National survey of the association of depressive symptoms with the number of off duty and on-call, and sleep hours among physicians working in Japanese hospitals: a cross sectional study

<p>Abstract</p> <p>Background</p> <p>Physicians' mental health may be adversely affected by the number of days of work and time spent on-call, and improved by sleep and days-off. The aim of this study was to determine the associations of depressive symptoms with taking days of off duty, hours of sleep, and the number of days of on-call and overnight work among physicians working in Japanese hospitals.</p> <p>Methods</p> <p>A cross-sectional study as a national survey was conducted by mail. The study population was 10,000 randomly selected physicians working in hospitals who were also members of the Japan Medical Association (response rate 40.5%). Self-reported anonymous questionnaire was sent to assess the number of days off-duty, overnight work, and on-calls, and the average number of sleep hours on days not working overnight in the previous one month. Depressive state was determined by the Japanese version of the Quick Inventory of Depressive Symptomatology. Logistic regression analysis was used to explore the associations between depressive symptoms and the studied variables.</p> <p>Results</p> <p>Among the respondents, 8.3% of men and 10.5% of women were determined to be depressed. For both men and women, depressive state was associated with having no off-duty days and averaging less than 5 hours of sleep on days not doing overnight work. Depressive state was positively associated with being on-call more than 5 days per month for men, and more than 8 days per month for women, and was negatively associated with being off-duty more than 8 days per month for men.</p> <p>Conclusion</p> <p>Some physicians need some support to maintain their mental health. Physicians who do not take enough days-off, who reduced sleep hours, and who have certain number of days on-calls may develop depressive symptoms.</p

Development of airflow limitation, dyspnoea, and both in the general population: the Nagahama study

Subjects with subclinical respiratory dysfunction who do not meet the chronic obstructive pulmonary disease (COPD) criteria have attracted attention with regard to early COPD intervention. Our aim was to longitudinally investigate the risks for the development of airflow limitation (AFL) and dyspnoea, the main characteristics of COPD, in a large-scale community-based general population study. The Nagahama study included 9789 inhabitants, and a follow-up evaluation was conducted after 5 years. AFL was diagnosed using a fixed ratio (forced expiratory volume in one second (FEV₁)/forced vital capacity (FVC) < 0.7). We enrolled normal subjects aged 40-75 years with no AFL, dyspnoea or prior diagnosis of asthma or COPD at baseline. In total, 5865 subjects were analysed, 310 subjects had subclinical respiratory dysfunction (FEV₁/FVC < the lower limit of normal; n = 57, and FEV₁ < 80% of the predicted value (preserved ratio impaired spirometry); n = 256). A total of 5086 subjects attended the follow-up assessment, and 449 and 1021 subjects developed AFL and dyspnoea, respectively. Of these, 100 subjects developed AFL with dyspnoea. Baseline subclinical respiratory dysfunction was independently and significantly associated with AFL with dyspnoea development within 5 years. Subjects with subclinical respiratory dysfunction are at risk of developing COPD-like features and require careful monitoring

Gastroesophageal reflux disease is a risk factor for sputum production in the general population: the Nagahama study

Background: Chronic sputum production in the general population is historically associated with clinical indices including male sex and smoking history. However, its relationship with gastroesophageal reflux disease (GERD), which may prove an underlying factor in sputum production, is unclear. We aimed to clarify factors associated with sputum production in the general population in cross-sectional and longitudinal manners. Methods: In the Nagahama study, a community-based cohort study, 9804 subjects were recruited between 2008 and 2010 (baseline assessment), 8293 of whom were followed from 2013 to 2015 (follow-up assessment). This study contained a self-completed questionnaire which included medical history, assessment of sputum production, and a frequency scale for symptoms of GERD. A Frequency Scale for Symptoms of Gastroesophageal Reflux Disease score of ≥ 8 was defined as GERD. In addition to the frequency of sputum production at each assessment, frequency of persistent sputum production defined as sputum production at both assessments was examined. Results: Frequency of sputum production was 32.0% at baseline and 34.5% at follow-up. Multivariable analysis demonstrated that sputum production at baseline was significantly associated with GERD [odds ratio (OR), 1.92; 95% confidence interval (CI) 1.73-2.13] and post-nasal drip (PND) (OR, 2.40; 95% CI 2.15-2.68), independent of other known factors such as older age, male sex and smoking history. These associations between sputum production and GERD or PND were also observed at follow-up. In longitudinal analysis, 19.4% had persistent sputum production and 12.3% had transient sputum production, i.e., at baseline only. Multivariable analysis for risk of persistence of sputum production revealed that persistent sputum production was associated with GERD and PND, in addition to the known risk factors listed above. The proportion of subjects with GERD at both assessments was highest among subjects with persistent sputum production. Conclusions: Cross-sectional and longitudinal analysis demonstrated an association in the general population between sputum production and GERD, as well as PND, independent of known risk factors. The presence of GERD should be assessed in patients complaining of sputum production

体外式腹部超音波が診断に有用であった十二指腸巨大Brunner 腺過形成の一例

Brunner 腺過形成は十二指腸腫瘍性病変で，大きさが40mm を超えるものは10% 未満と稀である．医学中央雑誌で「腹部超音波」「Brunner 腺過形成」のキーワードで検索すると，関連した報告はない．体外式超音波検査（US）が診断に有用であったBrunner 腺過形成の一例を報告する．症例は50歳代，女性．食欲不振，心窩部痛とタール便を主訴に近医受診．貧血を認め，出血源検索目的に行った上部消化管内視鏡検査（EGD）で胃内に約 45 mm の腫瘤性病変を認め精査目的に当院紹介となった．血液生化学検査ではHb 9.1 g/dl，MCV 89.1 fl，MCH 30.0 pg と正球性正色素性貧血を認め，BUN/CRE 比は43.1と上昇していた．当院でのEGD では十二指腸球部に内腔をほぼ閉塞する45×40 mm の腫瘤性病変を認めた．腫瘤表面の異型性は目立たないが，oozing bleeding を伴ったびらん形成を認めた．粘膜下腫瘍を疑い生検も行われたが確定診断には至らなかった．単純造影CT では十二指腸球部に 45 mm 程度の腫瘤性病変を認め，辺縁は遷延性に造影された．内部は低吸収域が認められ，嚢胞変性や壊死が疑われた．周囲臓器への浸潤や転移を示唆する所見は認めず，粘膜下腫瘍が疑われたが癌は否定できなかった．US では十二指腸球部後壁の第２層から第３層に存在する約55 mm の粘膜下腫瘍が認められた．固有筋層は正常で，内部は大半が多房性嚢胞からなり，嚢胞間に充実成分がみられた．血流は比較的豊富であるが血管径や形状に明らかな不整は認めなかった．以上より十二指腸Brunner 腺過形成が疑われた．外科的切除の方針となり，開腹で十二指腸粘膜下層剥離術を行った．術材の組織診断はBrunner 腺過形成で超音波診断と矛盾しない所見であった．十二指腸粘膜下腫瘍の鑑別には超音波内視鏡が有用であるが，大きな病変では全体の描出が困難などの欠点もある．一方でUS は内視鏡侵襲なく，比較的大きな病変も描出可能で，特に本症例の様に前庭部付近は良好な観察が期待できるため，上部消化管の精査に応用できる．Brunner’s gland hyperplasia is a duodenal neoplastic lesion, and its lesions measuring >40 mm in diameter are rare, accounting for <10% of cases. A search of the Ichushi (Japana Centra Revuo Medicina) database using the keywords “abdominal ultrasound” and “Brunner’s gland hyperplasia” yielded no relevant articles. Here we report a case of Brunner’s gland hyperplasia in which transabdominal ultrasonography (US) was useful for diagnosis. A female in her 50s presented to a local hospital complaining of anorexia, epigastric pain and tarry stool. She had anemia and esophagogastroduodenoscopy (EGD), which was performed to identify the source of bleeding, revealed a mass lesion measuring approximately 45 mm in diameter in the stomach. She was referred to our hospital for further examination. Blood biochemistry showed a hemoglobin (Hb) level of 9.1 g/dL, mean corpuscular volume (MCV) of 89.1 fL and mean corpuscular hemoglobin (MCH) of 30.0 pg, indicating normocytic normochromic anemia. The blood urea nitrogen (BUN)/creatinine (CRE) ratio was as high as 43.1. In our hospital, EGD revealed a 45×40 mm mass lesion almost obstructing the lumen in the duodenal bulb. Atypia of the mass surface was not prominent, but erosion with oozing bleeding was observed. A submucosal tumor was suspected, and biopsy was performed but did not lead to a definitive diagnosis. Plain contrast-enhanced computed tomography (CT) revealed a mass lesion with prolonged peripheral enhancement measuring approximately 45 mm in diameter in the duodenal bulb. There was a low-density area inside the mass, raising the suspicion of cystic degeneration and necrosis. There were no findings suggesting infiltration or metastasis to the surrounding organs, raising the suspicion of a submucosal tumor, but cancer could not be ruled out. US revealed a submucosal tumor measuring approximately 55 mm in diameter in the second to third layer of the posterior wall of the duodenal bulb. The muscularis propria was normal and mostly composed of multilocular cysts with solid components in the space between the cysts. Blood flow was relatively abundant, but there were no obvious irregularities in the diameter or shape of blood vessels. The above findings raised the suspicion of duodenal Brunner’s gland hyperplasia. It was decided to perform surgical resection, and she underwent open duodenal submucosal dissection. Histology of the surgical specimen revealed Brunner’s gland hyperplasia, cons istent with the ultrasonographic findings. Endoscopic ultrasonography is useful in the differential diagnosis of duodenal submucosal tumors, but also has disadvantages such that it is difficult to visualize the entire lesion, when the lesion is large. On the other hand, US can be applied to the detailed examination of the upper gastrointestinal tract, because there are no invasive endoscopic procedures and US can visualize relatively large lesions and, in particular, can be expected to satisfactory observe around the vestibule, like in the present case

含糖酸化鉄注射液の長期投与でFGF23関連低リン血症性骨軟化症を来たしたクローン病の１例

症例は50歳代，男性．クローン病で２年前に右半結腸切除術，小腸部分切除を施行．術後に他院にてアダリムマブを導入され，クローン病は臨床的寛解の状態であった．４か月前より下肢を中心とした疼痛が出現した．アダリムマブによる薬剤起因性ループスあるいは腸炎性関節炎を疑い，２か月前よりアダリムマブ投与を中止し，プレドニゾロンの内服を開始するも改善を認めなかった．血液検査にて，低リン血症と高アルカリフォスファターゼ血症を認め，精査治療目的で当院に紹介入院となった．骨塩定量検査にて骨密度の低下を，骨シンチグラフィーで疼痛を認める骨への多発取り込みを認め，骨軟化症と診断した．血清のfibroblast growth factor 23（FGF23）が175pg/ml と高値であり，入院前まで定期的に使用されていた含糖酸化鉄注射液による，FGF23関連低リン血症性骨軟化症と診断した．含糖酸化鉄注射液投与を中止し，リン製剤とビタミンD 製剤の投与を開始したところ，徐々に低リン血症と高アルカリフォスファターゼ血症の改善を認めた．その後の経過は良好で，FGF23値は徐々に低下を示し，下肢を中心とした疼痛は軽快し，退院した．長期的に含糖酸化鉄注射液を投与する場合は，FGF23関連低リン血症の早期発見のため，血中リン濃度を定期的に測定する必要がある．The case is a man in his 50s. He underwent operations of right half colon resection and small intestine segmental resection due to Crohn’s disease two years ago. After surgery, Adalimumab was introduced in other hospital, and he was a state of the clinical remission in Crohn’s disease. The sharp pain mainly on lower limbs develops from four months ago. We doubted drug origin-related lupus with Adalimumab or enteritis-related joint pain. Therefore, we stopped Adalimumab injection and started internal use of the prednisolone, however the symptoms did not improve and had continued for two months.Laboratory test showed hypophosphatemia and hyperphosphatasemia and then he was transported to our hospital. Bone mineral quantity showed bone salt decrease and bone scan showed increased uptakes in multiple bones. Fibroblast growth factor23 (FGF23) of the serum was high (175pg/ml), and we diagnosed him FGF23-mediated hypophosphatemic osteomalasia induced by prolonged administration of saccharated ferric acid.Saccharated ferric acid has regularly been used until hospitalization. After stopping the ferric acid injection, and taking phosphorus and vitamin D, hypophosphatemia and hyperphosphatasemia was gradually improved. FGF23 level gradually reduced, and the sharp pain mainly on lower limbs was relieved, and it became a discharge. Regular measurement of serum phosphorus concentration is necessary for early detection of the FGF23-related hypophosphatemia in patients with long term use of saccharated ferric acid

川崎医科大学附属病院におけるバルーン小腸内視鏡検査の現状 : 325症例の解析結果を含めて

バルーン小腸内視鏡(balloon assisted endoscopy; BAE)は,従来困難であった小腸の検査・治療に有用な検査法である.当院では,2004年にダブルバルーン小腸内視鏡(double balloon endoscopy; DBE)を導入し,2012年6月現在,234症例(延べ325症例;シングルバルーン小腸内視鏡[single balloon endoscopy; SBE]2例を含む)経験した.症例の内訳は,男性127例,女性107例で,平均年齢は62.6歳であった.主訴は,原因不明の消化管出血(obscure gastrointestinal bleeding; OGIB)症例が143例(61.1%)と最多であった.基礎疾患は心血管障害47例(20.1%)が最多で,抗血小板・抗凝固療法を施行している症例は53例(22.6%)にみられた.経口的アプローチは325症例中158例で,経肛門的アプローチは167例,経口的,経肛門的アプローチを両方施行された症例は56例あった.病変は78例(24.0%)に検出され,その内訳は,びらん及び潰瘍性病変23例(29.5%),腫瘍性病変22例(28.2%),血管性病変21例(26.9%)であった.また,外科的切除,内視鏡的止血術等の治療を58例(74.4%)に施行した.BAE により小腸疾患の診断・治療が大きく進歩した.しかしながら,一方で手技が煩雑な点,患者の身体的侵襲も少なくなく合併症を有する点が欠点として挙げられる.そのため,各種小腸疾患の診断,治療に対しては,個々の患者の状況により,BAEとカプセル内視鏡(capsule endoscopy; CA)とを使い分けていくことが重要である.Balloon assisted endoscopy (BAE) is a novel endoscopic technique developed to investigate small bowel diseases (SBDs). BAE has been installed from 2004 in Kawasaki Medical School Hospital. Since then, 234 patients (107 female, 117 male; mean age 62.6 years) with suspected or known SBDs underwent BAE, and we have performed a total of 325 consecutive BAE procedures. The most common indication for BAE was an obscure gastrointestinal bleeding. Cardiovascular disease was the most major coexisting disease (47 patients, 20.1%), and 53 patients (22.6%) were prescribed anti-platelet and/or anticoagulant therapy. One hundred and fifty eight patients were treated BAE via the oral approach, 167 patients were performed via the anal approach, and 56 patients were treated via the dual approach. The overall diagnostic yield was 24.0% (78/325 cases). Among the 78 cases, there were 23 erosions/ulcerations, 22 tumors, 21 angiovascular lesions, and other SBDs. The subsequent treatments, such as endoscopic therapy and surgical therapy were performed following the BAE procedure in 74.4% (58/78) of cases. BAE is a useful tool that not only allows diagnostic workup of SBDs, but also makes it possible to carry out therapeutic intervention. On the other hand, we should make careful decisions of indications for BAE, because it\u27s an invasive and complex procedure and the examination requires substantial time to complete

内視鏡的ドレナージが有効であった胃壁膿瘍を合併した胃迷入膵の１例

　症例は30歳代女性．３日前から心窩部痛が出現し，徐々に増悪してきたため当院を受診した．血液検査でWBC 15,120/μl，CRP 2.95mg/dl と炎症反応上昇を認め，腹部超音波検査で胃幽門前庭部前壁に約3.5cm の粘膜下腫瘍様隆起を認めた．腫瘍内部はechogenic particles の混在する液体の貯留を認めた．腹部造影CT 検査では，胃前庭部から胃体部前壁にリング状の造影効果を伴う著明な壁肥厚を認めた．以上より胃壁膿瘍と診断した．胃前庭部前壁の弾性硬のやや発赤した粘膜下腫瘍様隆起に対して，超音波内視鏡下穿刺術（EUS-FNA）を行った．粘稠な白色液体の流出を認め，膿瘍を示唆する所見であった．絶食・点滴・抗生剤投与による保存的加療を施行後，速やかに腹部症状は消失し，EUS-FNA 施行後５日目に退院した．４か月後，病変は上部内視鏡検査で頂部に陥凹を有する腫瘍に形態変化を認め，さらに縮小傾向であった．また，腹部超音波検査では粘膜下層内に約５mm 大の嚢胞性領域とそれに接する約４mm 大の境界不明瞭な低エコー域，不整な固有筋層の肥厚を認め，胃迷入膵の所見であった．以上より，胃壁膿瘍を合併した胃迷入膵と診断した．現在，再発なく当科で経過観察中である．胃壁膿瘍を合併した胃迷入膵の報告は非常に稀であり，貴重な症例と考えられた．　Here, we report a case of gastric wall abscess in aberrant pancreas. A 30-yearold woman visited our hospital for epigastric pain. Routine hematological examination showed increased white blood cell count and biochemical tests revealed elevated C reactive protein levels. Abdominal ultrasound revealed a submucosal tumor that appeared as a hypoechoic heterogenous mass in the stomach. Abdominal computed tomography revealed a thickened gastric wall with a low-density area. This mass was diagnosed as a gastric wall abscess, which was treated with endoscopic ultrasound-guided fine needle aspiration and conservative therapy with antibiotics. The patient’s pain resolved after the treatment. Four months after the episode, follow-up examinations showed that the submucosal tumor had changed to a small submucosal mass with depression. This lesion was diagnosed as an aberrant pancreas. Thus, the final diagnosis was a gastric wall abscess in the aberrant pancreas. This patient was followed up for one year following this episode with no incidence of recurrence

当院における便潜血陽性者に対する大腸CT(CTコロノグラフィー)検査の有用性:大腸がん検診への導入と課題

大腸がん検診におけるスクリーニング検査としての大腸CT(CT colonography: CTC)検査の有用性を検討するために,当院における便潜血陽性者に対するCTCと大腸内視鏡検査の精度比較を行った.2009年7月から2014年1月までに川崎医科大学附属病院で施行されたCTC検査673件中,スクリーニング目的で行われた411件の中で便潜血陽性者に対して行われた183名を対象とした.全例CTC検査と同日に全大腸内視鏡検査も行った.対象とする病変は内視鏡観察あるいは病理組織学的に腺腫,がんと診断されたものとした.CTCの前処置は,経口腸管洗浄剤に水溶性造影剤による標識(タギング)を付けて行った.CT装置は16列Multi-slice CT(MSCT),腸管拡張は自動炭酸ガス注入器を使用した.CTC読影は,まず仮想内視鏡(3D)で行い,後に多断面再構成像(Multi-planar reconstruction: MPR 像(2D))を行う3D primary 法で行った.183名(男性98名,女性85名,年齢40～86歳,平均年齢62.1歳±0.8歳)のうち,病変を認めなかったのは87名(47.5%)であり,病変を認めたのは96名(53%)であった.総病変数は191個であり,うち6mm以上の病変は77個(40%)で,そのうち10mm以上のものは46個(24%)であった.大腸癌は25例(全病変中13%)で,うち腺腫内癌16例(全病変中8%)であった.側方発育型腫瘍は8例(4%)(大きさ平均17mm)であった.病変のうち,内視鏡的切除が行われたものは34病変であり,手術が行われたものは22病変であった.病変形態別による描出率は隆起型病変80%で,平坦型病変65%であった.病変サイズ別の精度は10mm以上の病変(n=46)で感度96%,陽性適中率98%であり,6mm以上の病変(n=77)で感度83%,陽性適中率79%であった.CTCは便潜血陽性者において良好な精度を示し,大腸がんスクリーニング法としての可能性がある.The purpose of this study was to estimate the sensitivity and specificity of CT colonography (CTC) for colorectal cancer screeing following positive fecal occult blood test (FOBT) in Japan. To compare detection rates of colorectal cancer and adenoma between CTC and optical total colonoscopy (TCS). This study included 183 patients with positive result of FOBT in Japanese colorectal cancer screening program. The patients had both CTC and TCS on the same day. 96 patients (53%) had colorectal lesions, on the other hand 87 patients had no lesions. The total number of lesions was 191, including 77 lesions 6 mm in maximum diameter and larger, including 46 lesions 10 mm and larger