上原 孝紀

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 <Lack of confidence> and <Forgetting>, which is prevented by the checklist. The <Lack of successful experiences in detecting abnormalities> leads to a <Lack of confidence>. Repeated executions result in <Successful experiences and confidence building>. 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.

A 16-year-old boy who was a non-smoker presented with a prolonged severe dry cough and malaise of 3 months in duration. Despite an increase in the patient's inflammatory marker levels, no respiratory lesions were radiologically or serologically detected. We suspected that the cough reflex pathway had been stimulated by large vessel vasculitis (LVV, a non-respiratory inflammatory condition) and diagnosed the patient with Takayasu arteritis. While inflammation of either the ascending pharyngeal or pulmonary artery have been reported to cause cough in patients with LVV, the present case shows that intense inflammation of the aortic arch and the starting portion of its main branches may stimulate a vagus nerve branch as a novel mechanism causing cough.

Familial Mediterranean fever (FMF) is an autoinflammatory disease caused by mutations in the MEFV gene and characterized by recurrent episodes of fever and polyserositis. To date, over 317 MEFV mutations have been reported, only nine of which account for almost all Japanese patients with FMF. Therefore, the prevalence of rare MEFV variants and their clinical characteristics remains unclear. This study identified MEFV mutations previously unreported in the Japanese population and described their clinical features. We performed MEFV genetic testing in 488 Japanese patients with clinically suspected FMF. Of these patients, we retrospectively analyzed three patients with novel or very uncommon MEFV mutations. In all patients, the clinical diagnosis of FMF was made according to Tel-Hashomer's criteria. One novel missense mutation (N679H) and two rare mutations (T681I and R410H) were identified in the MEFV gene. These mutations were found in compound heterozygous or complex genotypes with other known mutations in exons 1 or 2. According to clinical images, all three patients exhibited typical FMF symptoms. A number of patients with FMF caused by novel or uncommon MEFV variants might exist in the Japanese population; therefore, careful genetic testing is required for accurate diagnosis of this curable genetic disorder.

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.

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.

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).

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.

A 65-year-old Japanese man was admitted with a 4-month history of fatigue and exertional dyspnea. Transthoracic echocardiography revealed a vegetation on the aortic valve and severe aortic regurgitation. Accordingly, infective endocarditis and heart failure were diagnosed. Although a blood culture was negative on day 7 after admission, a prolonged blood culture with subculture was performed according to the patient's history of contact with cats. Consequently, Bartonella henselae was isolated. Bartonella species are fastidious bacteria that cause blood culture-negative infective endocarditis. This case demonstrates that B. henselae may be detected by prolonged incubation of blood cultures.

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.

A 72-year-old woman was referred for a 15-year history of brief attacks of generalized weakness that occurred when she was tense or startled. During these episodes, she squatted, closed her eyes, and had difficulty speaking, but there was no disturbance of consciousness. The cerebrospinal fluid level of orexin/hypocretin was low (92 ng/L), leading to a diagnosis of narcolepsy with cataplexy according to the International Classification of Sleep Disorders (ICSD)-2 criteria. Cataplexy should be considered for sudden attacks of weakness lasting less than 2 minutes and with no alteration of consciousness. Measurement of cerebrospinal fluid levels of orexin/hypocretin is recommended when the diagnosis is uncertain.

BACKGROUND: This study aimed to clarify the influence of predicting a correct diagnosis from the history on physical examination by comparing the diagnostic accuracy of auscultation with and without clinical information. METHODS: The participants were 102 medical students from the 2013 clinical clerkship course. Auscultation was performed with a cardiology patient simulator. Participants were randomly assigned to two groups. Each group listened to a different simulated heart murmur and then made a diagnosis without clinical information. Next, a history suggesting a different murmur was provided to each group and they predicted the diagnosis. Finally, the students listened to a murmur corresponding to the history provided and again made a diagnosis. Correct and incorrect diagnosis rates of auscultation were compared between students with and without clinical information, between students predicting a correct or incorrect diagnosis from the history (correct and incorrect prediction groups, respectively), and between students without clinical information and those making an incorrect prediction. RESULTS: For auscultation with or without clinical information, the correct diagnosis rate was 62.7% (128/204 participants) versus 54.4% (111/204 participants), showing no significant difference (P=0.09). After receiving clinical information, a correct diagnosis was made by 102/117 students (87.2%) in the correct prediction group versus 26/87 students (29.9%) in the incorrect prediction group, showing a significant difference (P=0.006). The correct diagnosis rate was also significantly lower in the incorrect prediction group than when the students performed auscultation without clinical information (54.4% versus 29.9%, P<0.001). CONCLUSION: Obtaining a history alone does not improve the diagnostic accuracy of physical examination. However, accurately predicting the diagnosis from the history is associated with higher diagnostic accuracy of physical examination, while incorrect prediction is associated with lower diagnostic accuracy of examination.

Objective This study was performed to investigate the factors influencing the correlation between physician satisfaction and patient satisfaction in an outpatient setting.<br> 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.<br> 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.<br> 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.<br>

Background: There have been some studies of common primary care diseases in Japan, but no reports on which diseases it is difficult for general physicians to diagnose in daily practice. In this study, we identified diseases that provided a diagnostic challenge for Japanese general physicians in daily practice. Methods. The subjects were new undiagnosed patients referred to the General Outpatient Department of Chiba University Hospital during the one-year period from January 2008. We performed a retrospective chart review to identify the referring doctor, patient demographics, the duration of symptoms, the final diagnosis, and the outcome. Final diagnoses were classified according to the International Classification of Primary Care Second Edition (ICPC-2). In addition, the differences between referrals from general physicians and those from other physicians were assessed. Fisher's exact test and the Bonferroni-Holm correction were used for statistical analysis. Results: A total of 169 patients were referred by general physicians and 239 patients were referred by other physicians. The most common ICPC-2 diagnosis was "General & Unspecified" conditions (35 patients, 20.7%), followed by "Psychological" conditions (31 patients, 18.3%) and "Musculoskeletal" conditions (21 patients, 12.4%). No significant differences of the ICPC-2 category for the final diagnosis and each diagnosis were found between patients referred by general physicians and those referred by other physicians. The hospitalization rate was lower for patients referred by general physicians than for patients referred by other physicians (4 patients, 2.4% vs. 24 patients, 10.0%) (P = 0.002). Conclusions: Japanese general physicians found difficulty in diagnosing "Psychological" conditions, "Musculoskeletal" conditions, variations within the normal range, and viral infections that required diagnosis by exclusion. Because most of the patients referred by general physicians had mild conditions, further education at outpatient departments and clinics is required to improve diagnostic performance. Additionally, it is important to increase the gatekeeper role of general physicians and further development of the medical system by the government to distinguish the functions of clinics and hospitals is expected.

PURPOSE: To compare the diagnostic accuracy of diseases predicted from patient responses to a simple questionnaire completed prior to examination by doctors with different levels of ambulatory training in general medicine. PARTICIPANTS AND METHODS: Before patient examination, five trained physicians, four short-term-trained residents, and four untrained residents examined patient responses to a simple questionnaire and then indicated, in rank order according to their subjective confidence level, the diseases they predicted. Final diagnosis was subsequently determined from hospital records by mentor physicians 3 months after the first patient visit. Predicted diseases and final diagnoses were codified using the International Classification of Diseases version 10. A "correct" diagnosis was one where the predicted disease matched the final diagnosis code. RESULTS: A total of 148 patient questionnaires were evaluated. The Herfindahl index was 0.024, indicating a high degree of diversity in final diagnoses. The proportion of correct diagnoses was high in the trained group (96 of 148, 65%; residual analysis, 4.4) and low in the untrained group (56 of 148, 38%; residual analysis, -3.6) (χ (2)=22.27, P<0.001). In cases of correct diagnosis, the cumulative number of correct diagnoses showed almost no improvement, even when doctors in the three groups predicted ≥4 diseases. CONCLUSION: Doctors who completed ambulatory training in general medicine while treating a diverse range of diseases accurately predicted diagnosis in 65% of cases from limited written information provided by a simple patient questionnaire, which proved useful for diagnosis. The study also suggests that up to three differential diagnoses are appropriate for diagnostic prediction, while ≥4 differential diagnoses barely improved the diagnostic accuracy, regardless of doctors' competence in general medicine. If doctors can become able to predict the final diagnosis from limited information, the correct diagnostic outcome may improve and save further consultation hours.

RATIONALE, AIMS AND OBJECTIVES: To investigate the subsequent behaviour of doctor-shopping patients (defined as those attending multiple hospitals for the same complaint) who consulted our department and factors related to cessation of doctor shopping. METHODS: Patients who presented without referral to the Department of General Medicine at Chiba University Hospital in Japan (our department) completed a questionnaire at their first visit. A follow-up questionnaire was also sent to them in order to assess doctor shopping after 3 months. Then items in the questionnaires were investigated for significant differences between patients who continued or stopped doctor shopping. Logistic regression analysis was performed with items showing a significant difference between patients who stopped doctor shopping and those who continued it, in order to identify independent determinants of the cessation of shopping. RESULTS: A total of 978 patients who presented spontaneously to our department consented to this study, and 929 patients (95.0%) completed questionnaires correctly. Among them, 203 patients (21.9%) were identified as doctor shoppers. The follow-up survey was completed correctly by 138 patients (68.0%). Among them, 25 patients (18.1%) were found to have continued doctor shopping, which was a significantly lower rate than before (P < 0.001). Logistic regression analysis selected the following factors as independent determinants of the cessation of doctor shopping: 'confirmation of the diagnosis' (odds ratio: 8.12, 95% confidence interval: 1.46-45.26), and 'satisfaction with consultation' (odds ratio: 2.07, 95% confidence interval: 1.42-3.01). CONCLUSION: Doctor shopping decreased significantly after patients consulted our department, with 'confirmation of the diagnosis' and 'satisfaction with consultation' being identified as contributing factors.