Tele-education by an orthopedic specialist increased the confidence in orthopedics of a general practitioner at a rural solo-practice clinic.

Objective: General practitioners in rural clinics are required to deal with musculoskeletal problems, but they often lack the confidence. We aim to confirm changes in their confidence in orthopedic practices after using tele-education. Materials and Methods: We conducted tele-education in orthopedic practices from June 1, 2022, to November 30, 2022. Using a teleconference system, the first author, an orthopedic specialist, provided tele-education training to an independent general practitioner in a rural clinic. We adopted a 7-point Likert scale to assess the general practitioner's confidence levels. In pre- and post-research, the counts and confidence levels in the scale were assessed for 18 types of orthopedic practices each month. Furthermore, we interviewed the general practitioner to examine the factors influencing their confidence. Results: The confidence levels increased for all measurement items. The most experienced orthopedic practice was "Advising on daily care for musculoskeletal problems", with confidence levels increasing from 3 to 6. The least experienced orthopedic practice was "Manipulative reduction of radial head subluxation", with confidence levels increasing from 4 to 5. The factors that influenced the change in confidence levels were regular feedback and unrestricted availability of consultations. Conclusion: Tele-education in orthopedics may enhance general practitioners' confidence in orthopedic practices.

Utilization of and barriers to a telemedicine system at a rural general hospital in Japan: a mixed methods study.

Objective: The initial and operational costs of telemedicine are major barriers to its adoption. We aimed to investigate and identify the barriers to adopting a telemedicine system in a Japanese rural general hospital without incurring setup and operational costs. Materials and Methods: Our study was conducted between May and August 2018, and included six general practitioners working at a rural general hospital. We extracted data collected from messages (date and time, sender and recipient, and counts and contents of messages) and conducted semi-structured interviews, which were then analyzed using quantitative and qualitative methods. Results: We quantitatively analyzed the total counted of the 179 messages. The total counts recorded for each physician were 56 (A), 20 (B), 3 (C), 74 (D), 5 (E), and 21 (F). The mean monthly counts were 2.17 (May), 8.50 (June), 11.50 (July), and 7.67 (August). Interview data from the six physicians yielded 13 codes that included various points of dissatisfaction acting as barriers to using our system, which we grouped into mental and physical barriers. Mental barriers included suspicion of carrying, feelings of isolation, and loss, whereas physical barriers included portability, user authentication, internet speed, group chat system, notice, search image, typing, chat system, print facility, and limited function. Conclusion: The representative barriers to introducing a telemedicine system at a rural general hospital in Japan without initial and running costs could be classified as feelings of isolation and suspicion of carrying (mental barriers); and notice, portability, and user authentication (physical barriers). Continued investigation in this area is warranted, and solutions to these barriers could improve the shortage of medical staff in the context of declining birth rates and aging populations in Japan.

Takayasu arteritis presenting with fever of unknown origin and bilateral carotid artery tenderness: A case report.

A 51-year-old otherwise healthy woman was referred to our hospital with a fever of unknown origin, liver dysfunction, and anemia. One month prior, she had persistent and spontaneous anterior neck pain, with no exacerbation during swallowing or neck movements. Physical examination revealed no pharyngeal or tonsillar abnormalities, heart murmur, arthritis, skin rash, or lymphadenopathy, except for mild bilateral common carotid artery tenderness at the level of the thyroid cartilage. Blood tests showed nonspecific chronic inflammatory findings, anemia, and liver damage, whereas blood cultures, viral antibodies, interferon-γ release assay, and antibodies specific for any collagen disease showed negative results. Echocardiography and computed tomography without contrast of the neck, chest, abdomen, and pelvis showed no apparent abnormalities. She was subsequently diagnosed with Takayasu arteritis using positron emission tomography. Identifying a characteristic history of bilateral carotid artery tenderness and subsequent positron emission tomography can be useful for diagnosing Takayasu arteritis.

Evaluation of simulation-based ultrasound education using a bladder simulator for medical students in Japan: a prospective observational study.

PURPOSE: This study aimed to investigate the usefulness of ultrasound education for medical students using a bladder simulator. METHODS: This prospective observational study included volunteer fifth- and sixth-year medical students. An intravesical urine volume measurement simulator and a pocket-sized hand-held ultrasound device were used. The ultrasound education comprised pre-learning, briefing, simulation, debriefing, and learning summary. The simulation consisted of two tests: bladder simulator cube evaluation and scenario-based clinical application. A self-rated confidence score of 0-10 points along with reasons for the scores was recorded before and after the ultrasound education. RESULTS: Twelve participants (median age, 23 years; female, 75%) met the inclusion criteria and were examined. Participants' bladder simulator cube evaluation and scenario-based clinical application test results were good, and the educational difficulty level was appropriate. The mean confidence scores for main unit operation, probe control, image acquisition, image evaluation and clinical application before the ultrasound education were 1.0, 1.8, 1.3, 0.8 and 0.1 points, respectively. The mean confidence scores after the ultrasound education were 5.8, 5.9, 5.4, 5.5 and 5.1, respectively, with significant increases for all items (p < 0.01). The positive impression categories that affected confidence scores after ultrasound education were related to device operation, image acquisition, image evaluation, clinical application and learning. CONCLUSION: Ultrasound education using a bladder simulator increases confidence scores by imparting competencies related to device operation, image acquisition, image evaluation and clinical application, and it improves students' learning impression. This is a useful method for introductory ultrasound education for medical students.

Effectiveness of ultrasound-guided fascia hydrorelease on the coracohumeral ligament in patients with global limitation of the shoulder range of motion: a pilot study.

We conducted a prospective single-arm interventional study of the treatment efficacy of ultrasound-guided fascia hydrorelease (US-FHR) on the coracohumeral ligament (CHL) of patients with global limitation of shoulder range of motion (ROM) without local inflammation. The primary outcome was the change in passive ROM (pROM) of external rotation (ER) after first US-FHR. Secondary outcomes included the change in pROM of other directions from baseline, the pain visual analogue scale (pVAS) at the timepoints after each procedure (first, second US-FHR and rehabilitation) as well as the change in the Shoulder Pain and Disability Index (SPADI) from the first to the second visit. Eleven patients underwent US-FHR. The pROM of ER after the 1st US-FHR changed by a median of 7.1° (p < 0.01). There was a statistically significant improvement in the pROM of flexion, extension, abduction, external rotation, and internal rotation from baseline to each timepoints. The pVAS at rest showed no significant improvement, although the pVAS at maximal ER showed a trend towards improvement. The SPADI score decreased by a median of 13.4 (p < 0.01). No adverse events were observed. US-FHR on the CHL with or without rehabilitation might be an effective, less invasive treatment for patients with global limitation of shoulder ROM.

Pseudo-fever caused by predictive electronic thermometers: A case report.

A 33-year-old man was referred to our hospital with chief complaints of fever, dizziness, and headache. Although he had recurring fever and dizziness for 7 months, neurological examination, magnetic resonance imaging, computed tomography, electrocardiograms, and blood tests were normal. He was diagnosed with functional hyperthermia, cervical vertigo, and tension headache and was treated with oral medication and physical therapy. After treatment, the dizziness and headache resolved; however, the fever and anxiety did not. During follow-up, he noticed differing results from different electronic thermometers. The physician decided to use an accurate analog thermometer, a gallium thermometer, in combination with the other thermometers. The results differed significantly among the thermometers, and the electronic thermometer readings were found to be inappropriately high. The physician made a diagnosis of pseudo-fever, and the patient recognized that the gallium thermometer's results were the most accurate reflection of his physical condition, resolving his anxiety.

Functional hyperthermia caused by obstructive sleep apnea syndrome: A case report.

A 47-year-old farm worker with diabetes mellitus, dyslipidemia, and hyperuricemia was referred to our hospital for a 3-month history of fever and malaise. He had no respiratory tract or abdominal symptoms, skin rashes, or joint pain. There was no change to his regular medication or pesticide exposure. Blood tests and echocardiography revealed no abnormalities. Whole-body computed tomography revealed a fatty liver; however, non-alcoholic steatohepatitis was excluded. We diagnosed the patient with functional hyperthermia. He had a history of snoring and weight gain, and we suspected the obstructive sleep apnea syndrome to be a stressor. Polysomnography revealed severe obstructive sleep apnea syndrome with an apnea-hypopnea index of 44.5. Continuous positive airway pressure was introduced; the axillary temperature decreased gradually and malaise was resolved. Functional hyperthermia should be considered a cause of fever with a negative inflammatory response. Obstructive sleep apnea syndrome can be a stressor for functional hyperthermia, which can be improved by interventions.

Non-convulsive epilepsy with acute-onset and short-lasting repeated fatigue attacks: A case of 30-year-old man.

A 30-year-old man was referred to our department because of repeated acute-onset and short-lasting fatigue attacks, which occurred from 3 months before the referral. He had no abnormal findings in blood tests, electrocardiogram (including 24- h monitoring), or head MRI (including angiography). His vital signs were unremarkable, and his physical examination revealed no abnormal findings. Detailed history-taking with closed-ended questions revealed the occurrence of tingling sensation from the right fingers as the aura before his attacks. Electroencephalography was performed, which revealed focal epilepsy. Levetiracetam resolved his symptoms. Physicians could consider non-convulsive epilepsy as a potential cause of repeated acute-onset and short-lasting fatigue attacks of unknown etiology after underlying conditions, such as metabolic diseases, have been ruled out.

Clinical diagnosis of seasonal influenza by physicians: a retrospective observational study.

OBJECTIVE: To elucidate the diagnostic accuracy of pretest probability of influenza (%) by physicians and the factors affecting the clinical diagnosis. DESIGN: Retrospective, single-centre observational study. SETTING: A community primary care clinic in Japan. PARTICIPANTS: The participants were recruited from a database of studies conducted during the influenza season from December 2017 to April 2019. PRIMARY OUTCOME MEASURE: Sensitivity and specificity of the physician's clinical diagnosis of influenza recorded in the medical record as pretest probability. RESULTS: A total of 335 patients (median age, 31 years; male, 66.6%) were analysed in this study. The area under the curve (AUC) of the physician's pretest probability was 0.77. At a cut-off value of 30%, the sensitivity and negative likelihood ratio were 92.0% (95% CI 86.7 to 95.7) and 0.19 (95% CI 0.11 to 0.33), respectively. At a cut-off value of 80%, the specificity and positive likelihood ratio were 90.8% (95% CI 85.4 to 94.6) and 4.01 (95% CI 2.41 to 6.66), respectively. The AUCs of patients who had and had not taken any medications before visiting the clinic were 0.77 (95% CI 0.69 to 0.85) and 0.78 (95% CI 0.71 to 0.84), respectively. The AUCs of patients with type A and B influenza were 0.78 (95% CI 0.72 to 0.84) and 0.76 (95% CI 0.70 to 0.82), respectively. The AUCs of vaccinated and unvaccinated patients were 0.80 (95% CI 0.72 to 0.88) and 0.76 (95% CI 0.63 to 0.89), respectively. The AUC for patients less than 12 hours after onset was 0.69 (95% CI 0.51 to 0.88), and that for patients aged younger than 6 years was 0.69 (95% CI 0.49 to 0.88). CONCLUSIONS: The physician's pretest probability of influenza (%) may be useful for both definitive and exclusionary diagnoses within the limits of our study.

Analysis of Bovine Lactoferrin in Infant Formula and Adult Nutritional Products by Optical Biosensor Immunoassay: First Action 2021.07.

BACKGROUND: Bovine lactoferrin is increasingly being used as an ingredient in infant formula manufacture to enhance nutritional efficacy through the provision of immunoprotective, growth, and antimicrobial factors to the neonate. OBJECTIVE: To evaluate the analytical performance of an optical biosensor immunoassay for compliance with the method performance requirements described in SMPR 2020.005. METHOD: Following dilution of the sample in buffer, an automated, label-free, real-time optical biosensor immunoassay was used in a direct assay format to quantitate bovine lactoferrin by its interaction with an immobilized anti-lactoferrin antibody. Quantitation was accomplished by the external standard technique with interpolation from a 4-parameter calibration regression. RESULTS: The analytical range (0-200 mg/hg), method detection limit (0.8 mg/hg), recovery (96.1-109.2%), and repeatability (1.0-5.3%) complied with the requirements given in the lactoferrin SMPR. The method was shown to be specific for native, intact lactoferrin; thermally denatured lactoferrin generated no measurable binding response. CONCLUSION: The method described is suitable for the quantification of intact, undenatured lactoferrin in milk products, infant formulas (bovine milk protein-based, soy protein-based, and amino acid-based), and adult nutritionals and has been demonstrated to meet the performance requirements defined in SMPR 2020.005. HIGHLIGHTS: A single-laboratory validation (SLV) of an automated biosensor immunoassay for the determination of intact, undenatured lactoferrin is described.

Factors associated with children's seasonal influenza diagnosis by their guardians: a prospective observational study in Japan.

Introduction Children's influenza diagnosis by their guardians has been reported to be highly accurate, but clinical factors that improve the reliability of a guardian's diagnosis are unclear. Aim To determine the accuracy of guardians' influenza diagnosis of their children, investigate clinical factors that improve the diagnostic accuracy, and determine the additional clinical value of the guardian's diagnosis. Methods A prospective observational study was conducted at a primary care clinic in Japan from December 2017 to April 2019. Pre-examination checklists completed by guardians accompanying children aged Results A total of 112 patient pairs of child (median age, 6 years) and guardian (mother, 81.2%; father, 16.1%; grandmother, 1.8%; other, 0.9%) were included in the analysis. The AUC for guardians' influenza diagnosis was higher in mothers (0.72), as well as pairs with children with a history of influenza (0.72), guardians who were aware of the influenza epidemic (0.71), and unvaccinated children (0.76), than in other guardians. After multivariate analysis, the AUC increased significantly from 0.79 to 0.85. Discussion Guardians' influenza diagnosis for their children was highly accurate. We identified factors that improve the accuracy of the guardians' diagnosis and demonstrated that the guardians' diagnosis can support physicians' diagnostic accuracy.

A case of juvenile myoclonic epilepsy in which a disease-specific question led to the diagnosis.

A 17-year-old female patient presented to our hospital with repeated transient loss of consciousness lasting less than 10 min. After regaining consciousness, she experienced no disorientation, confusion, tongue-biting, or incontinence. Physical findings, blood tests, electrocardiogram, and echocardiogram showed no obvious abnormalities. On being asked whether she had experienced sudden rapid body movements, she answered "yes." Therefore, we suspected juvenile myoclonic epilepsy (JME) and obtained an electroencephalogram, which showed diffuse bilateral bursts of spike-and-wave complexes, confirming the diagnosis. In adolescent patients with transient loss of consciousness, myoclonic jerks should be actively confirmed for the diagnosis of JME.

A case of Raynaud's phenomenon of toes induced by whole-body warm stimulation.

Raynaud's phenomenon, induced by cold stimulation and emotional stress, is also induced by whole-body warm stimulation. A 74-year-old man was referred to our department because of nocturnal toe pain from 2 years prior and immediate color change of the toes from 1 year prior when submerging himself into a warm bath. Physical examination and blood tests revealed no abnormal findings suggestive of secondary Raynaud's phenomenon. Two years later, the signs and symptoms persisted. When physicians confirm Reynaud's phenomenon, they should check for the possibility of secondary Reynaud's phenomenon. Additional research on Reynaud's phenomenon induced by warm stimulation is needed.

Severe edema and blood blisters of the lower extremities caused by sitagliptin, a dipeptidyl peptidase-4 inhibitor.

Severe edema and blood blisters can occur as adverse events associated with sitagliptin. A history of dipeptidyl peptidase-4 inhibitors should be considered when examining patients with edema and blood blisters of uncertain cause.

Diagnostic accuracy of pocket-sized ultrasound for aspiration pneumonia in elderly patients without heart failure: A prospective observational study.

AIM: To investigate the diagnostic accuracy of pocket-sized ultrasound (PsUS) for aspiration pneumonia in elderly patients without heart failure. METHODS: This prospective observational study included patients with aspiration pneumonia. PsUS was performed in six areas (bilateral chest, four dorsal areas) by an independent examiner, blinded to the computed tomography (CT) results as a reference standard. Patients with heart failure were excluded. RESULTS: PsUS findings of 34 patients (median age, 87.5 years) and 204 areas were analyzed. Three or more B-lines (comet tail artifacts) were strongly suggestive (positive likelihood ratio [LR+] 17.302) of consolidation on CT (CT-consolidation, subpleural hypoechoic area with tissue-like echostructure) or pleural change on CT. Consolidation on US (US-consolidation) was suggestive of CT-consolidation or pleural changes on CT (LR+ 6.453). Pleural effusion on US was strongly suggestive (LR+ 10.989) of CT-consolidation or pleural change on CT. Absence of either three or more B-lines, US-consolidation, or US pleural effusion could not rule out CT-consolidation or pleural change on CT (negative likelihood ratio [LR-] 0.482-0.683). However, absence of all three findings could rule out abnormal CT findings (LR- 0.230). Chest radiograph findings proved difficult to confirm or exclude CT-consolidation or pleural changes on CT (LR+ 1.584, LR- 0.489); when combined with PsUS findings, LR- improved to 0.124. CONCLUSIONS: Three or more B-lines or US-consolidation on PsUS in elderly patients with aspiration pneumonia without heart failure suggested CT-consolidation or pleural changes on CT. When both PsUS and chest radiograph findings were negative, CT-consolidation and pleural change could be excluded. Geriatr Gerontol Int 2021; 21: 1118-1124.

An undiagnosed patient with skin rash, polyarthritis, and edema responding to low-dose colchicine: A case report.

A 54-year-old man was referred to our hospital with painful rashes on the extremities. He also developed polyarthritis and pitting pedal edema. Blood tests showed no specific autoantibodies and were negative for human leukocyte antigens B51, B15, and B27. Lower extremity venous ultrasonography and computed tomography angiography showed no vascular disorders. Skin biopsy showed no evidence of thrombosis or vasculitis. Direct fluorescence antibody analysis showed no antibody or complement deposition. Joint ultrasonography showed mild synovial thickening and/or synovial effusion in the extremities. Non-steroidal anti-inflammatory drugs and topical steroids were administered, followed by oral steroids. However, the signs and symptoms did not improve. Oral steroids were discontinued, and colchicine (0.5 mg/day) was administered. Thereafter, the symptoms of arthritis improved, and no skin rash developed. In potentially inflammatory conditions with skin rash, edema, and polyarthritis that are difficult to diagnose, low-dose colchicine administration may be considered for prompt relief of symptoms.

Long-term outcomes of oligometastatic breast cancer patients treated with curative intent: an updated report.

BACKGROUND: Oligometastatic breast cancer (OMBC) is characterized by limited metastatic tumor numbers and sites. We have reported a 20-year overall survival (OS) rate and relapse-free rate (RFR) of 34.1% and 27.4%, respectively, in a retrospective analysis of OMBC patients treated with curative intent including a multidisciplinary approach. Metastatic breast cancer (MBC) is generally incurable; however, OMBC might be a potentially curable subset. The previous analysis included isolated locoregional recurrence (ILRR) cases, which differs from distant metastasis in treatment strategies. Therefore, in this study, we excluded ILRR cases and provided an update on clinical outcomes. We also performed a detailed subgroup analysis of OMBC patients by introducing new prognostic variables. METHODS: Data of 73 OMBC patients, including 10 ILRR cases, treated in our institution between 1980 and 2010 were retrospectively analyzed. OMBC was defined as the presence of metastatic lesions in 1-2 organs, < 5 lesions per metastasized organ, and lesion diameter < 5 cm. RESULTS: The median follow-up duration was 151 (range 12-350) months. Twenty-eight (44%) patients received local therapy. Excluding ILRR cases, the OS rates were 28.3% and 18.9% and RFRs were 26.7% at 20 and 25 years, respectively. In multivariate analysis, single-organ involvement and three or fewer metastatic lesions per organ were associated with a longer progression-free and relapse-free interval (RFI). CONCLUSIONS: Relapse-free interval reached a plateau after 20 years at approximately 25% probability. Patients with long-term survival without disease relapse are considered cured. Curative-intent therapy should be considered for OMBC patients, especially those with low tumor volume.

Comparison of LC-MS/MS and Enzymatic Methods for the Determination of Total Choline and Total Carnitine in Infant Formula and Milk Products.

BACKGROUND: Choline and l-carnitine are classified as pseudo-vitamins because of their conditionally essential status. As they are involved in multiple physiological metabolic pathways in the human body, they are routinely fortified in infant and adult nutritional formulas. OBJECTIVE: The performance of an LC-MS/MS method for the analysis of choline and carnitine, compared with enzymatic methods in routine use for the analysis of total carnitine and total choline, is described. METHOD: Powder samples were reconstituted, with release of carnitine and choline facilitated by both acid and alkaline hydrolysis and the extract analyzed by LC-MS/MS. Quantitation was by internal standard technique using deuterium-labeled carnitine and deuterium-labeled choline. RESULTS: Method range, specificity, sensitivity, precision, recovery, accuracy, and ruggedness were assessed for milk powders, infant formulas, and soy- and milk-based nutritional products. Spike recoveries of 94.0-108.4% were obtained for both total carnitine and choline, and no statistical bias (α = 0.05) between measured results and certified values (choline: P = 0.36; free carnitine: P = 0.67) was found for NIST 1849a certified reference material (NIST1849a). Precision, as repeatability relative standard deviation (RSD), was 2.0% RSDr for total carnitine and 1.7% RSDr for total choline. Equivalent results for total choline and total carnitine were obtained by LC-MS/MS and enzymatic methods (n = 30). CONCLUSIONS: The described LC-MS/MS method is fit for purpose for routine product compliance release testing environments. This validation study has confirmed that alternative enzymatic assays can be used with confidence in laboratories in which LC-MS/MS platforms are unavailable. HIGHLIGHTS: An LC-MS/MS method was evaluated and found to be fit-for-purpose for routine product compliance release testing of infant formula. The LC-MS/MS method was compared with enzymatic methods for the analysis of total carnitine and total choline. Alternative enzymatic assays can be used with confidence in laboratories in which LC-MS/MS platforms are unavailable.

Vestibular migraine without headache treated with lomerizine: A 35-year-old woman undiagnosed for 10 years.

A 35-year-old woman presented with recurrent vertigo without headache, which had persisted for 10 years. Detailed medical history revealed that she experienced hearing loss, tinnitus, nausea, photophobia, phonophobia, and slight discomfort in the head during vertigo attacks, which often led to absence from work. Based on the diagnostic criteria of the International Classification of Headache Disorders, third edition, she was diagnosed with vestibular migraine and was prescribed lomerizine, as prophylaxis. Her symptoms markedly improved, enabling her to go to work. Accurate diagnosis and treatment are important for improving the quality of life of patients, since vestibular migraine is commonly underdiagnosed.

Initial assessment of femoral proximal fracture and acute hip arthritis using pocket-sized ultrasound: a prospective observational study in a primary care setting in Japan.

BACKGROUND: Acute hip pain caused by femoral proximal fractures or acute hip arthritis requires imaging for accurate diagnosis. Although pocket-sized ultrasound (PsUS) offers several advantages over other imaging modalities, there is limited information regarding its use in diagnosing femoral proximal fractures or acute hip arthritis. Thus, we aimed to validate the diagnostic accuracy of PsUS for both disorders. METHODS: In this prospective observational study, outpatients with acute hip pain were diagnosed according to a fixed procedure of the PsUS probe handling. We verified the diagnostic accuracy of PsUS findings (cortical discontinuity and joint fluid retention) and compared it with that of radiography, computed tomography, and magnetic resonance imaging. RESULTS: Our study included 52 outpatients (mean age, 78.0 years; female, 88.5%). Of 26 patients diagnosed with femoral proximal fractures, 14 had femoral neck fractures and 12 had femoral trochanteric fractures. The sensitivity and specificity for identifying cortical discontinuity in femoral proximal fractures were 0.96 and 0.92, respectively. The sensitivity for identifying either cortical discontinuity or joint fluid retention in femoral proximal fractures or acute hip arthritis was 0.97. CONCLUSIONS: Negative PsUS findings of cortical discontinuity and joint fluid retention in the hip are useful for ruling out femoral proximal fractures and acute hip arthritis. PsUS and radiography have comparable diagnostic accuracies, and PsUS could aid in the initial assessment of acute hip pain among the elderly in primary care settings.