Moyamoya Syndrome: Differential Diagnosis in Patients With Central Nervous System Symptoms and Hyperthyroidism.

Moyamoya syndrome, known as secondary moyamoya disease, is associated with various primary illnesses, such as brain tumor, meningitis, autoimmune disease, and thyrotoxicosis, and their relations are not clear. We report a rare case of moyamoya syndrome in a patient with Graves' disease. An 18-year-old woman was admitted to our hospital due to convulsions. She had symptoms of palpitations and fatiguability for half a year and transient numbness in her left upper extremity and dysarthria for a month. In physical findings, tachycardia and diffuse thyroid swelling were noted. A blood test revealed thyrotoxicosis and antithyroid antibody, and a diagnosis of Graves' disease was obtained. Brain magnetic resonance imaging (MRI) showed bilateral internal carotid artery occlusion. We finally diagnosed the patient with moyamoya syndrome caused by Graves' disease. Moyamoya disease or syndrome can cause symptoms like a stroke, sometimes requiring neurosurgical treatment. In our case, the therapy for Graves' disease resolved the symptoms. When diagnosing moyamoya disease, it is necessary to confirm whether there are any background diseases, such as Graves' disease.

Distribution of internal medicine rotations among resident physicians in Japan: a nationwide, multicenter, cross-sectional study.

BACKGROUND: In Japan, postgraduate clinical training encompasses a 2-year residency program, including at least 24 weeks of internal medicine (IM) rotations. However, the fragmented structure of these rotations can compromise the training's quality and depth. For example, a resident might spend only a few weeks in cardiology before moving to endocrinology, without sufficient time to deepen their understanding or have clinical experience. This study examined current patterns and lengths of IM rotations within the Japanese postgraduate medical system. It scrutinized the piecemeal approach-whereby residents may engage in multiple short-term stints across various subspecialties without an overarching, integrated experience-and explored potential consequences for their clinical education. METHODS: This nationwide, multicenter, cross-sectional study used data from self-reported questionnaires completed by participants in the 2022 General Medicine In-Training Examination (GM-ITE). Data of 1,393 postgraduate year (PGY) one and two resident physicians who participated in the GM-ITE were included. We examined the IM rotation duration and number of IM subspecialties chosen by resident physicians during a 2-year rotation. RESULTS: Approximately half of the participants chose IM rotation periods of 32-40 weeks. A significant proportion of participants rotated in 5-7 internal medicine departments throughout the observation period. Notable variations in the distribution of rotations were observed, characterized by a common pattern where resident physicians typically spend 4 weeks in each department before moving to the next. This 4-week rotation is incrementally repeated across different subspecialties without a longer, continuous period in any single area. Notably, 39.7% of participants did not undertake general internal medicine rotations. These results suggest a narrowed exposure to medical conditions and patient care practices. CONCLUSIONS: Our study highlights the need to address the fragmented structure of IM rotations in Japan. We suggest that short, specialized learning periods may limit the opportunity to gain broad in-depth knowledge and practical experience. To improve the efficacy of postgraduate clinical education, we recommend fostering more sustained and comprehensive learning experiences.

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.

The effects of resident work hours on well-being, performance, and education: A review from a Japanese perspective.

This article examines the impact of working-hour restrictions on the well-being, performance, and education of medical residents in Japan. Despite Japan's plan to introduce new regulations for resident working hours by 2024, there is still an ongoing debate regarding their appropriateness. This review provides a comprehensive overview of the current regulations of resident working hours worldwide, with a specific focus on weekly hours. The varying regulations are highlighted, including the 80-hour-per-week regulation in the United States and the 48-h-per-week regulation in the European Union influencing other regions. The article also discusses the effectiveness of working-hour restrictions on residents' mental health, with shorter working hours having potentially greater benefits. However, the impacts on medical safety and resident education are mixed, and further reduction in working hours must be carefully considered to avoid adverse effects. The planned changes to working-hour limits for residents in Japan offer a unique opportunity to gain new evidence on the impact of such regulations, which will be of interest to policymakers and researchers worldwide.

The environmental impact of inhaler replacement: A carbon footprint and economic calculation of the National Database of Health Insurance Claims in Japan.

Background: Drugs are a major source of greenhouse gas (GHG) emissions from healthcare systems. Pressurized metered-dose inhalers (pMDIs) have raised concerns over their environmental impact due to GHG emissions. Evaluations and reduction strategies for GHGs have been primarily studied in Europe, but not in other regions, including Japan. Therefore, our objective was to calculate the carbon footprint of inhalers in Japan and evaluate their reduction scenarios. Methods: Using the National Database of Health Insurance Claims, our analysis was conducted on inhaler prescriptions in Japan for the fiscal year of 2019. We calculated the number of inhalers used, GHG emissions, and total costs. Next, we simulated the environmental and economic impacts of three reduction scenarios: the first scenario replaced pMDI with dry power inhalers, followed by age-based replacements. In the last scenario, we replaced pMDI with a propellant with a lower global warming potential. Results: All inhaler-related GHG emissions were 202 ktCO2e, of which 90.9% were attributed to pMDI use. Scenario analysis demonstrated that replacing 10% pMDI with DPI would reduce emissions by 6.7%, with a relatively modest increase in cost; substituting 10% of pMDI used by adults (excluding children and older adults) with alternative inhalers would reduce emissions by 6.1%, with a 0.7% increase in cost; and, replacing 10% of pMDI propellants with lower global warming potential would reduce emissions by 9.3%. Conclusions: Selecting appropriate inhalers can mitigate GHG emissions in Japan, but its impact will be less than in other countries. Nevertheless, collaborative efforts between physicians, patients, and pharmaceutical companies are necessary to reduce GHG emissions.

Roles considered important for hospitalist and non-hospitalist generalist practice in Japan: a survey study.

BACKGROUND: An increased focus on quality and patient safety has led to the evolution of hospitalists. The number of hospitalists covering ward and outpatient care is on the rise in Japan. However, it is unclear what roles hospital workers themselves consider important in their practice. Therefore, this study investigated what hospitalists and non-hospitalist generalists in Japan consider important for the practice of their specialty. METHODS: This was an observational study that included Japanese hospitalists (1) currently working in a general medicine (GM) or general internal medicine department and (2) working at a hospital. Using originally developed questionnaire items, we surveyed the items important to hospitalists and non-hospitalist generalists. RESULTS: There were 971 participants (733 hospitalists, 238 non-hospitalist) in the study. The response rate was 26.1%. Both hospitalists and non-hospitalists ranked evidence-based medicine as the most important for their practice. In addition, hospitalists ranked diagnostic reasoning and inpatient medical management as the second and third most important roles for their practice, while non-hospitalists ranked inpatient medical management and elderly care as second and third. CONCLUSIONS: This is the first study investigating the roles Japanese hospitalists consider important and comparing those to that of non-hospitalist generalists. Many of the items that hospitalists considered important were those that hospitalists in Japan are working on within and outside academic societies. We found that diagnostic medicine and quality and safety are areas that are likely to see further evolution as hospitalists specifically emphasized on them. In the future, we expect to see suggestions and research for further enhancing the items that hospital workers value and emphasise upon.

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.

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.

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.

Purulent Pericarditis Due to Pneumococcal Bacteremia Caused by Acupuncture: An Autopsy Case Report.

Purulent pericarditis is an infection of the pericardial cavity that produces purulent fluid and is commonly caused by Streptococcus pneumoniae. We herein report an autopsy case that is unique in two respects: the patient had pneumococcal bacteremia from a skin and soft tissue infection associated with acupuncture as well as purulent pericarditis from pneumococcal bacteremia. This case suggests that bloodstream infection should be included in the differential diagnosis on observing pneumococcal pericarditis. Furthermore, it is necessary to recognize that S. pneumoniae may be the organism responsible for skin and soft tissue infections caused by trauma in immunosuppressed patients.

Burnout and its associated factors among healthcare workers and the general working population in Japan during the COVID-19 pandemic: a nationwide cross-sectional internet-based study.

OBJECTIVES: To examine the prevalence and the associated factors of burnout among both healthcare workers (HCWs) and the general working population, which has not yet been unknown, using large-scale, nationwide data. DESIGN: Cross-sectional internet-based study. SETTING: Nationwide internet survey conducted between 8 and 26 February 2021 in Japan. PARTICIPANTS: Workers aged 20-64 years. We classified the workers as HCWs and the general working population. EXPOSURES: Demographic characteristics (age, sex and marital status), socioeconomic status (education, employment and income), health-related, work-related and industry-related factors (smoking, alcohol use, physical and psychiatric comorbidities, working hours, types of healthcare professionals, experience on the COVID-19 frontline and working industries). MAIN OUTCOME MEASURES: Burnout defined as a score of ≥3 points on the Mini-Z Single-Item Burnout Scale. RESULTS: Of the included 12 650 workers, 1087 were HCWs. After inverse probability weighting on data from the 2016 Comprehensive Survey of Living Conditions, burnout in HCWs and the general working population was 33.5% (95% CI 29.2% to 38.0%) and 31.0% (95% CI 29.7% to 32.4%), respectively. In the weighted multivariable modified Poisson regression models, working 60 hours or more was associated with burnout in all workers (HCWs: prevalence ratio (PR) 2.52, 95% CI 1.68 to 3.76; general population: PR 1.26, 95% CI 1.07 to 1.48). Widowed/separated compared with married was associated with burnout only among HCWs (PR 1.69, 95% CI 1.16 to 2.47), whereas presence of physical or psychiatric comorbidities was associated with burnout among the general working population (PR 1.14, 95% CI 1.03 to 1.28; and PR 1.65, 95% CI 1.45 to 1.87, respectively). CONCLUSIONS: Burnout was prevalent in both HCWs and the general working population in Japan. Both common and specific risk factors were observed. Our findings highlight the need for the general workplace policy and targeted interventions for burnout prevention.

Work-related stress and coping methods of internists and primary care physicians during the COVID-19 pandemic in Japan: A mixed-method study.

Background: The COVID-19 pandemic has affected the mental health of health care workers. This study aimed to investigate the stress factors that cause burnout in Japanese physicians and their coping methods during the COVID-19 pandemic. Methods: We conducted a sequential explanatory mixed-method study to investigate the psychological responses of physicians in the early stages of the pandemic. A cross-sectional, web-based, anonymous survey was conducted among members of the American College of Physicians Japan Chapter to quantitatively investigate the stress factors and prevalence of burnout. An open-ended questionnaire with questions about stress factors and coping methods was additionally administered. The qualitative data were analyzed using qualitative content analysis. Results: Among the 1173 physicians surveyed, 214 (18.2%) responded. Among the participants, 107 (50.0%) responded "yes" to the question "I feel or have felt very stressed at work during the COVID-19 pandemic," and 68 (31.8%) reported burnout symptoms. Those who reported feeling stress (117 respondents) were asked to select 12 items of the stress factors related to COVID-19. The most significant stress factor related to COVID-19 was "Perceived risk of spreading COVID-19 to family members" (n = 47). Content analysis identified 12 categories for the stress factors and 7 for stress-coping methods corresponding to COVID-19 (Cohen's kappa = 0.84 and 0.95, respectively). Conclusion: Several distinct stressors existed during the COVID-19 pandemic, which might be related to burnout among physicians. Practicing stress-coping strategies, as identified in the present study, may help reduce work-related stress and prevent burnout.

Diagnostic accuracy of the Single-item Measure of Burnout (Japanese version) for identifying medical resident burnout.

Background: Burnout is a psychological syndrome consisting of emotional exhaustion, cynicism, and decreased professional efficacy. The Maslach Burnout Inventory (MBI) is widely used as the standard measure. However, the MBI is lengthy and not free to use, which makes it a less than ideal tool for regularly assessing burnout. The single question burnout measure (SMB) is a novel and simple measure of burnout, which is associated well with emotional exhaustion and has sufficient diagnostic performance for burnout. This study aimed to evaluate the concurrent and convergent validity of the Japanese version of the single-item measure of burnout (SMB-J) compared with the MBI. Methods: Ninety-four medical residents volunteered to complete the MBI-General Survey (MBI-GS) and the SMB-J. We assessed the concurrent (sensitivity and specificity) and convergent validity of the SMB-J compared with the MBI-GS. Results: The sensitivity for identifying burnout using the SMB-J was 53.8%, and the specificity was 88.2%. The area under the receiver operating characteristic curve (AUC) was 0.71. MBI-GS scores on the subscales of Emotional Exhaustion (r = 0.509, p < 0.0001) and Cynicism (r = 0.57, p < 0.0001) strongly correlated with the SMB-J scores. Conclusions: We concluded that for identifying burnout among Japanese medical residents, the psychometric properties of the SMB-J are comparable to those of the original version of the SMB. Although the SMB-J has low sensitivity to detect burnout, it is more convenient to use than the MBI.

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.