MAY 2022 Volume 4-3

ISSN 2436-018X

JOURNAL OF HOSPITAL GENERAL MEDICINE

JHGM 2022：4(3)：125-132

Original article

Clinical prediction rules for COVID-19：
Using a Chi-Squared Automatic Interaction
Detector (CHAID) Decision Tree Analysis Model

Sayato Fukui 1)※　　Daiki Kobayashi 2)　　Akihiro Inui 1)
Takehiro Katahira 4)　　Takayuki Komatsu 3)　　Manabu Sugita 3)
Toshio Naito 1)

1) Department of General Medicine, Juntendo University Faculty of Medicine
2) Department of Internal Medicine, St. Luke’s International Hospital
3) Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital
4) Department of Medicine, Metabolism and Endocrinology, Juntendo University Graduate School of Medicine

Key Words：coronavirus disease, polymerase chain reaction, risk factors, predictive rule

[Purposee] This study, which was performed in a Japanese university hospital, sought to identify predictors of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) PCR positivity and to determine which medical patients need SARS-CoV-2 PCR testing.
[Methods] This retrospective cross-sectional survey was conducted in the Juntendo University Nerima Hospital, Tokyo, Japan. The study population included all outpatients from whom SARSCoV-2 PCR samples were collected. Clinical information was extracted from medical charts, and factors potentially predictive of the SARS-CoV-2 PCR results were analysed using Student’s t-test or the Chi-squared test and the Chi-Squared Automatic Interaction Detector (CHAID) Decision Tree Analysis Model.
[Results] A total of 336 patients (male：female = 159：177；mean ± SD age, 44.64 ± 19.04 years) were included in this study, 76 (22.6%) of whom had positive SARS-CoV-2 PCR results. CHAID decision tree analysis showed that close contact history plus ground-glass opacity (GGO) in peripheral areas on CT indicated a quite-high-risk group. Moreover, non-close contact history plus GGO in peripheral areas on CT and non-enforcement CT plus close contact history plus age over 34 years were seen more frequently in the high-risk groups.
[Conclusions] These results emphasize the importance of performing SARS-CoV-2 PCR testing in quite-high and high-risk groups,

JHGM 2022：4(3)：133-138

Original article

Clinical characteristics of Hodgkin lymphoma
in adolescents and young adults

Daisuke Nagase 1)　　　Yosuke Sasaki 2)※　　　Ai Hirota 1)
Hirofumi Irita 1)　　Naoki Onda1) 　　Kazuhiko Natori 1)

1) Division of Hematology and Oncology, Department of Medicine, Toho University School of Medicine
2) Department of General Medicine and Emergency Care, Toho University School of Medicine

Key Words：diagnostic delay, fever, primary care physician, symptom interval

[Introduction] Hodgkin lymphoma (HL) is a common cancer affecting the adolescent and young adult (AYA) population. Because AYA patients with HL present to their primary care physicians with a variety of complaints, an understanding of the clinical characteristics of these patients is important to prevent diagnostic or referral delay. Thus, we investigated the clinical characteristics present in the AYA population at the time of their HL visit.
[Methods] In our exploratory single-center retrospective study, 21 AYAs (15-39 years) were compared with 45 middle-aged and older (MAO) patients (＞ 39 years), all with HL, who were diagnosed and treated at the Department of Hematology and Oncology, Toho University Medical Center Omori Hospital, between 2003 and 2018.
[Results] Lymphadenopathy was the most common physical finding in both age groups. Fever was more frequent in the AYA group than in the MAO group on their first visit (57.1% vs. 28.9%, p = 0.028). Only AYA patients were referred for an evaluation of mediastinal masses on chest radiographs (4 vs. 0, p = 0.003).
[Conclusions] Our study revealed that fever and mediastinal masses were prevalent in AYA patients. Fever and mediastinal masses may be clues of early diagnosis of HL in the AYA population.

JHGM 2022：4(3)：139-147

Original article

The depressive state of COVID-19-free patients
seen in a General Medicine Department before
and during the outbreak

Hisashi Ohseto1)#　　Michiaki Abe1)2)#※　　Takuhiro Yamaguchi3)　　Shin Takayama1)
Tetsuya Akaishi1)　　Takeshi Kanno1)　　Ko Onodera 1)　　Minoru Ohsawa 1)
Junichi Tanaka 1)　　Takehiro Numata 1)　　Yasunori Tadano 1)　　 Satoko Suzuki1)　　Kota Ishizawa 1)
Akiko Kikuchi 1)　　 Ryutaro Arita1)　　Natsumi Saito 1)　　Rie Ono 1)　　Tadashi Ishii 1)2)

# HO and MA contributed equally to this study.

1) Department of Education and Support for Regional Medicine, Tohoku University Hospital
2) Tohoku Medical Megabank Organization, Tohoku University
3) Division of Biostatistics, Tohoku University Graduate School of Medicine

Key Words：General medicine, depressive state, COVID-19 period, COVID-19-free patient, the Self-rating Depression Scale

[Background] Coronavirus disease 2019 (COVID-19) is spreading globally and has brought psychological stress to the general population. This study aimed to evaluate the depressive state of non-affected patients in a general medicine outpatient unit before and during the COVID-19 outbreak in Japan.
[Methods] This was a database study. A total of 454 patients who visited the general medicine department at one university hospital between January 2019 and January 2021 were enrolled. Depressive symptoms were assessed using the Self-rating Depression Scale (SDS). Dichotomous and continuous scores were compared before and during the COVID-19 period, with adjustments applied for age and sex.
[Results] SDS scores were significantly higher for women and aged patients during the COVID-19 period as compared to before. The logistic regression analysis showed that depressive state was correlated with visiting the hospital during the COVID-19 period (odds ratio and 95% confidence interval：1.56 [1.02 to 2.39]), with a SDS score increase of 2.39 (0.39 to 4.40).
[Conclusions] Our study indicated that being in a depressive state was common to COVID-19- negative general medicine patients during the COVID-19 period.

JHGM 2022：4(3)：148-152

Case report

A case of the efficacy of Kampo medicine
for relatively prolonged side effects following
coronavirus disease 2019 vaccine

Yasuhito Irie 1)2)※　　Hajime Nakae 1) 　　Saga Akiko 2)　　 Haruka Hikichi 2)
Ken Watanabe 2) 　Kasumi Satoh 1)2) 　Toshiharu Kitamura 1)2)　　Shigeharu Ueki2)

1) Akita University Hospital Advanced Emergency and Critical Care Center
2) Akita University Hospital General Physician Center

Key Words：Coronavirus disease 2019, side effect, vaccine

[Case] A 28-year-old man presented with fatigue, headache, bilateral shoulder pain, chills, and
diarrhea. Although he was healthy, his symptoms appeared on the day after vaccination with his second dose of the Pfizer-BioNTech vaccine. He visited our outpatient clinic for Kampo medicine treatment on day 10. Based on the clinical course, the patient was considered to have vaccineinduced side effects, and keishito was prescribed according to the Eastern medicine findings. On day 13, his sweating disappeared, and headache and chills showed improvement；however, shoulder pain and fatigue persisted. On day 27, purple spots on the tongue were considered blood stasis, so the patient was prescribed tsudosan, which improved his shoulder pain. On day 52, the numeric rating scale score was 1 point, indicating a trend toward improvement.
[Discussion] Side effects are typically common following vaccination as the body is building immunity to antigens；however, they usually subside within a few days. Western medicine alone cannot maintain the quality of life of patients experiencing prolonged symptoms.
[Conclusions] Kampo medicine can be used to develop complementary medical treatments, even in clinical areas where evidence is yet to be accumulated.

JHGM 2022：4(3)：153-157

Case report

Emphysematous Osteomyelitis of the Spine due to
Staphylococcus aureus

Shinnichi Mukai　　Hiroki Isono ※　　Kousuke Ihara
Momoko Isono　　Keisuke Kondo

Department of General Medicine, HITO Medical Center

Key Words：emphysematous osteomyelitis, spine, Staphylococcus aureus

　　We report a case of emphysematous osteomyelitis of the spine secondary to methicillinsusceptible Staphylococcus aureus (MSSA) bacteremia. A 70-year-old man with type 2 diabetes and diabetic renal failure presented with fever and swelling of the right lower extremity. He was admitted to the hospital after being diagnosed with acute cellulitis originating from an ulcer on the right thumb. MSSA was detected in blood culture, and cefazolin was administered. On the 12th hospitalization day, the patient complained of lumbar pain. Physical examination revealed tenderness of the lumbar spinous process. Plain computed tomography (CT) revealed gas around the fifth lumbar vertebral body (L5) and epidural area. Magnetic resonance imaging (MRI) showed edematous changes in the vertebral bodies and surrounding soft tissues at the L5/S1 level. The patient was diagnosed with emphysematous osteomyelitis of the spine. Antibiotic therapy was continued, and CT after almost 4 months of treatment revealed the disappearance of emphysema. Subsequently, the treatment was terminated. Emphysematous osteomyelitis of the spine has a presentation similar to pyogenic spondylitis；however, it has a high mortality rate and requires prompt diagnosis. Diagnosing emphysematous osteomyelitis might require both CT and MRI. In addition to gram-negative rods and anaerobes, MSSA may also be a causative agent.

JHGM 2022：4(3)：158-159

Key Image of General Medicine

Black esophagus as an indicator of diabetes
and cirrhosis

Yosuke Sasaki ※　　Katsuhito Kashiwagi　　Tadashi Maeda
Tomoyuki Shigeta　　Takahiro Sato　　Yoshihisa Urita

Department of General Medicine and Emergency Care, Toho University School of Medicine

Key Words：esophageal necrosis, Gurvits’ syndrome, ischemia

JHGM 2022：4(3)：160-162

Key Image of General Medicine

Un-palpated subcutaneous amyloid deposits
by insulin injection

Toshitaka Sawamura ※　　Ai Ohmori　　Kei Sawada

Asanogawa general hospital

Key Words：subcutaneous amyloid deposits, insulin ball, diabetes

JHGM 2022：4(3)：163-164

Key Image of General Medicine

Multiple Gouty Tophi with Urate Milk

Satsuki Araki※　　Takashi Nakagawa　　Hiroki Takahashi

Department of General Internal Medicine, National Hospital Organization Sendai Medical Center

Key Words：gout, gouty tophi, urate milk

JHGM 2022：4(3)：165-166

Key Image of General Medicine

Axillary lymphadenopathy detected by FDG/PET-CT
after COVID-19 mRNA vaccination

Yosuke Sasaki 1)※　　Tatsuki Nanami 2)　　Sunao Mizumura 3)
Yoshihisa Urita 1)　　Hideaki Shimada 2)

1) Department of General Medicine and Emergency Care, Toho University School of Medicine
2) Department of Surgery, Toho University School of Medicine
3)Department of Radiology, Toho University School of Medicine

Key Words：gastric cancer, metastasis, vaccine

JHGM 2022：4(3)：167-169

Brief report

A case of chronic thyroiditis with sudden
hypothyroidism after the administration
of the mRNA COVID-19 vaccine

Shigenori Nakamura 1)※　　Masatoshi Ishimori 1)　　　　Kenji Wakahara 2)

1) Thyroid and Diabetic Division, Department of Internal Medicine, Japanese Red Cross Gifu Hospital
2) Kitaisshiki-Family-Clinic

Key Words：chronic thyroiditis, hypothyroidism, mRNA COVID-19 vaccine

JHGM 2022：4(3)：170-171

LETTERS TO THE EDITOR

Five tips on clinical research mentorship
for Japanese generalists

Kiyoshi Shikino 1)　　Masaki Tago 2)※　　　Takashi Watari 3)
Yosuke Sasaki 4)　　Hiromizu Takahashi 5)　　　Taro Shimizu 6)

1) Department of General Medicine, Chiba University Hospital
2) Department of General Medicine, Saga University Hospital
3) General Medicine Center, Shimane University Hospital
4) Department of General Medicine and Emergency Care, Toho University School of Medicine
5) Department of General Medicine, Faculty of Medicine, Juntendo University
6) Department of Diagnostic and Generalist Medicine, Dokkyo Medical University

Key Words：clinical research, generalist, mentorship, mentee, research activity

JHGM 2022：4(3)：172-173

LETTERS TO THE EDITOR

How can we train exemplary general hospitalists?

Masaki Tago 1)※　　Kiyoshi Shikino 2)　　Risa Hirata 1)　　Kotaro Kunitomo 3)
Yumi Otaka 4)　　Sosuke Matsui 5)　　Taro Shimizu 4)

1) Department of General Medicine, Saga University Hospital
2) Department of General Medicine, Chiba University Hospital
3) Department of General Medicine, National Hospital Organization Kumamoto Medical Center
4) Department of Diagnostic and Generalist Medicine, Dokkyo Medical University
5) Department of General Medicine, Kensei Hospital