Journal of General and Family Medicine最新文献

We thank the reader for his knowledgeable comments on our study.^{1, 2} We were asked to disclose how the indication for lumbar puncture was determined during this study. Unfortunately, there was no uniform indication for lumbar puncture in this study, neither was data collected on the reason the physician performed the lumbar puncture in each case. This study was a retrospective study, and the decision to perform a lumbar puncture was at the discretion of the examining physician in each hospital. As you mentioned, determining which patients presenting with acute neck pain should undergo lumbar puncture is subjective.

From the present study, cervical rotation restriction (inability to rotate the neck or pain with even slow neck rotation) may be a characteristic finding of CDS. This is a different physical finding from the Jolt accentuation headache (accentuation of headache by horizontal rotation of the head at a frequency of two to three times per second) observed in meningitis. If cervical rotation restriction with neck pain is less frequent in meningitis, a finding of restricted cervical rotation with neck pain may be diagnostic of CDS and rule out meningitis. We hope that clinical criteria for diagnosing CDS, including cervical rotation restriction, that are distinct from those of meningitis will be developed.

All authors meet the ICMJE authorship criteria. HI wrote the manuscript, and all of author reviewed and edited the manuscript.

The authors have stated explicitly that there are no conflicts of interest in connection with this article.

We read the article by Isono et al.¹ with great interest. We were impressed not only by the largest number of cases recruited into this collaborative study but also by the detailed data collection under a unified protocol, which successfully delineated clinical features of crowned dens syndrome (CDS).

As clarified, neck pain exacerbated by rotation or pressure, accompanied by fever and an elevated inflammatory response on blood tests strongly suggests CDS. However, this clinical picture may mimic acute meningitis with head/neck pain with jolt accentuation especially when accompanied by fever.² For example, one of our patients presented with neck pain accompanied by headache, without fever or loss of consciousness, but an increased cell count on CSF led to the diagnosis of aseptic meningitis. Therefore, neck pain does not preclude the possibility of meningitis. Furthermore, Mizumoto³ reported a CDS patient with pleocytosis, which alert the possibility of meningitis even in the presence of CDS. Because it is not yet known when calcification around the dens as a hallmark of CDS appears, persists, or disappears, overreliance on calcification around dens may overlook CDS mimics like meningitis. Indeed, among the CDS patients by Isono and colleagues, 8% had impaired consciousness and 15% underwent lumbar puncture, suggesting that some of these CDS patients may mimic meningitis to warrant an emergent need of lumbar puncture. Although our department of neurology shares this feeling, the major difficulty is how to select candidates for lumbar puncture to rule out possible coexistence of meningitis. It is necessary to establish clinical criteria for CDS in distinction from meningitis, which needs a prospective approach. Before such criteria are available, indication of lumbar puncture may remain relative. Therefore, it is currently very informative if the authors are ready to disclose how the indication of lumbar puncture was decided during this study. This is necessary and helpful to establish reliable management of CDS.

The authors declare no conflict of interest regarding this submission.

An 88-year-old man was treated with high-dose systemic steroid therapy for COVID-19 and idiopathic interstitial pneumonia months before admission to the hospital because of swelling and redness in his left arm. Cryptococcus neoformans was detected in his blood sample on day eight of admission, and despite antifungal therapy, he died on day 43. Clinicians should be vigilant about the risk of prolonged immunosuppression as a side effect of high-dose systemic steroid usage for COVID-19.

This article examines the impact of working-hour restrictions on the well-being, performance, and education of medical residents in Japan. Despite Japan's plan to introduce new regulations for resident working hours by 2024, there is still an ongoing debate regarding their appropriateness. This review provides a comprehensive overview of the current regulations of resident working hours worldwide, with a specific focus on weekly hours. The varying regulations are highlighted, including the 80-hour-per-week regulation in the United States and the 48-h-per-week regulation in the European Union influencing other regions. The article also discusses the effectiveness of working-hour restrictions on residents' mental health, with shorter working hours having potentially greater benefits. However, the impacts on medical safety and resident education are mixed, and further reduction in working hours must be carefully considered to avoid adverse effects. The planned changes to working-hour limits for residents in Japan offer a unique opportunity to gain new evidence on the impact of such regulations, which will be of interest to policymakers and researchers worldwide.

Hypervirulent Klebsiella pneumoniae has virulence genes relevant to capsule overproduction, which could lead to the finding of thick transparent area (“halo”) in Gram stain. In sputum Gram stain, observation of a large Gram-negative rod with a thick capsule may not only indicate that it is K. pneumoniae but also that it is a highly virulent strain.