Background: Since acute abdomen requires accurate diagnosis and treatment within a particular time limit to prevent mortality, the Japanese Society for Abdominal Emergency Medicine in collaboration with four other medical societies launched the Practice Guidelines for Primary Care of Acute Abdomen that were the first English guidelines in the world for the management of acute abdomen. Here we provide the highlights of these guidelines (all CQ and recommendations were shown in supplementary information).
Methods: A systematic and comprehensive evaluation of the evidence for epidemiology, diagnosis, differential diagnosis, and primary treatment for acute abdomen was performed to develop the Practice Guidelines for Primary Care of Acute Abdomen 2015. Because many types of pathophysiological events underlie acute abdomen, these guidelines cover the primary care of adult patients with nontraumatic acute abdomen.
Results: A total of 108 questions based on 9 subject areas were used to compile 113 recommendations. The subject areas included definition, epidemiology, history taking, physical examination, laboratory test, imaging studies, differential diagnosis, initial treatment, and education. Japanese medical circumstances were considered for grading the recommendations to assure useful information. The two-step methods for the initial management of acute abdomen were proposed. Early use of transfusion and analgesia, particularly intravenous acetaminophen, were recommended.
Conclusions: The Practice Guidelines for Primary Care of Acute Abdomen 2015 have been prepared as the first evidence-based guidelines for the management of acute abdomen. We hope that these guidelines contribute to clinical practice and improve the primary care and prognosis of patients with acute abdomen.

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Background: Obstructive sleep apnea syndrome (OSAS) and chronic kidney disease (CKD) are common diseases encountered in primary care. These diseases share the same pathophysiology of chronic inflammation. In recent years, it was reported that the inflammasome participates in chronic inflammation, and interleukin (IL)-18 has received significant attention as an inflammasome marker. IL-18 is also closely associated with renal function, and is a stronger predictive marker of renal function disorder than high-sensitivity C-reactive protein (hsCRP) or IL-6. OSAS is also reported to be an independent risk factor of CKD. However, other basal diseases associated with OSAS and severe renal function disorders may also be CKD risk factors, such as hypertension, diabetes mellitus, and hyperlipidemia. So it should be carefully interpreted. Therefore, we investigated renal function in OSAS patients with no potentially confounding disorders using IL-18.
Methods: We assessed OSAS severity (apnea–hypopnea index [AHI]); renal function (estimated glomerular filtration rate); and hsCRP, IL-6, and IL-18 levels in 23 patients newly diagnosed with OSAS and free from other diseases.
Results: Serum levels of IL-18 demonstrated a significant negative correlated with eGFR (P < 0.05).
Conclusions: Even when renal dysfunction is mild, chronic inflammation is present in OSAS patients. We hypothesize that IL-18 is a useful marker to detect chronic inflammation in OSAS patients and that this chronic inflammation contributes to CKD. These results suggest that IL-18 is an associative marker for OSAS and renal function disorder, and can help achieve early treatment intervention in primary care.

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Objective: Low-carbohydrate diets have favorable short-term effects on body weight and risk factors for cardiovascular disease. However, they are potentially associated with an increased long-term risk of mortality. Our objective was to elucidate their effects on the incidence of diabetes.
Methods: Several databases (MEDLINE, EMBASE, ISI Web of Science, Cochrane Library, and ClinicalTrials.gov) were searched for relevant articles that were published prior to May 2015. Cohort studies with a follow-up period of at least one year were included. Identified articles were systematically reviewed, and those with pertinent data were selected for inclusion in a meta-analysis. The pooled risk ratio (RR) with 95% confidence interval (CI) for the incidence of diabetes was calculated using the random-effects model with inverse-variance weighting.
Results: We included 13 studies in a systematic review, followed by a meta-analysis using pertinent data. Among the 440,669 people that were included in 11 cohort studies, 27,887 (6.3%) cases of diabetes were documented. The risk of incident diabetes among individuals with a low-carbohydrate diet was not significantly different from that of individuals with a high-carbohydrate diet: the pooled RR was 1.03 (95% CI, 0.91–1.16).
Conclusion: Low-carbohydrate diets did not show any benefit on the risk of diabetes. However, this analysis is based on limited observational studies, and large-scale trials examining the complex interactions between low-carbohydrate diets and long-term outcomes are needed.

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According to recent study, hyperuricemia is not only a basic pathology of gout, but has been found that it is intimately related to the development and progress of hypertension, chronic renal disease (CKD), cardiovascular disease, and stroke. This means that hypertension, CKD and cardiovascular disease are caused by the direct effect (pro-oxidant effect) of urate without going through urate crystal deposition.
If the above issues can be indicated as clear evidence by treatment of interventional clinical trials, it can be thought that the treatment strategy for hyperuricemia to prevent organ damage will see substantial progress.

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Background: Patients with dementia may have already progressed to an advanced stage of illness before they receive a proper diagnosis in a medical institution. Early detection of dementia is critical, and simplified screening methods are needed to support this goal.
Methods: An easy-to-complete questionnaire, consisting of 15 items that assess behaviors associated with dementia, was used for this study. Respondents were asked to fill out both the questionnaire and the Hasegawa Dementia Rating Scale-Revised (HDS-R). Multivariate regression analyses were used to identify which of the 15 items were significantly related to the HDS-R.
Results: The response rate was 74% (217/293). Using multivariate logistic regression, 4 items from the questionnaire were identified as predictors of an HDS-R score ≤20 (“Needs to be diagnosed”). These items include: “Cannot perform multiple tasks at the same time”, “Unable to count money”, “Unable to choose one’s seasonal clothes”, and “Repeatedly buying the same thing” (all ps < 0.05). Age and gender were also significant predictors in the model. A revised questionnaire based on these results combines the 6 significant predictors; sensitivity and specificity were 93.9% and 82.1%, respectively.
Conclusions: This work developed a simplified screening method for dementia that can be implemented in primary care settings.

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Background: Among the elderly, the rate of complications resulting from malnutrition is high. A mini nutritional assessment short-form (MNA-SF) was confirmed overseas to identify malnutrition and predict clinical outcomes. This study aimed to evaluate the MNA-SF usefulness in Japanese small-sized hospital.
Methods: This was a prospective cohort study conducted on hospitalized patients at small-sized hospital, Department of General Internal Medicine which has 30 beds. All consecutive hospitalized patients for 4 months were included. A MNA-SF assessment on admission was implemented as exposure factor. Primary outcomes included death and complications such as infectious disease, organ failure, delirium, falls, diagnosis of malignancy and poor oral intake. Secondary outcomes including days of hospitalization and discharge rate back to home were also measured.
Results: 177 patients were analyzed with the MNA-SF assessment. Twenty-three (13%) patients were “normal nutritional status”, 64 (36%) were “at risk” and 90 (51%) were “malnourished”. The mortality rate was 0, 1.4 and 6.9 cases/1000 person-day (incidence ratio 4.9 times), respectively. The complications incidence rate was 0, 18 and 30.1 cases/1000 person-day (incidence ratio 1.7 times), respectively. The number of days in hospital were 11.1, 14.0 and 21.6 days (p < 0.01), respectively. The discharge to home rate was 90.4, 84.4 and 53.3% (p < 0.01), respectively.
Conclusions: Among all patients on a Japanese general medicine ward, those with poor nourishment assessed by the MNA-SF showed a high death rate and complication incidence rate. And they are also proved to be difficult to early discharge from the hospital back to the patient’s homes.

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Nausea is a common symptom and usually suggests a gastrointestinal disease rather than rare and severe neurological disorders such as neuromyelitis optica (NMO). A 69-year-old female with a prior history of Miller–Fisher syndrome presented with unremitting vomiting and hiccups. She was diagnosed with gastroenteritis over multiple visits to our hospital. However, she developed right-sided vision loss and bilateral lower extremity weakness. Magnetic resonance imaging of her spinal cord showed a lesion extending from T4 to L4, indicating transverse myelitis, and another lesion in the right ophthalmic nerve. Aquaporin-4 antibody testing was positive. A definitive diagnosis of NMO was made 23 days after the manifestation of her initial symptom however treatment produced only partial recovery of muscle weakness, and no recovery of her vision. It is important to make a timely diagnosis of NMO since specific treatment may be effective if provided at an earlier stage of the disease.

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Our patient was a 76-year-old woman with a history of hypertension and a major depressive disorder who presented to the hospital with a sudden onset of dizziness followed by chest discomfort. ECG findings revealed that there was no ST-segment elevation in V1 and ST-segment elevation in V2-V6. Echocardiography revealed left ventricular wall motion abnormalities. ST-segment elevation in anterior leads except V1 lead which caused us to suspect Takotsubo-cardiomyopathy. We confirmed the diagnosis after performing coronary angiography and left ventriculography. Clinicians should suspect Takotsubo-cardiomyopathy from this typical ECG finding.

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Physical examination is still needed in this modern era in spite of the recent development of advanced imaging modalities. However, not only clinicians but also researchers (including clinical researchers) seem to pay less attention to physical examination as a research topic. A PubMed search revealed that instead of an increasing percentage of diagnostic imaging articles, there were decreasing percentages of physical examination articles, especially in Japan. We should reconsider physical examinations as an important research topic, which might be especially interesting for general internal medicine doctors.

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