Experience of caring for patients with COVID-19 and educational achievement among Japanese resident physicians: a nationwide survey with general medicine in-training examination.

BACKGROUND: As healthcare professional trainees, resident physicians are expected to help with COVID-19 care in various ways. Many resident physicians worldwide have cared for COVID-19 patients despite the increased risk of burnout. However, few studies have examined the experience with COVID-19 care among resident physicians and its effects on competency achievement regarding clinical basics and COVID-19 patient care. METHOD: This nationwide, cross-sectional Japanese study used a clinical training environment questionnaire for resident physicians (PGY-1 and - 2) in 593 teaching hospitals during the General Medicine In-Training Examination in January 2021. The General Medicine In-Training Examination questions comprised four categories (medical interviews and professionalism; symptomatology and clinical reasoning; physical examination and clinical procedures; and disease knowledge) and a COVID-19-related question. We examined the COVID-19 care experience and its relationship with the General Medicine In-Training Examination score, adjusting for resident and hospital variables. RESULTS: Of the 6,049 resident physicians, 2,841 (47.0%) had no experience caring for patients with COVID-19 during 2020. Total and categorical General Medicine In-Training Examination scores were not different irrespective of the experience with COVID-19 patient care. For the COVID-19-related question, residents with experience in COVID-19 care showed a significant increase in correct response by 2.6% (95% confidence interval, 0.3-4.9%; p = 0.028). CONCLUSIONS: The resident physicians' COVID-19 care experience was associated with better achievement of COVID-19-related competency without reducing clinical basics. However, approximately half of the residents missed the critical experience of caring for patients during this unparalleled pandemic in Japan.

Comparison of serum acylcarnitine levels in patients with myalgic encephalomyelitis/chronic fatigue syndrome and healthy controls: a systematic review and meta-analysis.

BACKGROUND: Myalgic encephalomyelitis/chronic fatigue syndrome/systemic exertion intolerance disease (ME/CFS/SEID) is a condition diagnosed primarily based on clinical symptoms, including prolonged fatigue and post-exertional malaise; however, there is no specific test for the disease. Additionally, diagnosis can be challenging since healthcare professionals may lack sufficient knowledge about the disease. Prior studies have shown that patients with ME/CFS/SEID have low serum acylcarnitine levels, which may serve as a surrogate test for patients suspected of having this disease. This systematic review and meta-analysis aimed to investigate the differences in serum acylcarnitine levels between patients with ME/CFS/SEID and healthy controls. METHODS: This systematic review was conducted using PubMed and Ichushi-Web databases. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we included all studies from the databases' inception until February 17, 2023, that evaluated blood tests in both patients with ME/CFS/SEID and healthy control groups. The primary endpoint was the difference in serum acylcarnitine levels between the two groups. RESULTS: The electronic search identified 276 studies. Among them, seven met the eligibility criteria. The serum acylcarnitine levels were analyzed in 403 patients with ME/CFS/SEID. The patient group had significantly lower serum acylcarnitine levels when compared with the control group, and the statistical heterogeneity was high. CONCLUSION: The patient group had significantly lower serum acylcarnitine levels when compared with the control group. In the future, the measurement of serum acylcarnitine levels, in addition to clinical symptoms, may prove to be a valuable diagnostic tool for this condition.

Aseptic meningitis after amenamevir treatment for herpes zoster ophthalmicus with oculomotor nerve palsy in a patient taking immunosuppressant.

A 79-year-old woman presented with vomiting after being prescribed amenamevir by her primary care physician. She had a medical history of rheumatoid arthritis and was administered prednisolone and methotrexate. She was finally diagnosed with herpes zoster ophthalmicus and aseptic meningitis, and intravenous antiviral therapy was initiated. However, the patient developed oculomotor nerve palsy on the 11th day of hospitalization. In this case, there was a time lag between the administration of antiviral drugs and clinical improvement. Our case suggests the necessity of selecting antivirals, especially in high-risk cases of CNS complications, to avoid the low intracerebral transferability of antiviral drugs, including amenamevir.

Association between prolonged weekly duty hours and self-study time among residents: a cross-sectional study.

PURPOSE: In 2024, the Japanese government will enforce a maximum 80-hour weekly duty hours (DHs) regulation for medical residents. Although this reduction in weekly DHs could increase the self-study time (SST) of these residents, the relationship between these two variables remains unclear. The aim of the study was to investigate the relationship between the SST and DHs of residents in Japan. METHODS: In this nationwide cross-sectional study, the subjects were candidates of the General Medicine In-Training Examination in the 2020 academic year. We administered questionnaires and categorically asked questions regarding daily SST and weekly DHs during the training period. To account for hospital variability, proportional odds regression models with generalized estimating equations were used to analyse the association between SST and DHs. RESULTS: Of the surveyed 6117 residents, 32.0% were female, 49.1% were postgraduate year-1 residents, 83.8% were affiliated with community hospitals, and 19.9% worked for ≥80 hours/week. Multivariable analysis revealed that residents working ≥80 hours/week spent more time on self-study than those working 60-70 hours/week. Conversely, residents who worked <50 hours/week spent less time on self-study than those who worked 60-70 hours/week. The factors associated with longer SST were sex, postgraduate year, career aspiration for internal medicine, affiliation with community hospitals, academic involvement, and well-being. CONCLUSION: Residents with long DHs had longer SSTs than residents with short DHs. Future DH restrictions may not increase but rather decrease resident SST. Effective measures to encourage self-study are required, as DH restrictions may shorten SST.

Prevalence and appropriateness of indwelling urinary catheters in Japanese hospital wards: a multicenter point prevalence study.

BACKGROUND: Indwelling urinary catheters are commonly used in hospitalized patients, which can lead to the development of urinary catheter complications, including catheter-associated urinary tract infection (CAUTI). Limited reports on the appropriateness of urinary catheter use exist in Japan. This study investigated the prevalence and appropriateness of indwelling urinary catheters, and the incidence of CAUTI in non-intensive care unit (non-ICU) wards in Japanese hospitals. METHODS: This prospective observational study was conducted in 7 non-ICU wards from 6 hospitals in Japan from October 2017 to June 2018. At each hospital the study teams evaluated urinary catheter prevalence through in-person bedside evaluation for at least 5 days of each week for 3 months. Catheter associated urinary tract infection (CAUTI) incidence and appropriateness of catheter use was collected via chart review. RESULTS: We assessed 710 catheter-days over 5528 patient-days. The mean prevalence of indwelling urinary catheter use in participating wards was 13% (range: 5% to 19%), while the mean incidence of CAUTI was 9.86 per 1000 catheter-days (range: 0 to 33.90). Approximately 66% of the urinary catheter days assessed had an appropriate indication for use (range: 17% to 81%). A physician's order for catheter placement was present in only 10% of catheterized patients. CONCLUSION: This multicenter study provides epidemiological information about the appropriate use of urinary catheters in Japanese non-ICU wards. A multimodal intervention may help improve the appropriate use of urinary catheters.

Inappropriate use of antibiotics in primary care for patients with infective endocarditis.

Inappropriate use of antibiotics without blood cultures could delay diagnosis of infective endocarditis (IE). The pattern of use of antibiotics by primary care physicians who were later diagnosed with IE is unclear. A retrospective cohort study of patients with a definite diagnosis of IE at a community teaching hospital in the Kanagawa prefecture was performed over a 12-year period (2006-2017). Of the 145 patients, 38 patients (26%) had initially attended primary care clinics. The mean age was 63 ± 18 years, and 24 patients (63%) were men. Only one patient (3%) was prescribed antibiotics after obtaining blood cultures. Twenty patients (53%) received antibiotics. Fluoroquinolones (50%) and macrolides (25%) were the most antibiotics prescribed. There were no obvious differences in physicians' specialty between the prescriber and non-prescriber groups. Compared to patients without antibiotic prescription, those prescribed antibiotics had delayed admission and higher mortality (10 vs. 14 days and 11% vs. 30%, respectively). In conclusions, about one-quarter of IE patients initially attended primary care clinics. Of them, about half were inappropriately prescribed antibiotics (without blood cultures obtaining). IE patients receiving inappropriate antibiotics potentially have a worse outcome.

Delayed isolation of smear-positive pulmonary tuberculosis patients in a Japanese acute care hospital.

BACKGROUND: Active pulmonary tuberculosis (TB) is associated with intra-hospital spread of the disease. Expeditious diagnosis and isolation are critical for infection control. However, factors that lead to delayed isolation of smear-positive pulmonary TB patients, especially among the elderly, have not been reported. The purpose of this study is to investigate factors associated with delay in the isolation of smear-positive TB patients. METHODS: All patients with smear-positive pulmonary TB admitted between January 2008 and December 2016 were included. The setting was a Japanese acute care teaching hospital. Following univariate analysis, significant factors in the model were analyzed using the multivariate Cox proportional hazard model. RESULTS: Sixty-nine patients with mean age of 81 years were included. The median day to the isolation of pulmonary TB was 1 day with interquartile range, 1-4 days. On univariate analysis, the time to isolation was significantly delayed in male patients (p = 0.009), in patient who had prior treatment with newer quinolone antibiotics (p = 0.027), in patients who did not have chronic cough (p = 0.023), in patients who did not have appetite loss (p = 0.037), and in patients with non-cavitary lesion (p = 0.005), lesion located other than in the upper zone (p = 0.015), and non-disseminated lesion on the chest radiograph (p = 0.028). On multivariate analysis, the time to isolation was significantly delayed in male patients (hazard ratio [HR], 0.47; 95% confidence interval [CI], 0.25 to 0.89; P = 0.02), in patients who did not have chronic chough (HR, 0.52; 95% CI, 0.28 to 0.95; P = 0.033), and in patients with non-cavitary lesion on the chest radiograph (HR, 0.46; 95% CI, 0.23 to 0.92; P = 0.028). CONCLUSIONS: In acute care hospitals of an aging society, prompt diagnosis and isolation of TB patients are important for the protection of other patients and healthcare providers. Delay in isolation is associated with male gender, absence of chronic cough, and presence of non-cavitary lesions on the chest radiograph.

A Contemporaneous Onset of Eosinophilic Granulomatosis with Polyangiitis and Myasthenia Gravis: A Case Report.

Autoimmune neuromuscular disorders in patients with eosinophilic granulomatosis with polyangiitis (EGPA) are relatively uncommon. Although two cases of myasthenia gravis (MG) comorbid with EGPA have been reported, both patients developed EGPA several years after starting immunosuppressive treatment for MG. We herein report a 75-year-old man with a rare co-occurrence of EGPA and MG that developed simultaneously and was successfully treated with immunosuppressive therapy. Distinguishing the neurological symptoms of EGPA from complications of other neurological autoimmune diseases, such as MG, is crucial, especially in patients with eosinophilia.

Association of sleep quality with duty hours, mental health, and medical errors among Japanese postgraduate residents: a cross-sectional study.

Long duty hours (DH) impair sleep and negatively affect residents' health and medical safety. This cross-sectional study investigated the association among residents' DH, sleep duration, insomnia, sleep impairment, depressive symptoms, and self-reported medical errors among 5579 residents in Japan who completed the General Medicine In-Training Examination (2021) and participated in the training-environment survey. Weekly DH was classified under seven categories. Sleep duration and insomnia symptoms, from the Athens Insomnia Scale, were analysed to determine sleep impairment; depressive symptoms and medical errors were self-reported. Among 5095 residents, 15.5% slept < 5 h/day, and 26.7% had insomnia. In multivariable analysis, compared with ≥ 60 and < 70, DH ≥ 90 h/week associated with shorter sleep duration and worsen insomnia symptoms. Shorter durations of sleep and more intense symptoms of insomnia were associated with increased depressive symptoms. Medical errors increased only among residents with insomnia, but were not associated with sleep duration. DH > 90 h/week could lead to shorter sleep duration, worsen insomnia symptoms, and negatively impact well-being and medical safety. There was no significant association between sleep duration and medical errors; however, insomnia conferred an increased risk of medical errors. Limiting DH for residents to avoid excessive workload can help improve resident sleep, enhance resident well-being, and potentially reduce insomnia-associated medical errors.

Hospital Use of a Web-Based Clinical Knowledge Support System and In-Training Examination Performance Among Postgraduate Resident Physicians in Japan: Nationwide Observational Study.

Background: The relationship between educational outcomes and the use of web-based clinical knowledge support systems in teaching hospitals remains unknown in Japan. A previous study on this topic could have been affected by recall bias because of the use of a self-reported questionnaire. Objective: We aimed to explore the relationship between the use of the Wolters Kluwer UpToDate clinical knowledge support system in teaching hospitals and residents' General Medicine In-Training Examination (GM-ITE) scores. In this study, we objectively evaluated the relationship between the total number of UpToDate hospital use logs and the GM-ITE scores. Methods: This nationwide cross-sectional study included postgraduate year-1 and -2 residents who had taken the examination in the 2020 academic year. Hospital-level information was obtained from published web pages, and UpToDate hospital use logs were provided by Wolters Kluwer. We evaluated the relationship between the total number of UpToDate hospital use logs and residents' GM-ITE scores. We analyzed 215 teaching hospitals with at least 5 GM-ITE examinees and hospital use logs from 2017 to 2019. Results: The study population consisted of 3013 residents from 215 teaching hospitals with at least 5 GM-ITE examinees and web-based resource use log data from 2017 to 2019. High-use hospital residents had significantly higher GM-ITE scores than low-use hospital residents (mean 26.9, SD 2.0 vs mean 26.2, SD 2.3; P=.009; Cohen d=0.35, 95% CI 0.08-0.62). The GM-ITE scores were significantly correlated with the total number of hospital use logs (Pearson r=0.28; P<.001). The multilevel analysis revealed a positive association between the total number of logs divided by the number of hospital physicians and the GM-ITE scores (estimated coefficient=0.36, 95% CI 0.14-0.59; P=.001). Conclusions: The findings suggest that the development of residents' clinical reasoning abilities through UpToDate is associated with high GM-ITE scores. Thus, higher use of UpToDate may lead physicians and residents in high-use hospitals to increase the implementation of evidence-based medicine, leading to high educational outcomes.

A case of post-COVID-19 myalgic encephalomyelitis/chronic fatigue syndrome characterized by post-exertional malaise and low serum acylcarnitine level.

COVID-19 afflicts patients with acute symptoms and longer term sequelae. One of the sequelae is myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), which is often difficult to diagnose, having no established tests. In this article, we synthesize information from literature reviews on patients with ME/CSF that developed after recovery from COVID-19.

Relationship between COVID-19 care and burnout among postgraduate clinical residents in Japan: a nationwide cross-sectional study.

OBJECTIVE: The relationship between the care of patients with COVID-19 and mental health among resident physicians in Japan is imperative for ensuring appropriate care of patients with COVID-19 and should be clarified. We herein assessed the relationship between the care of patients with COVID-19 and mental health among postgraduate year 1 (PGY-1) and PGY-2 resident physicians and factors associated with mental health. DESIGN: This nationwide cross-sectional study analysed data obtained using the clinical training environment self-reported questionnaire. SETTING: An observational study across Japan among resident physicians (PGY-1 and PGY-2) from 583 teaching hospitals. PARTICIPANTS: Examinees who took the general medicine in-training examination of academic year 2020. PRIMARY AND SECONDARY OUTCOME MEASURES: The Patient Health Questionnaire and Mini-Z 2.0 were used to assess mental health, and experience of caring for patients with COVID-19 was divided into three groups (none, 1-10 and ≥11). The prevalence of mental conditions in the three groups was compared using the 'modified' Poisson generalised estimating equations by adjusting for prefecture-level, hospital-level and resident-level variables. RESULTS: Of the 5976 participants analysed, 50.9% were PGY-1. The prevalence of burnout was 21.4%. Moreover, 47.0% of all resident physicians had no experience in the care of patients with COVID-19. The well-experienced group accounted for only 7.9% of the total participants. A positive association was found between the number of caring patients with COVID-19 and burnout (prevalence ratio 1.25; 95% CI 1.02 to 1.53). Moreover, the shortage of personal protective equipment was identified as a major contributor to burnout (prevalence ratio 1.60; 95% CI 1.36 to 1.88). CONCLUSIONS: Resident physicians who experienced more care of patients with COVID-19 had slightly greater burnout prevalence than those who did not. Approximately half of resident physicians did not participate in the care of patients with COVID-19, which posed a challenge from an educational perspective.

Impact of duty hours on competency-related knowledge acquisition among community hospital residents.

Background: The effect of duty hour (DH) restrictions on postgraduate residents' acquisition of clinical competencies is unclear. We evaluated the relationship between DHs and competency-related knowledge acquisition using the General Medicine In-training Examination (GM-ITE). Methods: We conducted a multicenter, cross-sectional study of community hospital residents among 2019 GM-ITE examinees. Self-reported average DHs per week were classified into five DH categories and the competency domains were classified into four areas: symptomatology and clinical reasoning (CR), physical examination and clinical procedure (PP), medical interview and professionalism (MP), and disease knowledge (DK). The association between these scores and DHs was examined using random-intercept linear models with and without adjustment for confounding factors. Results: We included 4753 participants in the analyses. Of these, 31% were women, and 49.1% were in the postgraduate year (PGY) 2. Mean CR and MP scores were lower among residents in Category 1 (<50 h) than in residents in Category 3 (≥60 and <70 h; reference group). Mean DK scores were lower among residents in Categories 1 and 2 (≥50 and <60 h) than in the reference group. PGY-2 residents in Categories 1 and 2 had lower CR scores than those in Category 3; however, PGY-1 residents in Category 5 showed higher scores. Conclusions: The relationship between DHs and each competency area is not strictly linear. The acquisition of knowledge of physical examination and clinical procedures skills in particular may not be related to DHs.

Crowned dens syndrome: A case series of 72 patients at eight teaching hospitals in Japan.

Background: Crowned dens syndrome (CDS) is characterized by calcification around the odontoid process, accompanied by neck pain. Although CDS is supposedly rare, we regularly diagnose and manage this condition, indicating a perception gap between previous studies and our experience. The purpose of this study was to determine the annual incidence of CDS, time to diagnosis in CDS, as well as the features of CDS. Methods: The study design was a retrospective case series study conducted at eight teaching hospitals in Japan. We identified CDS cases from April 2013-March 2015. CDS was diagnosed when patients had acute onset of neck pain and CT showed calcification around the dens and when other diagnoses were unlikely. Results: Seventy-two CDS cases were identified. Mean annual incidence was 4.6 ± 2.3 cases at each hospital. Among those with available data, 57 of 64 had limited rotation (89.1%). The diagnosis of CDS was made in general internal medicine or the emergency medicine department in 61 cases (84.7%). A total of 62 cases (86.1%) were diagnosed within 1 day of presentation, and the median time from initial presentation at the hospital to diagnosis was 0.0 days (25th-75th percentiles, 0.0-1.0). For treatment, NSAIDs were used in 56cases (77.8%) and acetaminophen in 20 cases (27.8%). Conclusion: CDS might be more common than has been reported to date. Time to diagnosis of CDS was within 1 day of visiting a teaching hospital. Cervical motion restriction is common in CDS and may be useful in establishing the diagnosis.

Suspected Gastroparesis With Concurrent Gastroesophageal Reflux Disease Induced by Low-Dose Liraglutide.

A 74-year-old woman with type 2 diabetes mellitus presented with nausea and abdomen distension. Four days prior, liraglutide 0.6 mg had been commenced. An abdominal computed tomography scan revealed gastric dilatation without mechanical obstruction which clinically suggested gastroparesis (GP). Her symptoms resolved after liraglutide discontinuation. A gastroscopy revealed reflux esophagitis. Taken together, GP may have developed along with reflux esophagitis due to liraglutide administration. Liraglutide's action inhibits gastric motility. Physicians should be cognizant of the side effects of GLP-1 agonists even in low dose in patients who have gastric emptying symptoms suggesting GP.

Pituitary insufficiency with masked inflammation: Pituitary abscess.

A 29-year-old woman presented with fever and amenorrhea. Laboratory findings showed no elevation inflammatory markers; however, hormonal evaluation revealed panhypopituitarism. She was finally diagnosed with pituitary abscess, and underwent transsphenoidal excision. The patient was treated with antibiotics and oral hormonal supplementation, and her pituitary function finally normalized.

Effects of Electrocardiographic Monitoring Education on Nurses' Confidence and Psychological Stress: An Online Cross-Sectional Survey in Japan.

We aimed to investigate the association between nurses' electrocardiographic (ECG) monitoring education and their confidence and psychological stress regarding ECG monitoring. In 2019, a web-based cross-sectional study was conducted among Japanese nurses. A multivariable logistic regression analysis was performed to evaluate the effects of education on nurses' confidence and psychological stress regarding ECG monitoring. In total, 1652 nurses were included in the study. Factors significantly associated with nurses' confidence were post-graduate education experience (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.6-3.6), ≥11 post-graduate years (OR, 2.2; 95% CI, 1.5-3.1), male gender (OR, 4.4; 95% CI, 2.9-6.6), ≥5 helpful experiences with ECG monitoring (OR, 10.7; 95% CI, 6.0-19.1), work experience in an intensive care unit (OR, 2.3; 95% CI, 1.5-3.7), and work experience in a cardiology department (OR, 1.7; 95% CI, 1.2-2.4). Factors significantly associated with nurses' psychological stress were male gender (OR, 1.9; 95% CI, 1.2-2.9), ≥5 helpful experiences with ECG monitoring (OR, 1.9; 95% CI, 1.2-2.9), and work experience in an emergency room (OR, 2.4; 95% CI, 1.3-4.8). These results suggest that nurses' post-graduate ECG monitoring education enhanced their confidence, but did not reduce psychological stress regarding ECG monitoring.

Antibody responses to SARS-CoV-2 nucleocapsid and spike proteins in hospitalized patients with COVID-19: A multicenter, retrospective, cross-sectional study in Japan.

BACKGROUND: There are many commercially available automated assays for assessing coronavirus disease 2019 (COVID-19) immune responses; however, owing to insufficient data, their validities remain unknown. Here, we examined antibody responses during acute-phase COVID-19 using four assays that detect anti-spike protein IgM (S-IgM), anti-nucleocapsid protein IgG (N-IgG), anti-spike protein total Ig (S-total Ig), and anti-spike protein IgG (S-IgG). METHODS: We measured antibody levels in 1154 serum samples collected from 286 hospitalized patients with confirmed COVID-19 by a gene amplification method between February and December 2020 in Japan. Sera from 860 healthcare workers were used as negative controls. RESULTS: The antibody positivity rates increased on week 2, peaked, and then started to plateau by the beginning of week 3 after symptom onset. On week 1, there were some significant differences in seropositivity rates between assays (p = 0.032): 14.9% (11.0%-19.4%) for S-IgM and 8.9% (6.0%-12.7%) for N-IgG. The seropositivity for the S-total Ig (10.6% [7.3%-14.6%]) assay was considerably better than that for the S-IgG (6.9% [4.3%-10.4%]) assay, although the difference was not statistically significant (p = 0.150). The levels of S-IgM antibodies and the three others peaked on weeks 3 and 5, respectively. All four assays showed high specificities (>99%). CONCLUSIONS: All four assays had good specificities and were suitable for seropositivity detection after week 3 of symptom onset. Assays of IgM alone or total Ig (containing IgM) were better than those of IgG alone as an adjunct serological test for early-stage COVID-19 diagnosis, albeit the use of a serological assay alone is insufficient.

Association between mental health and duty hours of postgraduate residents in Japan: a nationwide cross-sectional study.

The new duty hour (DH) limit for doctors in Japan will begin in 2024, setting the maximum DHs for postgraduate residents at approximately 80 h weekly. To set appropriate limits, understanding the association between DHs and psychological health is necessary. Thus, we assessed the relationship between residents' psychological health and DHs. We conducted a cross-sectional study involving examinees of the General Medicine In-training Examination 2020. Mental health outcomes were measured dichotomously using the Patient Health Questionnaire-2 for depression and Mini-Z 2.0, for burnout, stress, and satisfaction. Weekly DHs were measured in seven categories at 10-h intervals. The prevalence ratios (PRs) between the DH categories were estimated for each outcome. Of the 6045 residents who provided data on DHs and psychological outcomes, 37.3% showed signs of depression, 21.6% experienced burn out, and 39.2% were highly stressed. In contrast, 62.3% were highly satisfied with their training. Proportions of burnout were higher among residents in Category 6 (≥ 90 and < 100 h; PR 1.36; 95% CI 1.11-1.66) and Category 7 (≥ 100 h; PR 1.36; 95% CI 1.10-1.68) compared with residents in Category 3 (≥ 60 and < 70 h; reference). The results partially support the weekly 80-h DH limit in terms of resident well-being.