石川 由紀子

Background: Cervical lymphadenopathy is commonly seen in general practice, and its etiology is diverse. Establishing the diagnostic strategy for lymphadenopathy would be desirable to avoid overlooking neoplasms or other critical conditions. This study aims to identify the useful laboratory parameters for cervical lymphadenopathy that require clinical observation or intervention. Methods: The participants were outpatients presenting cervical swelling or cervical lymph node (LN) pain who consulted the General Internal Medicine department from 2010 to 2016. We evaluated the characteristics, physical findings, and laboratory parameters with final diagnoses by multivariate logistic regression analysis. We categorized the final diagnoses as "Clinical Intervention Required Group (CIRG)" including necrotizing lymphadenitis, hematologic neoplasms, metastatic lymphadenopathy, tuberculous lymphadenitis, bacterial infectious diseases, infectious mononucleosis, autoimmune diseases, and other abnormal conditions or "No-CIRG" not requiring further clinical observation or intervention. Results: We evaluated 409 participants, with 130 (31.8%) diagnosed as belonging to the CIRG. There was an association between CIRG and various parameters: age ≥60 years old (adjusted odds ratio [AOR], 2.70; 95% confidence interval [CI], 1.48-4.90), having a referral (AOR, 1.83; 95% CI, 1.12-3.00), diameter of LN ≥ 2 cm (AOR, 1.91; 95% CI, 1.05-3.48), fixed LNs (AOR, 2.74; 95% CI, 1.02-7.37), and lactate dehydrogenase (LD) ≥400 U/L (AOR, 3.78; 95% CI, 1.46-9.77). Eighty-two percent of LD ≥ 400 cases in the CIRG were infectious mononucleosis or necrotizing lymphadenitis. Conclusions: Besides the clinical indicators reported previously, we may apply an elevated LD level as a useful indicator of cervical lymphadenopathy that requires further clinical observation or intervention.

Background: Subjects with prehypertension (pre-HT; 120/80 to 139/89 mm Hg) have an increased risk of cardiovascular disease (CVD); however, whether the risk of pre-HT can be seen at the pre-HT status or only after progression to a hypertensive (HT; >= 140/90 mm Hg) state during the follow-up period is unknown. Methods: The Jichi Medical Cohort study enrolled 12,490 subjects recruited from a Japanese general population. Of those, 2227 subjects whose BP data at baseline and at the middle of follow-up and tracking of CVD events were available (median follow-up period: 11.8 years). We evaluated the risk of HT in those with normal BP or pre-HT at baseline whose BP progressed to HT at the middle of follow-up compared with those whose BP remained at normal or pre-HT levels. Results: Among the 707 normotensive patients at baseline, 34.1% and 6.6% of subjects progressed to preHT and HT, respectively, by the middle of follow-up. Among 702 subjects with pre-HT at baseline, 26.1% progressed to HT. During the follow-up period, there were 11 CVD events in normotensive patients and 16 CVD events in pre-HT patients at baseline. The subjects who progressed from pre-HT to HT had 2.95 times higher risk of CVD than those who remained at normal BP or pre-HT in a multivariable-adjusted Cox hazard model. Conclusion: This relatively long-term prospective cohort study indicated that the CVD risk with pre-HT might increase after progression to HT; however, the number of CVD events was small. Therefore, the results need to be confirmed in a larger cohort. (C) 2016 The Authors. Publishing services by Elsevier B.V. on behalf of The Japan Epidemiological Association.

目的 : 当学には, 卒後9年間就業を継続するという前提がある. 今回, 当学女子医学生に求められている卒前教育プログラムを調査するため, ワークライフバランスに関するニーズ分析を行った.方法 : 全女子在校生187人に自記式調査を依頼した.結果 : 回答者104人のうち, 義務年限内に結婚・出産を希望した者はそれぞれ71％, 68.6％であった. 80.0％が「出産」に対して, 78.1％が「家庭との両立」に対して不安が高いと回答した. 回答者の8割以上が希望したプログラムは「卒業生女性医師の経験談」「卒業生女性医師との懇談会」「女性医師支援制度についての情報提供」「キャリアアップについての情報提供」であった.結論 : 当学女子医学生の不安は大きいが, 地域医療に貢献する卒業生女性医師との交流を生かしたプログラムを受けられるメリットがある. 当学の卒前教育において, ロールモデルの存在を明確にすることが求められていると考えられた.

Purpose: General practitioners have an important role in diagnosing a variety of patients, including psychiatric patients with complicated symptoms. We evaluated the relationship between physical symptoms and psychiatric disorders in general internal medicine (GIM) outpatients in a Japanese university hospital. Materials and methods: We coded the symptoms and diagnoses of outpatients from medical documents using the International Classification of Primary Care, second edition (ICPC-2). The participants were new outpatients who consulted the GIM outpatient division at Jichi Medical University Hospital in Tochigi, Japan from January–June, 2012. We reviewed all medical documents and noted symptoms and diagnoses. These were coded using ICPC-2. Results: A total of 1,194 participants were evaluated, 148 (12.4%) of whom were diagnosed as having psychiatric disorders. The prevalence of depression, anxiety disorder, and somatization was 19.6% (number [n] =29), 14.9% (n=22), and 14.2% (n=21), respectively, among the participants with psychiatric disorders. The presence of several particular symptoms was associated with having a psychiatric disorder as compared with the absence of these symptoms after adjusting for sex, age, and the presence of multiple symptoms (odds ratio [OR] =4.98 [95% confidence interval {CI}: 1.66–14.89] for palpitation OR =4.36 [95% CI: 2.05–9.39] for dyspnea OR =3.46 [95% CI: 1.43–8.36] for tiredness and OR =2.99 [95% CI: 1.75–5.13] for headache). Conclusion: Not only the psychiatric symptoms, but also some physical symptoms, were associated with psychiatric disorders in GIM outpatients at our university hospital. These results may be of help to general practitioners in appropriately approaching and managing patients with psychiatric disorders.

Background Ambulatory blood pressure (BP) (ABP) is a better predictor of adverse cardiovascular events than office BP (OBP). Owing to the extensive literature on the 'white coat effect', it is widely believed that ABP tends to be lower than OBP, with statements to this effect in Joint National Committee VII. However, recent evidence suggests that the difference varies systematically with age. Methods We searched PubMed to identify population studies, published before April 2009, which assessed OBP and either ABP or home BP (HBP). On account of significant heterogeneity in the outcomes, random effect models were used for the meta-analyses. Results OBP increased with age more steeply than awake ABP. OBP became higher than awake systolic/diastolic ABP at the age of 51.3/42.7 years in men (13 studies, N = 3562) and 51.9/42.3 years in women (11 studies, N = 2585). In the data in which OBP and HBP were measured (eight studies, N = 4916), OBP was higher than HBP at all ages. In the data in which OBP, awake ABP, and HBP were all measured (two studies, N = 895), awake ABP was higher than HBP at younger ages, becoming similar at the older age. Conclusion OBP tends to be higher than awake ABP only after the age of 50 years for systolic and after the age of 45 years for diastolic BP, but is lower than ABP at younger ages; in contrast OBP tends to exceed HBP at all ages. Blood Press Monit 16: 159-167 (C) 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.

目的:かかりつけ医による生活習慣病予備軍への行動科学的個別支援プログラムの効果をランダム化比較試験により評価する。方法:健康診査受診者のうち高血圧・高脂血症・糖尿病それぞれの予備軍を対象者とした(介入群199人、対照群145人)。1年後追跡した者(介入群124人、対照群97人)の健康診査および生活習慣に関する自記式調査により効果を検討した。成績:BMI増加の抑制(介入群22.9±3.2kg/m2→22.8±3.3kg/m2、対照群22.4±4.1kg/m2→22.8±3.4kg/m2,P<0.05)および「運動不足」に対する回答への改善を認めた(17.4%,7.3%OR=2.7,P<0.05)。「禁煙」の行動ステージの改善に対して効果がある可能性があった(38.1%,6.3%OR=9.2,P=0.05)。結論:本支援プログラムは運動不足であるという意識の改善および肥満の抑制への効果があった。(著者抄録)

欧米あるいはわが国における地域住民を対象としたさまざまなエビデンスから、JNC7において前高血圧(pre-hypertension)と定義された群の心血管あるいは脳血管イベントのリスク上昇が指摘されてきた。また地域住民を対象とした自治医科大学コホート研究においては、3分の1がpre-hypertensionであり、この群における規定因子は心血管イベントのハイリスクとされてきた肥満、脂質異常症、糖代謝異常によるものであったこと、また欧米と比較し、軽度の肥満であってもpre-hypertensionへの有意な関連があることを報告した。本稿では、わが国におけるpre-hypertensionの特徴を示し、この群へのハイリスクアプローチの必要性を解説する。(著者抄録)

It has been reported that subjects with prehypertension (pre-HT) (systolic blood pressure [SBP] 120-139 mmHg and/or diastolic blood pressure [DBP] 80-89 mmHg) have an increased risk of cardiovascular disease (CVD). We evaluated the prevalence and determinants of pre-HT in a Japanese general population. We enrolled 4,706 males and 7,342 females aged 18 to 90 years whose BPs were measured at baseline. The subjects' BPs were classified as follows: normotension (NT: SPB/DBP<120/80 mmHg), pre-HT (120/80-139/89 mmHg), and hypertension (HT: >= 140/90 mmHg or treated hypertension). The prevalence of pre-HT was 34.8% (males), and 31.8% (females). Body mass index (BMI) of more than 23.0 kg/m(2) was the strongest determinant of pre-HT (Males-BMI: 23.0-24.9 kg/m(2), odds ratio [OR]=1.47, 95% confidence interval [Cl]=1.21-1.79; BMI: 25.0-26.9 kg/m(2), OR=2.20,95% CI=1.68-2.87; BMI: 27.0-29.9 kg/m(2), OR=2.75, 95% CI=1.80-4.19; BMI: >= 30.0 kg/m(2), OR=3.39, 95% CI=1.21-9.46. Females-BMI: 23.0-24.9 kg/m(2), OR=1.67, 95% CI=1.421.95; BMI: 25.0-26.9 kg/m(2), OR=1.79,95% CI=1.46-2.19; BMI: 27.0-29.9 kg/m(2), OR=3.65, 95% CI=2.73-4.89; BMI: >= 30.0 kg/m(2), OR=4.23, 95% CI=2.33-7.70). The other determinants of pre-HT were hyperlipidemia (Males: OR=1.25; Females: OR=1.43), and aging (by 10 years; Males: OR=1.12; Females: OR=1.48). Determinants of pre-HT in females were impaired glucose tolerance (OR=1.41, 95% CI=1.03-1.94), diabetes (OR=2.01, 95% CI=1.16-3.47) and a family history of HT in both parents (OR=1.90, 95% CI=1.38-2.62), whereas in males the only other predictor was alcohol drinking (OR = 1.45, 95% CI = 1.23-1.70). In conclusion, even subjects with a mild increase of BMI (23.0-24.9 kg/m2) had an increased risk of pre-HT in a Japanese population, and the level of BMI associated with pre-HT was lower than that in Western countries. Additionally, there were gender differences in the determinants of pre-HT. (Hypertens Res 2008; 31: 1323-1330)

原因不明で1ヵ月以上に亘って発熱がみられた患者(≦37.5℃)を対象として,Q熱リケッチア(Coxiella burnetii)保菌者の頻度をNested PCR法により検討した.観察期間は1999年1月〜2000年9月であった.54例中13例が陽性であり,C.burnetii感染者では発熱の症状だけでなく倦怠感(7例),頭痛(7例),嘔気(5例),咳(4例),睡眠障害(3例)など複数の症状を訴えた.非感染群(41例)では,持続する微熱だけの訴えが多かった(25例).感染群ではCRP,白血球数,好酸球数,自己抗体陽性率において非感染群と有意差はなかった.血清IgE高値の患者が感染群に多かった.更に血清IgE値が感染群で有意に高値であり,血清IgEとC.burnetii感染の関連が示唆された.感染者12例にミノサイクリンを4週間投与したが,全例でDNA検出は陰性となり,9例で症状は軽快した.3例では発熱は軽快したが症状は継続してNested PCR法でのDNA検出は一旦は陰性化した後,2〜3ヵ月で再度陽性となり治療抵抗性の可能性が示唆された

Prospective studyとして本邦で初めて, 慢性型Q熱リケッチア感染症の検討を報告する. 感染の同定には, 従来の血清学検査ではなく, Nested PCR法でのスクリーニングとA/Jマウスを用いたバイオアッセイによる確認を行った.<BR>原因不明で一カ月以上にわたって発熱がみられた患者 (≦37.5℃) を対象として, 1999年1月から2000年9月までの観察期間で, Q熱リケッチア (Coxiella bumefii) 保菌者の頻度をNestedPCR法により検討した. 結果は54例中13例 (24.1%) が陽性であった. C. bumefii感染者では, 発熱の症状だけでなく, 倦怠感 (7例), 頭痛 (7例), 嘔気 (5例), 咳 (4例), 睡眠障害 (3例) など複数の症状を訴えた. 非感染群 (41例) では, 持続する微熱だけの訴えが多かった (25例, 61.0%). 感染群では, CRP (0.69±1.19mg/dl), 白血球数 (6089±2189/μl), 好酸球数 (a.4±3.6%), 自己抗体陽性率 (53.8%) において非感染群と有意差はなかった. 血清IgE高値の患者が感染群に多かった (76.9%: 22.0%, p=0.016). さらに, 血清IgE値が感染群で有意に高値であり, 血清IgEとC. burnetii感染の関連が示唆された (1, 388±1706vs.533±913IU/ml, P=0.045). 感染者12例にミノサイクリン (200mg/日) を4週間投与したが, 全例でDNA検出は陰性となり, 9例で症状は軽快した. 3例では, 発熱は軽快したが症状は継続し, Nested PCR法でのDNA検出は一旦陰性化した後, 2-3カ月で再度陽性となり治療抵抗性の可能性が示唆された.