Feedback of patient survey on medication improves the management of polypharmacy: a pilot trial.

BACKGROUND: Patient awareness surveys on polypharmacy have been reported previously, but no previous study has examined the effects of sending feedback to health professionals on reducing medication use. Our study aimed to conduct a patient survey to examine factors contributing to polypharmacy, feedback the results to health professionals, and analyze the resulting changes in the number of polypharmacy patients and prescribed medications. METHODS: After conducting a questionnaire survey of patients in Study 1, we provided its results to the healthcare professionals, and then surveyed the number of polypharmacy patients and oral medications using a before-after comparative study design in Study 2. In Study 1, we examined polypharmacy and its contributing factors by performing logistic regression analysis. In Study 2, we performed a t-test and a chi-square test. RESULTS: In the questionnaire survey, significant differences were found in the following 3 items: age (odds ratio (OR) = 3.14; 95% confidence interval (CI) = 2.01-4.91), number of medical institutions (OR = 2.34; 95%CI = 1.50-3.64), and patients' difficulty with asking their doctors to deprescribe their medications (OR = 2.21; 95%CI = 1.25-3.90). After the feedback, the number of polypharmacy patients decreased from 175 to 159 individuals and the mean number of prescribed medications per patient decreased from 8.2 to 7.7 (p < 0.001, respectively). CONCLUSIONS: Providing feedback to health professionals on polypharmacy survey results may lead to a decrease in the number of polypharmacy patients. Factors contributing to polypharmacy included age (75 years or older), the number of medical institutions (2 or more institutions), and patients' difficulty with asking their physicians to deprescribe their medications. Feedback to health professionals reduced the percentage of polypharmacy patients and the number of prescribed medications. TRIAL REGISTRATION: UMIN. Registered 21 June 2020 - Retrospectively registered, https://www.umin.ac.jp/ctr/index-j.htm.

How Accurate Are First Visit Diagnoses Using Synchronous Video Visits with Physicians?

BACKGROUND: Telediagnosis (TD), which uses information and communications technology, has recently undergone rapid development. Since no studies have compared the diagnostic precision of TD to that of face-to-face diagnosis (FD), we examined and compared the diagnostic accuracy of these diagnostic approaches among general medicine outpatients. METHODS: Data of 97 patients (45 men and 52 women with a mean age of 52 years) who underwent initial examinations at a regional hospital were analyzed. Two fully trained general medicine physicians were selected from a group of three physicians to perform FD and TD. Levels of agreement (as κ coefficients) were determined between TD and FD diagnoses as well as between final diagnoses and TD and FD diagnoses. RESULTS: The κ coefficients were 0.75 for TD and FD and 0.81 for both, the final diagnoses and the TD and FD diagnoses, revealing a sufficiently high level of diagnostic agreement. CONCLUSIONS: TD can provide the same level of diagnostic accuracy as FD among general medicine outpatients for adults. The help of medical assistants and the utilization of physical examination devices might enable medical staff to provide TD care similar in quality to FD. TD could be a useful diagnostic tool when medical work force is limited (e.g., in remote areas, during natural disasters, and in at-home care).

Behavior-based medical diagnosis-Applying perspectives of behavioral science to clinical reasoning.

Behavioral science, the scientific study of human behavior and the elucidation of its laws, is also applied to medicine, and is included in pre-graduate education.Understanding patient behaviors that correspond to behavior-based medical diagnosis and interpreting the clinical information suggested by these patient behaviors can be useful in avoiding diagnostic errors in clinical practice.

Relationship between the presence of primary care physicians and health-related quality of life.

Background: The supply of primary care physicians is associated with better health outcomes and a lower total cost of health services. However, the effect of the presence or absence of primary care physicians on health-related quality of life (QOL) is unknown. We comparatively investigated the health-related QOL of ordinary citizens according to the presence or absence of a primary care physician. Methods: We conducted an observational cross-sectional study using a propensity score analysis. A questionnaire on health-related QOL (SF-36v2, age, gender, presence or absence of a primary care physician, and chronic disease status) was mailed to 2200 individuals identified through stratified random sampling. We used propensity scores to compensate for covariates and analyzed three component SF-36 summary scores and subscale scores of the "primary care physician" and "no primary care physician" groups. Results: Valid responses were received from 1095 individuals (49.8%). The "primary care physician group" comprised 653 individuals (59.6%). The physical health component scores of the "primary care physician group" were significantly lower than those of the "no primary care physician group," and the "mental health component" scores were significantly higher (p = 0.032, p = 0.009). For the subscales, scores for "vitality" and "mental health" were significantly higher in the "primary care physician group" (p = 0.014, p = 0.018). Conclusions: Patients who had a primary care physician with whom they could comfortably consult at any time had a high mental health component score, and low physical health component score in the health-related QOL.

The Clinical Key Features of Persistent Postural Perceptual Dizziness in the General Medicine Outpatient Setting: A Case Series Study of 33 Patients.

Objective This case series aimed to investigate the clinical and pathological characteristics of persistent postural perceptual dizziness (PPPD). Methods We retrospectively examined the medical records of patients with chronic dizziness in our department, and tracked the percentage of PPPD, the age and sex, disorder duration, exacerbating factors for dizziness, and duration of momentary worsening dizziness. We also examined the duration of momentary worsening dizziness in cases of depression, anxiety disorder, and somatic symptom disorder. Results Among 229 patients with chronic dizziness, 14.4% (33/229) met the diagnostic criteria for PPPD. PPPD was the second most common disorder of patients with chronic dizziness after depression. The median age of patients with PPPD was 75 (75.8% female) and the median duration of the disorder was 60 months (range: 3-360 months). The exacerbating factors were motion without regard to direction or position (90.9%), upright posture (66.7%), and exposure to moving visual stimuli or complex visual patterns (30.3%). While the duration of momentary worsening dizziness was less than 10 minutes in 93.9% of patients with PPPD, the duration in patients with depression, anxiety disorder, and somatic symptom disorder were 3.6 % (2/55), 16.1% (5/31), and 0% (0/11), respectively. When the duration was less than 10 minutes, the odds ratios of PPPD for depression and anxiety disorder were 46.5 (95% CI: 6.1-362.0) and 40.3 (95% CI: 7.4-219.3), respectively. Conclusion Short episodes of momentary worsening dizziness constitute a distinctive feature of PPPD that may be useful for differentiating PPPD from other types of psychogenic dizziness.

Do Checklist-Induced Behavioral Changes Improve Self-Confidence in Fundoscopic Examination? A Mixed-Methods Study.

PURPOSE: Fundoscopic exams are conducted during outpatient consultations to assess intracranial disease and complications from chronic diseases. Low level of confidence in these skills which physicians have is one of the causes that implementation frequency is low. Research has not yet identified specific measures through which the healthcare system may increase the implementation of fundoscopic exams nor a qualitative process that enables physicians to gain confidence in their fundoscopic exam skills. We introduced a checklist and conducted a mixed-methods study. METHODS: This study is a before-and-after study, within an embedded-experimental mixed-methods design. We sampled 15 physicians in the department of general medicine at a university hospital assigned to initial consultation. We introduced a checklist to verify whether the fundoscopic exam was implemented. Measures are implementation ratio of the fundoscopic exam to the total number of indication cases, and Visual Analog Scale (VAS) values for the confidence in procedure are measured before and after the intervention. We obtained qualitative data from interviews and used the Modified Grounded Theory Approach. RESULTS: We observed significant increases in the implementation ratio (19.2% (29/151 cases) vs 64.8% (105/162 cases), p<0.001) and in the VAS value for the confidence (1.89 mm vs 4.68 mm (p<0.001)). Analysis of the interviews revealed the following. To increase the implementation, it is necessary to reduce the and , which is prevented by the checklist. The leads to a . Repeated executions result in . CONCLUSION: The intervention increased the implementation ratio, thereby increasing successful experiences and confidence among physicians. The growth of confidence boosted motivations to implement fundoscopic exams.

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.

Bilateral variations of the vertebral arteries: the left originating from the aortic arch and the left and right entering the C5 transverse foramina.

During the dissection course for second year medical students at the University of Toyama in 2005, we encountered variations of the bilateral vertebral arteries: the left directly came off from the aortic arch as the third branch between the left common carotid artery and the left subclavian artery and entered the transverse foramen of C5, instead of C6, whereas the right originated from the right subclavian artery and entered the transverse foramen of C5. The present vertebral artery of each side was possibly formed by the 6th cervical intersegmental artery linked with the longitudinal anastomoses between the cervical intersegmental arteries. Detailed knowledge of vertebral artery variations is crucially important for surgical treatment of blood vessels in the brain, neck and chest.

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.

Utilizing a medical questionnaire to predict anxiety and depression in outpatients.

INTRODUCTION: Anxiety and depressive symptoms are seen in patients with anxiety and mood disorders but are also common in those with organic disorders. However, since physical symptoms are predominant complaints from patients who visit nonpsychiatric outpatient clinics, anxiety and depressive symptoms are often unrecognized. It is important for physicians to be aware of these issues concurrent with the physical symptoms. We therefore examined whether a self-administered medical questionnaire could identify anxiety and depressive symptoms. PATIENTS AND METHODS: A total of 453 patients on their first visit to the Department of General Medicine, Chiba University Hospital, Chiba, Japan, participated in this study. They were asked to complete a medical questionnaire and the Hospital Anxiety and Depression Scale questionnaire before examination. Data on age, sex, number of complaints, symptom duration, and number of previous physicians were extracted from the medical questionnaire. These data were used as independent variables in logistic regression analysis to develop a predictive model for the presence of anxiety and depressive symptoms. RESULTS: Data from 358 (79.0%) patients were included in the analyses. Logistic regression analysis identified the following predictors: "three or more complaints" (odds ratio [OR] 2.39; 95% confidence interval [CI] 1.48-3.88) and "four or more previous physicians" (OR 1.72; 95% CI 1.10-2.69). In the predictive model for the presence of symptoms of anxiety and depression, the likelihood ratio was 2.40 (95% CI 1.33-4.34) in patients reporting both conditions and 1.35 (95% CI 1.04-1.77) in those reporting either condition. CONCLUSION: The presence of anxiety and depressive symptoms can be predicted from the items of a medical questionnaire in outpatients visiting a general medicine department of a university hospital. When patients report three or more complaints or four or more previous physicians on a medical questionnaire, physicians should consider the presence of anxiety or depression or both in differential diagnosis.

Olmesartan-induced Enteropathy Manifesting as Wernicke-Korsakoff Syndrome.

Cases of sprue-like enteropathy associated with olmesartan have sporadically been encountered since it was first reported in 2012, and their most characteristic manifestation is severe diarrhea. We herein report the first case of sprue-like enteropathy manifesting as Wernicke-Korsakoff syndrome due to vitamin B1 malabsorption with only minimally increased bowel movements. When patients are receiving olmesartan and they complain of nonspecific chronic gastrointestinal symptoms, it is important to consider changing the drugs before any serious malabsorption syndrome develops.

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.

Iliac Vein Compression Syndrome due to Bladder Distention Caused by Urethral Calculi.

We report a rare case of iliac vein compression syndrome caused by urethral calculus. A 71-year-old man had a history of urethral stenosis. He complained of bilateral leg edema and dysuria for 1 week. Physical examination revealed bilateral distention of the superficial epigastric veins, so obstruction of both common iliac veins or the inferior vena cava was suspected. Plain abdominal computed tomography showed a calculus in the pendulous urethra, distention of the bladder (as well as the right renal pelvis and ureter), and compression of the bilateral common iliac veins by the distended bladder. Iliac vein compression syndrome was diagnosed. Bilateral iliac vein compression due to bladder distention (secondary to neurogenic bladder, benign prostatic hyperplasia, or urethral calculus as in this case) is an infrequent cause of acute bilateral leg edema. Detecting distention of the superficial epigastric veins provides a clue for diagnosis of this syndrome.

Satisfaction of Patients and Physicians with Outpatient Consultations at a University Hospital.

OBJECTIVE: This study was performed to investigate the factors influencing the correlation between physician satisfaction and patient satisfaction in an outpatient setting. METHODS: New patients attending the General Medicine Outpatient Clinic of Chiba University Hospital and their physicians were enrolled. After the initial consultation, both the patients and the physicians completed an anonymous questionnaire. RESULTS: There were 875 patients (381 men and 494 women; mean age: 54 years) and 10 physicians (4 men and 6 women; mean experience: 6 years). The satisfaction of the patients and the physicians was not correlated (r=0.14, p<0.001). A logistic regression analysis revealed that the factors associated with greater physician satisfaction were "guidance/advice from senior colleagues" [odds ratio (OR)=2.03; 95% confidence interval (CI)=1.76-2.34] and "confidence in the diagnosis" (OR=1.52; 95%CI=1.37-1.69), while "a difficult patient" (OR=0.73; 95%CI=0.68-0.78) was associated with reduced satisfaction. The factors associated with greater patient satisfaction were "the doctor listened carefully" (OR=1.98; 95%CI=1.62-2.42) and "my diagnosis is correct" (OR=1.57; 95%CI=1.41-1.74). One item in the questionnaire for the physicians, "I diagnosed psychogenic illness" (OR=0.87; 95%CI=0.81-0.94), was associated with lower patient satisfaction. CONCLUSION: The satisfaction of the patients and the physicians was not correlated. If only the factors promoting the satisfaction of one party are targeted, the satisfaction of the other party will not increase. The satisfaction of the physicians may be increased by receiving advice from mentors and an improved diagnostic ability, while the patients wants a physician who listens carefully and makes the correct diagnosis.

Hd3a and RFT1 are essential for flowering in rice.

RICE FLOWERING LOCUS T 1 (RFT1/FT-L3) is the closest homologue of Heading date 3a (Hd3a), which is thought to encode a mobile flowering signal and promote floral transition under short-day (SD) conditions. RFT1 is located only 11.5 kb from Hd3a on chromosome 6. Although RFT1 RNAi plants flowered normally, double RFT1-Hd3a RNAi plants did not flower up to 300 days after sowing (DAS), indicating that Hd3a and RFT1 are essential for flowering in rice. RFT1 expression was very low in wild-type plants, but there was a marked increase in RFT1 expression by 70 DAS in Hd3a RNAi plants, which flowered 90 DAS. H3K9 acetylation around the transcription initiation site of the RFT1 locus had increased by 70 DAS but not at 35 DAS. In the absence of Hd3a and RFT1 expression, transcription of OsMADS14 and OsMADS15, two rice orthologues of Arabidopsis APETALA1, was strongly reduced, suggesting that they act downstream of Hd3a and RFT1. These results indicate that Hd3a and RFT1 act as floral activators under SD conditions, and that RFT1 expression is partly regulated by chromatin modification.