before hospitalization (88.5%) and had taken some preventive measures (96.3%), however after discharge, all (100%) practiced social distancing and infection prevention. Twenty patients (80%) considered changing their lifestyles, and 19 (79.2%) decided to use sick leave when they felt ill; these trends were more prominent during the second wave. Six patients (23.1%) reported experiencing discrimination or harassment after discharge. While most patients with COVID-19 had a strong fear of infection before hospitalization, their views about health and health behaviors changed after hospitalization.

Effects of Vaccination Day Routine Activities on Influenza Vaccine Efficacy and Vaccination-Induced Adverse Reaction Incidence: A Cohort Study.

We aimed to investigate the effect of vaccination day routine activities on the influenza vaccine efficacy and vaccination-induced adverse reaction incidence. Study participants were workers at three hospitals in the Hyogo Prefecture, Japan, who received the influenza vaccine between October and November, 2018 and 2019. Their data were collected using a questionnaire. The main factors, which were examined for vaccination day routine activities, were personal hygiene (bathing), smoking, alcohol consumption, caffeine intake, and exercise. The main outcome markers included influenza incidence during the winter season and vaccination-induced local or systemic adverse reaction incidence. The risk ratio for the main factors of vaccination day routine activities was calculated against the main outcome markers using the modified Poisson regression. Overall, 3780 people received the influenza vaccination, and 2731 submitted the questionnaire. We found that vaccination day routine activities did not affect the influenza vaccine efficacy, and engaging in strenuous exercise on the vaccination day tended to cause systemic adverse reactions. Moreover, lifestyle-related activities had no impact on the incidence of systemic or local adverse reactions. Therefore, it is advisable to only avoid strenuous physical exercise, and no other lifestyle-related restrictions are necessary on the day of influenza vaccination.

Acute kidney injury and acyclovir-associated encephalopathy after administration of valacyclovir in an elderly person with normal renal function: A case report and literature review.

INTRODUCTION: Acyclovir (ACV)-associated encephalopathy is related to an increase in plasma levels of 9-carboxymethoxymethylguanine, an ACV metabolite, and is often reported in patients with renal dysfunction. We report a case of ACV-associated encephalopathy with rapid progression of renal dysfunction after oral administration of valacyclovir (VACV) and review literature of previous ACV-associated encephalopathy cases. PATIENT CONCERNS: An 88-year-old man was diagnosed with herpes zoster. VACV (3000 mg/day) treatment was initiated. Serum creatinine (Cr) level was 0.80 mg/dL. However, irritability, memory impairment, and decreased responsiveness occurred after 3 days. The Cr level was 6.76 mg/dL on admission. DIAGNOSIS: He was diagnosed with ACV-associated encephalopathy with acute kidney injury. INTERVENTIONS: VACV was discontinued, hemodialysis was initiated on the day of admission, and then the signs and symptoms improved approximately 72 hours after the admission. CONCLUSION: Worsening of renal function and encephalopathy should be a focus when using VACV or ACV, regardless of age and original renal function. Acute kidney injury and ACV-associated encephalopathy may particularly occur in the elderly even when renal function is normal. Therefore, regular monitoring of renal function and consciousness is necessary during VACV treatment.

Invasive Haemophilus influenzae type a infection and polyarthritis in a 72-year-old Japanese man: A case report.

Haemophilus influenzae is a small, nonmotile, non-spore-forming bacterium classified into 6 serotypes (a to f) and non-typeable strains that lack a capsule. Although H. influenzae serotype a (Hia) is prevalent in Canada, the United States, Brazil, Australia, across the African continent, and several other locations, it has not been reported in Japan thus far. Our case was of a 72-year-old Japanese man who sought medical consultation after presenting with chills, fever, and polyarthritis. Cultures of blood and synovial fluid from the left knee revealed H. influenzae infection. Diagnostic imaging showed poor contrast regions in both kidneys, fluid retention around both knee joints, the left shoulder joint, and both elbow joints. Subsequently, the patient was diagnosed with invasive H. influenzae infection accompanied by polyarthritis and renal infarction. 16S ribosomal RNA gene sequencing revealed that the bacterial strain was Hia. The patient was treated with antimicrobial agents and arthroscopic curettage. We present a case of invasive Hia infection accompanied by polyarthritis and renal infarction. To the best of our knowledge, this is the first case of Hia infection in Japan. The case is very rare considering that the disease occurred in an elderly patient who developed polyarthritis.

Toxic shock syndrome with a cytokine storm caused by Staphylococcus simulans: a case report.

BACKGROUND: Exotoxins secreted from Staphylococcus aureus or Streptococcus pyogenes act as superantigens that induce systemic release of inflammatory cytokines and are a common cause of toxic shock syndrome (TSS). However, little is known about TSS caused by coagulase-negative staphylococci (CoNS) and the underlying mechanisms. Here, we present a rare case of TSS caused by Staphylococcus simulans (S. simulans). CASE PRESENTATION: We report the case of a 75-year-old woman who developed pneumococcal pneumonia and bacteremia from S. simulans following an influenza infection. The patient met the clinical criteria for probable TSS, and her symptoms included fever of 39.5 °C, diffuse macular erythroderma, conjunctival congestion, vomiting, diarrhea, liver dysfunction, and disorientation. Therefore, the following treatment was initiated for bacterial pneumonia complicating influenza A with suspected TSS: meropenem (1 g every 8 h), vancomycin (1 g every 12 h), and clindamycin (600 mg every 8 h). Blood cultures taken on the day after admission were positive for CoNS, whereas sputum and pharyngeal cultures grew Streptococcus pneumoniae (Geckler group 4) and methicillin-sensitive S. aureus, respectively. However, exotoxins thought to cause TSS, such as TSS toxin-1 and various enterotoxins, were not detected. The patient's therapy was switched to cefazolin (2 g every 8 h) and clindamycin (600 mg every 8 h) for 14 days based on microbiologic test results. She developed desquamation of the fingers on hospital day 8 and was diagnosed with TSS. Conventional exotoxins, such as TSST-1, and S. aureus enterotoxins were not detected in culture samples. The serum levels of inflammatory cytokines, such as neopterin and IL-6, were high. CD8+ T cells were activated in peripheral blood. Vß2+ population activation, which is characteristic for TSST-1, was not observed in the Vß usage of CD8+ T cells in T cell receptor Vß repertoire distribution analysis. CONCLUSIONS: We present a case of S. simulans-induced TSS. Taken together, we speculate that no specific exotoxins are involved in the induction of TSS in this patient. A likely mechanism is uncontrolled cytokine release (i.e., cytokine storm) induced by non-specific immune reactions against CoNS proliferation.

End-of-life home care of an interstitial pneumonia patient supported by high-flow nasal cannula therapy: A case report.

BACKGROUND: High-flow nasal cannula (HFNC) therapy and morphine continuous subcutaneous infusion (CSI) have been used to ameliorate dyspnea in non-cancer patients with end-stage respiratory diseases, including chronic obstructive pulmonary disease and interstitial pneumonia, primarily in hospital settings. However, it is rare to perform home-based medical treatment using these. We observe a case to assess the feasibility of this treatment strategy. CASE SUMMARY: Here, we report a case of a 75-year-old man who was diagnosed with interstitial pneumonia 11 years ago and was successfully nursed at home during his terminal phase for over 10 mo without hospitalization, by introducing domiciliary uses of HFNC and morphine CSI with a patient-controlled analgesia device. CONCLUSION: Active utilization of HFNC and morphine CSI with patient-controlled analgesia device would substantiate successful end-of-life palliative home care of idiopathic interstitial pneumonia patients.

Acceptance of a homestay program and attitude toward community medicine among medical students.

BACKGROUND: In community-based medical education, opportunities for medical students to interact with local residents are important. To facilitate such interaction, we aimed to evaluate acceptance of a homestay program and attitude toward community medicine among medical students. METHODS: The participants (n = 39) were allowed to stay in the local homes of residents for one night in August 2016, 2017, and 2018. Before and after the homestays, the students responded to a self-reported questionnaire using the visual analog scale (VAS; 0-100 mm). The questionnaire included four questions on homestay/community medical training and community medicine and four questions about attitude toward community medicine in the local areas of medical students. Then, we compared the VAS scores before and after training. RESULTS: The VAS scores for all questions about homestay/community medical training and community medicine significantly increased: "Is it worthwhile for you to have experience in the field of community medicine," "Did you find the homestay enjoyable," "Does the homestay add educational significance to the program," and "Is direct interaction with residents meaningful?" For the two questions about attitude toward community medicine, the VAS scores significantly increased: "Is there a challenge to practicing community medicine" and "In the future, do you want to work in Tamba area where you stayed?" CONCLUSIONS: The medical students were extremely enthusiastic about the educational program for community medicine involving residential homestays, which improved their attitudes toward practicing community medicine. Moreover, the students appreciated that their training sites could become their future workplaces.

[Curd Formation Resulting from a Reaction between Cranberry Juice and Enteral Formula].

White solids were observed in the esophagus of a patient with multiple system atrophy. The patient was receiving enteral nutrition with a polymeric formula and cranberry juice via nasogastric feeding. To test the assumption that the precipitates were formed from a reaction between the juice and the formula, a verification experiment was conducted usingformulae of differinging redients, pH and protein content. The results indicated that a precipitate was formed when formulae with lower pH values and higher protein content were used. Mixing a pH neutral enteral formula with cranberry juice, vinegar or their 2- fold diluted solutions may result in the formation of precipitates in the stomach and esophagus.

Adult-onset Still's disease with macrophage activation syndrome diagnosed and treated based on cytokine profiling: a case-based review.

Adult-onset Still's disease (AOSD) is a relatively rare systemic inflammatory disorder and is diagnosed using various sets of classification criteria, with the Yamaguchi criteria as the most widely used criteria. Herein, we present the case of a 21-year-old woman admitted with a high fever, lasting for over 1 month, who did not fulfill the Yamaguchi criteria. However, by analyzing the inflammatory cytokine profile, we defined this case as AOSD based on a greatly elevated serum interleukin-18 level. In addition, we predicted the occurrence of macrophage activation syndrome by a characteristic increase in the soluble tumor necrosis factor receptor II level, which allowed a timely intervention for this malicious complication. Therefore, we suggest that cytokine profiling will be useful for the diagnosis and management of AOSD.

Two cases of pneumococcal spondylitis in the same household: a case report.

BACKGROUND: Pneumococci normally reside in the nasopharynx, and when individuals are in close contact with each other such as in a community or a family setting, it is transmitted from carriers and sometimes results in pneumonia. CASE PRESENTATION: Case 1: The patient was a 55-year-old woman who visited the hospital complaining of fever and headache. Lumbar pain occurred on hospital day 2, and purulent spondylitis was diagnosed using lumbar MRI. Blood culture results were positive for pneumococcus. Case 2: The patient was a 60-year-old male, and the husband of the woman in the Case 1. Fever and lumbar pain occurred on the same day similar to Case 1. Inpatient treatment was provided for pneumococcal bacteremia. Although no abnormalities were observed on the lumbar MRI scan taken on hospital day 2, purulent spondylitis was diagnosed by an MRI taken on hospital day 9. Both patients received appropriate antimicrobial treatment. When bacterial strain analysis was performed on samples from Cases 1 and 2, we noted that the capsule serotype was 12F, the drug sensitivity was similar, and the sequence typing matched completely, indicating that the causative bacteria for both cases were identical. CONCLUSIONS: Pneumococcal bacteremia and purulent spondylitis can occur in different members of a family simultaneously. Pneumococcal infection can transmit between two close family members; hence, whenever a close family member of an individual who has already been infected with pneumococcal infection, develops fever, the possibility of transmission must be considered.