Prompt diagnosis and appropriate treatment of Japanese spotted fever: A report of three cases

Background

Japanese Spotted Fever (JSF) is a Spotted Fever Group (SFG) rickettsiosis caused by Rickettsia japonica. More than 300 cases are diagnosed annually in Japan, and the number of reported cases has been increasing. Correct diagnoses depend on the triad of symptoms and signs, including fever, rash, and eschar, which can be seen at the site of vector bites. JSF is not life-threatening if treated appropriately without diagnostic delay but there are some fatal cases every year. This negligence leads to disseminated intravascular coagulation (DIC) and multiple organ failure (MOF), and poor prognoses, consequently. Prompt diagnosis of JSF is difficult when the aforementioned triad of signs and symptoms is not initially present.

Case report

This report describes three JSF cases: an 87-year-old woman with fever, shock, pancytopenia, DIC, and MOF; a 79-year-old man with fever and difficulty in movement; and a 78-year-old man with fever, general fatigue, and appetite loss. All patients had a rash and eschar, which led to prompt diagnosis and appropriate treatment immediately. All patients were treated without any complications.

Why should an emergency physician be aware of this?

As mentioned above, JFS can be fatal with delayed diagnoses and treatment initiations. The key for a prompt diagnosis is to recognize the triad of symptoms and signs, which are not often present initially, and it makes JSF diagnosis challenging. Repeated comprehensive physical examinations are essential for prompt diagnosis and improve prognosis of JSF.

Accelerometer-measured physical activity and posture among older adults in assisted-living residences

Objective

Few studies have detailed the physical activity and postural patterns (e.g. lying or sitting) in older adults with declining activities of daily living (ADL). Therefore, we aimed to address this issue by quantifying physical activity using an accelerometer and measuring time spent in various postures among older adults in assisted-living residences.

Methods

We quantified physical activity using an accelerometer (ActivPAL) and measured time spent in various postures in 35 older adults (mean age: 89.1 years) with chronic conditions residing in two assisted-living residences in Japan. ActivPAL was attached to the thigh and trunk of patients to distinguish between sitting and lying postures.

Results

Participants had a mean count of 6.2 comorbidities, and they were divided into three groups (fully independent, requiring minimal assistance and requiring care) based on their activities of daily living capacity using the Barthel Index. Residents aged ⩾90 years walked a mean of 1109.1 steps and spent 167.3 min upright per day. Fully independent participants walked a mean of 3587.6 steps daily; those requiring minimal assistance walked 1681.0 steps daily; and those requiring care walked 428.9 steps daily.

Conclusions

Our findings indicated that step count, number of sit-to-stand transitions, stepping time, and upright time decreased significantly as activities of daily living capacity decreased. Comorbidity type and number of comorbidities were not related to their lying time except for depression status. Lying time was associated with depression status.

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.

Prevalence of Burnout among Internal Medicine and Primary Care Physicians before and during the COVID-19 Pandemic in Japan

Objective To evaluate the change in the prevalence of burnout during the COVID-19 pandemic among internists and primary care physicians in Japan, and to identify factors associated with the exacerbation of burnout among these populations during this period. Methods This was a cross-sectional study based on two web-based surveys conducted in January 2020 (before the declaration of the COVID-19 pandemic) and June 2020 (during the pandemic). The participants were internists and primary care physicians of the Japanese Chapter of the American College of Physicians. The main outcome was the change in the prevalence of burnout between before and during the "first wave" of the pandemic. We also examined factors associated with the exacerbation of burnout during this period. Results Among the 283 respondents in the first survey and 322 in the second survey, 98 (34.6%) and 111 (34.5%) reported symptoms of burnout, respectively. In June 2020, 82 respondents (25.5%) reported that their level of burnout exacerbated compared to January 2020. Only the experience of self-quarantine was associated with the exacerbation of burnout [odds ratio (OR) 3.12; 95% confidence interval (CI) 1.49-6.50; p=0.002], while being a woman, being a resident physician, and an experience of having worked in a prefecture under a state of emergency were not. Conclusions No marked change in the prevalence of burnout among internists and primary care physicians in Japan was observed during the COVID-19 pandemic as a whole. However, self-quarantine was associated with the exacerbation of the burnout level.

Translation, Cultural Adaptation, and Validation of the Mini-Z 2.0 Survey among Japanese Physicians and Residents

Objective The Mini-Z 2.0 is a new, simple, and nonproprietary tool for assessing physician well-being and burnout. To date, a non-English version of the Mini-Z 2.0 survey has not been validated. Therefore, we aimed to develop a Japanese version of the Mini-Z 2.0 and to evaluate its validity and reliability using survey data from physicians affiliated with an internal medicine academic society. Methods The Mini-Z 2.0 survey was translated into Japanese using a forward-backward translation method. The participants belonged to the American College of Physicians' Japan Chapter. The translated version of the Mini-Z 2.0 survey was distributed to participants using an electronic mailing list. Convergent validity was assessed between burnout and other items using Pearson's product-moment statistic. Structural validity was evaluated using an exploratory factor analysis and confirmatory factor analysis, and reliability was assessed using internal consistency. Results Of the 1,255 physicians and medical residents contacted, 283 responded (22.5%). Burnout was present in 34.6% of the participants, with 48.8% reporting high stress levels. Convergent validity was demonstrated, with satisfactory correlations between burnout and satisfaction, value alignment, work control, and stress. An exploratory factor analysis identified two factors (i.e., Well-Being and Relationships and Work-Related Stressors); however, the three models evaluated using the confirmatory factor analysis revealed a poor fit. Cronbach's alpha for the sample was 0.80. Conclusion The Japanese version of the Mini-Z 2.0 demonstrated good internal consistency and convergent validity. Despite its inadequate structural validity, it can be used to measure physician well-being and related workplace conditions in Japan.

Characteristics of Patients and Their Ascites Who Underwent Repeated Cell-Free and Concentrated Ascites Reinfusion Therapy

Novel cell-free and concentrated ascites reinfusion therapy (KM-CART) is easy to use, safe and applicable for refractory ascites. We can get the full amount of ascites, filtrate, and concentrate in a short time. KM-CART can be applied as palliative care for dying patients including patients with massive malignant ascites. Some patients who underwent repeated KM-CART survived longer than those who did not repeat the therapy. The aim of this study was to identify the type of patients with ascites for whom KM-CART would be effective and candidates for repeated KM-CART. In this retrospective cohort observational study, we examined 123 CART processes performed on 58 patients with refractory ascites. Data were collected before and after processing of the ascites. We compared two groups; patients who underwent KM-CART ≥ 5 times and those who underwent this process ≤ 4 times. Age, disease, benign or malignant status of the disease, the amount of ascites, concentrations of total protein (TP) and albumin (Alb) and their amounts in the original ascites and the filtered and concentrated ascitic fluid and the recovery ratio of TP and Alb were determined. No significant difference was observed between the two groups in age, disease, amount of ascites, and the recovery ratio of TP and Alb. Significant differences were observed in the amounts of TP and Alb in the original ascites and the filtered and concentrated ascitic fluid. Patients who underwent KM-CART ≥ 5 times had higher Alb levels in the original ascites than those who underwent this therapy ≤ 4 times. Patients with higher Alb concentrations in the original ascites could be candidates for repeated KM-CART.

Glycated albumin predicts the risk of mortality in type 2 diabetic patients on hemodialysis: evaluation of a target level for improving survival

Glycated albumin (GA) is considered a more reliable marker than glycated hemoglobin (HbA1c) for monitoring glycemic control, particularly in diabetic hemodialysis patients. We investigated the associations of GA, HbA1c, and random serum glucose levels with survival, and evaluated possible targets for improving survival in diabetic hemodialysis patients. In this prospective, longitudinal, observational study, we enrolled 90 diabetic hemodialysis patients across six dialysis centers in Japan. The median duration of follow-up was 36.0 months (mean follow-up, 29.8 months; range, 3-36 months). There were 11 deaths during the observation period. GA was a significant predictor for mortality (hazard ratio, 1.143 per 1% increase in GA; 95% confidence interval, 1.011-1.292; P = 0.033), whereas HbA1c and random glucose levels were not predictors for mortality. Receiver operating characteristics curve analysis showed that the cutoff value of GA for predicting the risk of mortality was 25%. In the Kaplan-Meier analysis, the cumulative survival rate was significantly greater in patients with GA ≤ 25% than in patients with GA >25%. GA predicted the risk of all-cause and cardiovascular mortality in diabetic hemodialysis patients. Our results suggest that GA ≤ 25% is an appropriate target for improving survival in diabetic hemodialysis patients.

AP-VAS 2012 case report: a case of ANCA-negative crescentic glomerulonephritis complicating multiple opportunistic infections in the digestive tract

Crescentic glomerulonephritis (GN) is one of the common causes of rapidly progressive glomerulonephritis (RPGN). Pauci-immune crescentic GN is usually associated with anti-neutrophil cytoplasmic antibody (ANCA). However, patients with pauci-immune crescentic GN who lack ANCAs have recently been reported. Approximately 10-30 % of patients with pauci-immune crescentic GN lack ANCAs. The clinical characteristics of patients with ANCA-negative pauci-immune crescentic GN are not entirely the same as patients with ANCA-positive GN, and this suggests that ANCA-negative and ANCA-positive pauci-immune crescentic GN might be different disease entities. We report a patient with ANCA-negative crescentic GN complicated with multiple opportunistic infections (Candida albicans, herpes simplex virus, and Cytomegalovirus) in the digestive tract during the course of immunosuppressive therapy. After antifungal and antiviral therapies including itraconazole, valaciclovir, and ganciclovir, she recovered from multiple opportunistic infections. The occurrence of comorbid opportunistic infections during the course of immunosuppressive therapy may not be rare in the elderly. However, a case of multiple opportunistic infections limited to the digestive tract is very rare.

Immunoglobulin G4-related disease with scant tissue IgG4

A 56-year-old man was admitted to our hospital for renal dysfunction and symmetrical swelling of submandibular glands. Laboratory and imaging findings were consistent with immunoglobulin G4-related disease (IgG4RD). Histological findings of the submandibular gland and the kidney were also consistent with IgG4RD. However, the patient did not have elevated serum or tissue IgG4 levels. Oral prednisolone therapy, initially 50 mg/day and gradually tapered over 12 months, improved his laboratory abnormalities and the swelling of his affected organs. These findings prompted our final diagnosis of IgG4RD. IgG4RD is a newly recognised disease with an unknown aetiology. This case suggests that IgG4 antibodies do not play a primary role in the aetiology of IgG4RD. Furthermore, clinicians should not exclude the diagnosis of IgG4RD in patients lacking elevated IgG4 levels in their affected tissues, particularly if they have other features of IgG4RD. Steroid therapy should be considered for such patients.

[Case of suspected pseudo-elevation of serum creatinine immediately after intra-articular injection into a wrist joint of a pharmaceutical preparation of dexamethasone containing creatinine as a buffer]

We report a case of suspected pseudo-elevation of serum creatinine in a patient with rheumatoid arthritis, whose blood sample was obtained from his right cubital vein immediately after the intra-articular injection of 0.67 mg of a pharmaceutical preparation of dexamethasone (Decadron) containing creatinine as a buffer into his right wrist joint to alleviate arthralgia. The 61-year-old male patient, who had been treated for rheumatoid arthritis, was referred to our outpatient clinic by his family doctor because of sudden elevation of his serum creatinine, which hitherto had been normal. Acute kidney injury (AKI) was suspected, but his medical history, physical examinations, and laboratory findings did not support the diagnosis of AKI. The preserved serum sample obtained when the elevation of his serum creatinine was reported was examined and revealed that the serum concentration of cystatin C was normal, but the serum concentration of creatinine measured with high-performance liquid chromatography method was elevated to a degree consistent with the serum creatinine concentration measured with enzymatic method. Accordingly, we predicted the possibility that creatinine contained in Decadron as a buffer was included in the measurement of his intrinsic serum creatinine. To test this hypothesis, the creatinine concentration of serum samples from another patient with known amounts of added Decadron were measured, and the additive effect of the extrinsic creatinine in the measurement of serum creatinine concentration was confirmed. These findings clearly suggest that we should consider the influence of extrinsic creatinine as an inactive ingredient in the measurement of serum creatinine.

[Unstable hypertension due to renal artery compression by the developed diaphragm in a 17-year-old athlete: a case report]

A 17-year-old high school boy was admitted to our hospital because of hypertension. Doppler ultrasound of the renal arteries and 3D-CT angiography showed a stenosis of the right renal artery, which was pushed against the aorta by the right crus of the diaphragm. He underwent aortography and selective renal arteriography. His right renal artery originated from the aorta at a higher level than the left renal artery, between the celiac artery and the superior mesenteric artery. Renal arteriography confirmed a 50% reduction in diameter (stenosis) of the proximal right renal artery entrapped by the right diaphragmatic crus. This pathology, unlike common renal artery stenosis, sometimes requires surgical decompression or an aortorenal bypass graft, because renal angioplasty with stenting is reported to be at risk of complication by a fracture of the stent. However, the patient rejected surgical decompression for fear of deterioration of his athletic ability. Therefore we decided to follow up his blood pressure and renal size by ultrasound every six months. Renovascular hypertension caused by diaphragmatic entrapment is a very rare disease. The diagnosis may be overlooked easily at angiography if optimal views are not obtained. It is important to display images of the renal arteries, the celiac artery and the superior mesenteric artery in both inspiration and expiration.

C-106T polymorphism of AKR1B1 is associated with diabetic nephropathy and erythrocyte aldose reductase content in Japanese subjects with type 2 diabetes mellitus

BACKGROUND

The C-106T polymorphism of AKR1B1, which encodes aldose reductase (AR), was reported to be associated with diabetic nephropathy (DN). However, this association in Japanese patients with type 2 diabetes mellitus and its potential role as a clinical marker remain unclear.

METHODS

The C-106T polymorphism was genotyped in 228 cases (microalbuminuria or overt proteinuria) and 220 controls (normoalbuminuria with diabetes duration > or =10 years) for a case-control comparison, and the association with erythrocyte AR content was investigated. In addition, a new C-11G polymorphism in the promoter region of AKR1B1 was genotyped.

RESULTS

The distribution of genotypes of the C-106T polymorphism in cases was significantly different from that in controls (P = 0.031). Carriers of the TT genotype at the C-106T polymorphism were more frequent in cases than controls, with an odds ratio of 4.7 (95% confidence interval, 1.3 to 17). Erythrocyte AR content was significantly elevated in TT carriers in comparison to non-TT carriers (13.1 +/- 1.2 versus 10.2 +/- 1.2 ng/mg hemoglobin [Hb]; P < 0.001) and in cases in comparison to controls (10.6 +/- 1.3 versus 10.1 +/- 1.2 ng/mg Hb; P = 0.041). However, distribution of genotypes of the C-11G polymorphism and estimated frequencies of haplotypes defined by these 2 polymorphisms did not differ between cases and controls.

CONCLUSION

The TT genotype of the C-106T polymorphism of AKR1B1 increases the risk for DN in Japanese subjects with type 2 diabetes mellitus, which could be linked in part to greater expression of AR.

APOE polymorphism and the progression of diabetic nephropathy in Japanese subjects with type 2 diabetes: results of a prospective observational follow-up study

OBJECTIVE

The aim of this study is to clarify the conflicting results of the epsilon2/epsilon3/epsilon4 APOE polymorphism as a risk factor on diabetic nephropathy by a cohort study.

RESEARCH DESIGN AND METHODS

A total of 429 Japanese subjects with type 2 diabetes and with normoalbuminuria (n = 299) or with microalbuminuria (n = 130) were enrolled in a prospective observational follow-up study during 1995-1998 and followed until 2001 (for at least 3 years). The endpoint was the occurrence of a renal event defined as the progression to a higher stage of diabetic nephropathy.

RESULTS

During the study (the mean follow-up period: 4.4 +/- 1.0 years), 31 of 429 subjects progressed: 21 from normoalbuminuria to microalbuminuria and 10 from microalbuminuria to overt proteinuria. The allele frequency of the APOE polymorphism was significantly different between the progressors and the nonprogressors. Eight of 42 epsilon2 carriers (19%) progressed, whereas 23 of 387 noncarriers (6%) progressed with a relative risk of 3.2 (95% CI 1.5-6.7). When subjects were stratified by renal status at baseline, each relative risk for the progression in the epsilon2 carriers was 2.7 (0.99-7.4) in those with normoalbuminuria and 4.2 (1.3-13.3) in those with microalbuminuria. Furthermore, when analyzed only in subjects with normoalbuminuria and short duration of diabetes (<15 years) at baseline, the risk in the epsilon2 carriers became higher to 3.2 (1.2-8.8).

CONCLUSIONS

Our follow-up study indicates that the epsilon2 allele of the APOE polymorphism is a prognostic risk factor for both the onset and the progression of diabetic nephropathy in Japanese type 2 diabetes.

[Investigation of reinforcement of the free enamel--the adhesive strength test and SEM observation by using the composite resin]

In this study, the purpose of which is to examine reinforcement of free enamel, we employed visible light-cured adhesive composite resins applied to the inner surface of free enamel and the enamel surface. An Autograph DCS-5000 was used to measure physical tensile shearing strength; a scanning electron microscope (SEM) was used to observe the fracture surface of the adhesive area between the enamel and the composite resin. Results 1. Adhesive strength on the inner surface of free enamel was about 20% lower than that of the enamel surface. Nonetheless, we judged the inner surface of free enamel to have adhesive strength. 2. SEM observation showed that breaking occurred at the boundary of the adhesive surface between the enamel and the bonding material. It is possible to expect a certain amount of reinforcement of free enamel from the use of composite resins.

[Investigation of etching and bonding on the inner surface of free enamel. SEM observation and thermal cycling test for pigment invasion]

The purpose of this study is to examine adhesive condition on the inner surface of free enamel. If it was possible to use an adhesive composite resin to reinforce free enamel, it would be unnecessary to remove the free enamel entirely. To this study, we have used a visible light-cured and adhesive composite resin for the inner surface of free enamel. At the first, we carried out SEM examination of adhesive condition on the inner surface of free enamel. Then we performed thermal cycling test for pigment invasion. Results 1. SEM observation found tag-like extensions on the inner surface of free enamel. These extensions were of 2 shapes: horseshoe and beehive. 2. Thermal cycling test for pigment invasion showed practically no difference in marginal leakage between the experimental free-enamel cavities and control box cavities. 3. As a result of observation of adhesive conditions on the inner surface of free enamel, we believe that a certain degree of reinforcement of that enamel can be expected from composite resin.