JULY 2023 Volume5-4

ISSN 2436-018X

JOURNAL OF HOSPITAL GENERAL MEDICINE

Original Articles

Association between sleep disorders and lifestyle habits
in an underpopulated area of Japan・・・・・・・・・・・・・・・・・・Ryo Tabata　　111
Co-management of Neurosurgery Patients by General Physicians Improves
the Examination Rate for Hepatitis B and Hepatitis C Screening
Test-Positive Patients・・・・・・・・・・・・・・・・・・・・・ Hiroyuki Yamamoto　　119
Is physician specialty related to decision-making for Do-Not-Attempt-Resuscitation
among older adults admitted with pneumonia? ・・・・・・・・・・・・Mari Aihara　　128

Case Reports

Short Case Reports

Nontyphoidal Salmonella urinary tract infection in a young man ・・・・・Mai Hongo　　166
A Case of Pontine Infarction Diagnosed from Bilateral Cheiro-Oral
Syndrome and Truncal Ataxia ・・・・・・・・・・・・・・・・・・・Tetsu Sakamoto　　168

Letters To The Editor

Comments on “A Case of Right Brachiocephalic Vein and Right Internal Jugular
Vein Thrombophlebitis Secondary to Air Entry into a Central Venous Catheter
Inserted into the Right Subclavian Vein”・・・・・・・・・・・・・・・・ Hiroki Isono　　171
Response to questions regarding ‘A Case of Right Brachiocephalic Vein and Right
Internal Jugular Vein Thrombophlebitis Secondary to Air Entry into a Central
Venous Catheter Inserted into the Right Subclavian Vein.’ ・・・・・Haruhiko Egawa　　172
Pseudogout in the temporomandibular joint diagnosed by ultrasound・・Naoto Ishimaru　　174
Ball valve syndrome・・・・・・・・・・・・・・・Tomoyuki Shigeta　　177
Sudden subcutaneous hemorrhaging of a middle-aged woman’s hand：
Achenbach syndrome ・・・・・・・・・・・・・・・・・・・・・・Kotaro Kunitomo　　179

JHGM 2023：5(4)：111-118

Original Articles

Association between sleep disorders and lifestyle
habits in an underpopulated area of Japan

Ryo Tabata1)　　Risa Wada2)　　Yoshihiro Ookura3)　　Harutaka Yamaguchi1)　　Kenji Tani3)※

1) Department of General Medicine, University of Tokushima Graduate School of Biomedical Sciences
2) Student Lab, The University of Tokushima Faculty of Medicine
3) Department of General Medicine and Primary Care, Tokushima University Hospital

Key Words：sleep disorders, lifestyle habits, older adults, underpopulated area

[Introduction] This study aimed to determine the relationship between lifestyle and sleep disorders among community-dwelling people, while considering local specialties and social infrastructure, via the administration of questionnaires pertaining to daily behaviors, such as eating, drinking, walking, and driving.
[Methods] This study was conducted in Kaifu County, Tokushima Prefecture, Japan, which is an underpopulated area. The questionnaire included demographic information (e. g., age, sex, marital status, living status, and the status of diabetes mellitus) and 23 queries regarding lifestyle-related behaviors (e.g., food, meal timing, smoking, drinking, and driving).
[Results] The multivariable logistic regression analysis showed that “Eat sudachi frequently” was negatively associated with sleep disorders (odds ratio [OR]= 0.43, 95% confidence interval [CI]：0.22-0.84, p = 0.013) and that “Anxious and frustrated about current life” was positively associated with sleep disorders (OR = 2.62, 95% CI：1.27-5.38, p = 0.009). [Conclusions] These results provide an indication as to what types of lifestyle habits should be cultivated to get a good night’sleep. Moreover, because lifestyle habits vary depending on local characteristics, such as the diet and social infrastructure in a region, these factors should be considered when evaluating sleep disorders.

JHGM 2023：5(4)：119-127

Original Articles

Co-management of Neurosurgery Patients
by General Physicians Improves the Examination Rate
for Hepatitis B and Hepatitis C Screening
Test-Positive Patients

Hiroyuki Yamamoto 1)※　　 Mamoru Komatsu 1)　　Shouhei Noshiro 2)　　Masafumi Ohtaki 2)

1) Department of General Medicine, Obihiro Kosei General Hospital
2) Department of Neurosurgery, Obihiro Kosei General Hospital

Key Words：Co-management, Hepatitis B, Hepatitis C, Hepatitis virus screening test

[Background]Co-management is a model of care in which a general physician collaborates with other departments to provide a more comprehensive evaluation of the patient’s overall health than is done with the conventional consultation model, wherein the responding doctor treats specific problems. It remains unknown whether co-management improves the examination ratio for hepatitis virus screening in test-positive patients. We evaluated the effectiveness of comanagement in the neurosurgery department for appropriate examination of patients who tested positive for hepatitis virus.
[Methods]We conducted a single-center retrospective analysis of patients admitted to the neurosurgery department whose hepatitis virus screening test was positive to compare the ratio of appropriate examinations before and after co-management was initiated.
[Results] The virus polymerase chain reaction testing ratio increased from 1 of 14 (7.1%) to 17 of 18 (94.4%) (P ＜ 0.001) patients in whom hepatitis B virus was newly indicated before and after co-management and from 0 of 31 (0.0%) to 24 of 30 (80.0%) (P ＜ 0.001) patients in whom hepatitis C virus was newly indicated.
[Conclusions]Co-management improveed the examination rate for hepatitis virus screening in test-positive patients.

JHGM 2023：5(4)：128-137

Original Articles

Is physician specialty related to decision-making
for Do-Not-Attempt-Resuscitation among older adults
admitted with pneumonia?

Mari Aihara1)2)※　　 Kenya Ie 1)2)3) 　　Masanori Hirose 1)　　Iori Motohashi 1)2)
Tomoya Tsuchida 1)　　 Takuya Otsuki 1)2) 　　Mio Kushibuchi 1)2)　　Steven M. Albert 3)
Chiaki Okuse 1)2)　　Takahide Matsuda 1)　　Yoshiyuki Ohira 1)

1) Department of General Internal Medicine, St. Marianna University School of Medicine
2) Division of General Internal Medicine, Department of Internal Medicine, Kawasaki Municipal Tama Hospital
3) Department of Behavioral and Community Health Sciences, School of Public Health, University of Pittsburgh

Key Words：decision-making, do-not-attempt-resuscitate order, end-of-life care, geriatric medicine, pneumonia

　　We examined whether physicians’ specialty, including general medicine (GM), internal medicine (IM), and emergency medicine (EM), is related to code status decision-making by patients admitted to hospital with a diagnosis of pneumonia. A retrospective analysis was conducted on 648 patients aged 65 years and above. Code status was divided into a Do Not Attempt Resuscitation (DNAR) group and a FULL code group from the medical record review. Multivariable logistic regression analysis was performed with code status as the outcome variable, physician’s specialty as the main explanatory variable, and patient’s and physician’s demographic factors as covariates. There were 386 patients (59.6%) in the DNAR group. Older age, the presence of severe dementia, and low activities of daily living before hospitalization were significant predictors of DNAR orders. Compared to patients seen by EM physicians, those seen by GM were more likely to have DNAR orders (aOR 4.29, 95% Cl: 2.40-7.66). Patients seen by an IM were also more likely to have DNAR orders (aOR 4.11, 95% Cl: 2.16-7.80). Patients were more likely to choose DNAR orders when they were asked about their code status by GM or IM physicians, compared to EM physicians, even after controlling for covariates.

JHGM 2023：5(4)：138-144

Case Reports

Ischemic stroke in a young adult diagnosed
by anti-VZV IgG antibody in cerebrospinal fluid
4 months after herpes zoster ophthalmicus

Satoru Okada 1)※　　Hirofumi Saito 2)

1) Department of Family and General Medicine, Tokyo-Kita Medical Center
2) Department of Anesthesiology and Intensive Care, Saitama Medical Center, Jichi Medical University

Key Words：VZV vasculopathy, stroke, varicella-zoster virus

　　We describe a case of delayed stroke due to varicella-zoster virus (VZV) vasculopathy caused by herpes zoster ophthalmicus 4 months prior. A healthy 30-year-old man with acute left hemiplegia and impaired consciousness was admitted to our hospital. Magnetic resonance imaging showed multiple acute ischemic strokes in the right cerebrum and basal ganglia, and contrast-enhanced magnetic resonance angiography revealed occlusion of the right middle cerebral arteries (MCA) at the stem and thickening of the vessel wall with enhancement of the MCA, suggesting vasculitis. Four months earlier, the patient had herpes zoster infection in the first branch of the right trigeminal nerve area. Although cerebrospinal fluid (CSF) VZV DNA presence was negative, CSF VZV IgG was positive. Therefore, ischemic stroke due to VZV vasculopathy was diagnosed, and the patient was treated with acyclovir and steroids. Thereafter, there was no progression of ischemic stroke, and the right MCA occlusion subsequently improved.
　　If a patient with ischemic stroke has a recent history of herpes zoster, poor cardiovascular risk factors, recurrent cases, imaging findings atypical for atherosclerosis, immunocompromised patients, chronic headache, altered mental status, or fever, VZV vasculopathy should be suspected and CSF VZV IgG should be examined for diagnosis.

JHGM 2023：5(4)：145-150

Case Reports

Tetanus initially diagnosed as cervical spinal cord
injury due to jaw contusion

Yosuke Sasaki ※　　Takeshi Suzuki　　Tadashi Maeda　　Fumiya Komatsu　　Tomoyuki Shigeta
Takahiro Sato　　Katsuhito Kashiwagi　　Takeo Mori　　 Yoshihisa Urita

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

Key Words：trismus, spasm, hyperreflexia

　　Tetanus is a disease caused by a toxin produced by Clostridium tetani that presents with muscular spasm and autonomic nervous system disturbance. Thanks to the initiation of regular vaccination since 1968, tetanus has become rare in Japan. Nevertheless, tetanus remains a “Do not miss” diagnosis that requires early diagnosis due to its high fatality rate. Japanese individuals born before 1968 did not receive public vaccinations for tetanus and are at risk for developing tetanus. We report a case of a 62-year-old woman with tetanus that was initially diagnosed with cervical spinal cord injury due to jaw contusion. Despite the patient presenting with a typical combination of tetanus, namely, trismus and muscular spasm, she was diagnosed with cervical spinal cord injury until 4 days after hospital admission because she had had a jaw contusion that served as a “red herring.” Given that tetanus toxoid and anti-tetanus globulin can prevent the development of tetanus even after trauma, our report underscores the importance of tetanus as a differential diagnosis of spasticity in all situations and the importance of availability bias, zebra retreat, authority bias, and diagnostic momentum in diagnostic error.

JHGM 2023：5(4)：151-154

Case Reports

Tosufloxacin-induced severe hypoglycemia
in a non-diabetic patient

Nobuyuki Takahashi 1)※　　 Takashi Sugamori 2)　　Shunichi Hamaguchi 1)
Tsunetaka Kijima 1)　　 Shingo Yamagata 1)　　Tetsuya Makiishi 3)

1) Shimane University Faculty of Medicine, Department of General Medicine, Oda Training Center of General Practice
2) Oda Municipal Hospital, Department of Cardiology
3) Shimane University Faculty of Medicine, Department of General Medicine

Key Words：tosufloxacin, hypoglycemia, non-diabetic patient

　　An 89-year-old woman with a history of receiving treatment for hypertension, dyslipidemia, and osteoporosis consulted her general practitioner because of a productive cough. She was diagnosed with a respiratory infection and tosufloxacin was prescribed. After 4 days, the patient was transferred to our hospital because of impaired consciousness and a blood glucose level of 32 mg/dL. Intravenous dextrose was immediately administered after which she quickly regained consciousness. The patient was not on any antidiabetic treatment; therefore, we suspected that the hypoglycemia was caused by tosufloxacin. After tosufloxacin was discontinued, the patient did not have any recurrence of hypoglycemia.
　　Although several case reports of hypoglycemia caused by fluoroquinolones have been published, there are few reports on hypoglycemia associated with tosufloxacin use. Furthermore, hypoglycemia secondary to fluoroquinolones may be more common in patients with diabetes (especially if treated with hypoglycemic agents); however, our patient had no history of diabetes or treatment with hypoglycemic agents. Clinicians should be aware of the risk of hypoglycemia in patients treated with quinolones, even in non-diabetic patients.

HGM 2023：5(4)：155-159

Case Reports

Short-term Effects of Hemodialysis Therapy
in the Fluid Management of Elderly Heart
Failure Patients with Chronic Kidney Disease:
Considering the Position of Renal Replacement
Therapy in Cardiorenal Syndrome

Masaru Nakayama 1)※　　Hirofumi Nakano 2)　　Ren Arai 1)　　Takuma Ishikawa 1)

Manabu Fujihara 1)　　Satoko Watanabe 1)　　Fumie Nakayama 1)　　Atsushi Ishii 1)

1) Division of Hospital General Medicine, Youjyoukai Kashima Hospital
2) Division of Nephrology, Youjyoukai Kashima Hospital

Key Words：heart failure, cardio-renal syndrome, hemodialysis

　　When heart failure (HF) becomes refractory to treatment, symptomatic palliation becomes a primary goal. This is especially true for elderly patients who are not candidates for heart transplantation, and end-of-life care becomes a primary focus. Hemofiltration therapy is a relatively straightforward method of fluid management to initiate, but its indication is limited to symptoms based on renal function or end-stage renal failure. In this case report, we investigated the background and course of elderly end-stage HF patients with chronic kidney disease who underwent hemodialysis (HD) for treatment-resistant HF. We studied 10 patients with an average age of 82 years, 7 of whom had HF with preserved left ventricular ejection fraction. All patients required oxygen therapy at the time of dialysis induction, but none had uremia. Four patients died after HD induction, but there were no cases of fluid management failure during the follow-up period. Although the patients were initially targeted for transition to end-of-life care, the introduction of HD contributed to short-term improvement in HF symptoms. These results suggest that HD may be effective in improving refractory HF symptoms in the elderly population.

JHGM 2023：5(4)：160-165

Case Reports

A case of prostate cancer with normal serum
prostate-specific antigen values and suspected
immunoglobulin G4-related disease caused
by periarteritis

Masahiro Yokosawa 1)※　　Kaori Kaneko 1)　　Yuko Tonoike 1)　　Tomotaka Toba 2)
Kosuke Tsuboi 1)　　Akira Iwashima 1)　　Takashi Tomidokoro 1)

1) Department of General Medicine, Nagaoka Chuo General Hospital
2) Department of Urology, Nagaoka Chuo General Hospital

Key Words：high serum IgG4, periarteritis, normal serum PSA

　　A 71-year-old Japanese man who had elevated serum immunoglobulin G4 (IgG4) levels presented with periarteritis of the left external iliac artery. Whole body fluorodeoxyglucose positron emission tomography/computed tomography revealed abnormal uptake at the left external iliac artery (maximum standardized uptake value 4. 4), subcarinal lymph nodes (maximum standardized uptake value 6.4), and prostate (maximum standardized uptake value 5.7). Laboratory examination showed high serum IgG4 l and normal prostate-specific antigen levels. A needle biopsy of the prostate was performed. The histopathological examination revealed carcinoma, but did not show lymphoplasmacytic infiltration. A biopsy of the subcarinal lymph nodes with transbronchial biopsy was also performed, and the histopathological examination did not find infiltration of plasma cells or malignant cells. During evaluation, hydronephrosis was indicated by increased soft tissue shadows around the left external iliac artery. After three months of hormone therapy for prostate cancer, the soft tissue shadows decreased, and the hydronephrosis disappeared. The levels of serum IgG4 did not change during the treatment. The periarteritis was considered a paraneoplastic syndrome of prostate cancer.

JHGM 2023：5(4)：166-167

Short Case Reports

Nontyphoidal Salmonella urinary tract infection
in a young man

Mai Hongo 1)※　　Yukinori Harada 2)　　Taro Shimizu 2)

1) Department of General Practice, Saka General Hospital
2) Department of Diagnostic and Generalist Medicine, Dokkyo Medical University

Key Words：nontyphoidal Salmonella, urinary tract infection, young man

JHGM 2023：5(4)：168-170

Short Case Reports

A Case of Pontine Infarction Diagnosed from Bilateral
Cheiro-Oral Syndrome and Truncal Ataxia

Tetsu Sakamoto　　 Taro Shimizu ※

Department of Diagnostic and Generalist Medicine, Dokkyo Medical University Hospital

Key Words：cheiro-oral syndrome, acute cerebral infarction

JHGM 2023：5(4)：171

Letters To The Editor

Comments on “A Case of Right Brachiocephalic Vein
and Right Internal Jugular Vein Thrombophlebitis
Secondary to Air Entry into a Central Venous Catheter
Inserted into the Right Subclavian Vein”

Hiroki Isono

Department of General Medicine, HITO Medical Center

JHGM 2023：5(4)：172-173

Letters To The Editor

Response to questions regarding
‘A Case of Right Brachiocephalic Vein and Right
Internal Jugular Vein Thrombophlebitis Secondary
to Air Entry into a Central Venous Catheter Inserted
into the Right Subclavian Vein.’

Haruhiko Egawa

Internal Medicine, Sakai Wakabakai Hospital

JHGM 2023：5(4)：174-176

Key Images

Pseudogout in the temporomandibular joint
diagnosed by ultrasound

Naoto Ishimaru ※　　Saori Kinami

Department of General Internal Medicine, Akashi Medical Center

Key Words：pseudogout, temporomandibular joint, ultrasonography, Calcium pyrophosphate dihydrate crystal deposition disease

JHGM 2023：5(4)：177-178

Key Images

Ball valve syndrome

Tomoyuki Shigeta ※　　 Yosuke Sasaki　　Tadashi Maeda 　　Yoshihisa Urita

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

Key Words：ball valve syndrome, frequent vomiting, gastrostomy tube

JHGM 2023：5(4)：179-180

Key Images

Sudden subcutaneous hemorrhaging of
a middle-aged woman’s hand：Achenbach syndrome

Kotaro Kunitomo ※　　Fumitaka Yoshimura 　　Junko Kubosaki　　 Takahiro Tsuji

Department of General Medicine, Kumamoto Medical Center

Key Words：Achenbach syndrome, Diagnostic excellence