[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.

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[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 co- management 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.

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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.

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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.

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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.

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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.

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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.

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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.

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