NOVEMBER 2021 Volume 3-6

ISSN 2436-018X

JOURNAL OF HOSPITAL GENERAL MEDICINE

JHGM 2021：3(6)：181-189

Original article

Importance of lifestyle-related diseases
as a risk factor of bone fragility fracture

Ichiro Yoshii 1)※　　Shohei Kokei 2)

1) Department of Rheumatology and Musculoskeletal Medicine, Yoshii Hospital
2) Department of Internal Medicine, Yoshii Hospital

Key Words：bone fragility fracture, lifestyle-related disease, musculoskeletal ambulation disability symptom complex,non-vertebral body fracture, T-score, vertebral body fracture

[Background] The impact of lifestyle-related disease (LSD) as a risk factor for bone fragility fracture (BFF) in patients with high osteoporotic risks was retrospectively investigated.
[Methods] Japanese subjects who were followed up for 8 years or more were recruited. Theoccurrence and survival rates of BFF during follow up were statistically evaluated with comparison between a patient group who suffered LSD (LSD group) and a patient group who did not (non-LSD group). The hazard ratio of the risk in the LSD group compared to the non-LSD group was evaluated using the Kaplan-Meier survival curve.
[Results] A total of 610 patients in the LSD group and 321 in the non-LSD group were included in the study. There was no significant difference of T-score of either the lumbar spine or the femoral neck between the two groups. The survival rate after BFF occurrence in the non-LSD group was significantly higher compared to the LSD group. In the LSD group, a significant risk factor that contributed the occurrence of an incident of BFF was musculoskeletal ambulation disability symptom complex (MADS). After excluding patients with MADS, the hazard ratio of the LSD group compared to the non-LSD group was evaluated using cox regression analysis. For 426 of the LSD and 308 of the non-LSD group patients, risk ratio was 2.28 in the LSD group compared to the non-LSD group with 0.0006 of p-value.
[Conclusions] These results suggested that LSD is an independent risk factor for BFF.

JHGM 2021：3(6)：190-199

Original article

Polypharmacy in Japanese primary care
and association with length of hospital stay：
a prospective cohort study

Noboru Horinouchi 1)2)　　　Seiji Shiota 1)2)3)※　　　Takeshi Takakura1)
Kyoko Yamamoto 2) 　Eishi Miyazaki 2)3)

1) Department of General Medicine, Oita Almeida Memorial Hospital
2) Department of General Medicine, Oita University Faculty of Medicine
3) Center for Community Medicine, Oita University Faculty of Medicine

Key Words：Polypharmacy, Length of stay, Malnutrition, Older people

[Background] Early prediction of the risk of prolonged length of stay (LOS) in the elderly is crucial. We aimed to investigate the prevalence of polypharmacy among hospitalized patients in Japanese primary care and the association between the presence of polypharmacy and prolonged LOS.
[Methods] This prospective cohort study was conducted for patients ≥ 65 years old admitted to a general medicine department in a community hospital. Polypharmacy was defined as ≥ 5 drugs. Activities of daily living (ADL) and nutritional status were also evaluated. Prolonged LOS was defined as an LOS equal to or longer than the median (12 days).
[Results] Among 150 patients (mean age, 85.0 years), the frequency of polypharmacy was 46.2% at 65-74 years, 69.6% at 75-84 years, and 70.4% at ≥ 85 years. Median LOS was 11 days for non-polypharmacy (≤ 4 drugs), 12 days for polypharmacy (5-9 drugs), and 11 days for hyperpolypharmacy (≥ 10 drugs), showing no significant differences. Multivariate analysis showed that polypharmacy was not independently associated with prolonged LOS. Coexistence of malnutrition and low ADL scores was significantly associated with prolonged LOS.
[Conclusions] Although polypharmacy itself was not significantly associated with prolonged
LOS, polypharmacy was common among hospitalized patients in this Japanese primary care setting.

JHGM 2021：3(6)：200-208

Original article

Clinical significance of procalcitonin measurement
in patients with bacterial infections
in the emergency setting

Motoo Kikuchi 1)※　　Kyouji Senoo 2) 　　Hirotaka Ohra3)

1) Department of General Medicine, Nagoya City University West Medical Center
2) Department of Gastroenterology, Nagoya City University West Medical Center
3) Department of Community-based Medical Education, Nagoya City University Graduate School of Medical Sciences

Key Words：medical emergency setting, diagnosis, procalcitonin, prognosis, sepsis

[Background] Procalcitonin (PCT) is a bacterial infection biomarker；the significance of its middle-range concentrations remains uncertain. We evaluated PCT for the diagnosis and to determine the prognosis of patients in an emergency setting.
[Methods] We enrolled 150 emergency outpatients with suspected bacterial infections between January and June 2017. PCT levels were measured and bacterial infections proven by culture, while probable bacterial infections were based on diagnostic modalities. Quick sequential organ failure assessment (qSOFA) and systemic inflammatory response syndrome (SIRS) scores were determined.
[Results] There were 87 and 63 patients in the low-PCT (LPCT) (PCT ≤ 0.5 ng/mL) and high- PCT (HPCT) (PCT ＞ 0.5 ng/mL) groups, respectively, with no significant demographic differences between the two groups. Three month hospital admission rate, diabetes incidence, positive blood culture frequency, and SIRS scores were higher in the HPCT group than the LPCT group. Lower respiratory tract infections were more common in the LPCT group, and hepatobiliary tract infections and pyelonephritis were more common in the HPCT group. qSOFA scores were not different. Treatment periods were shorter with adequate treatment in the LPCT group. No correlation was found between elapsed time from arrival to start of antibiotics and inpatient stay.
[Conclusions] PCT was predictive of infection severity and multiorgan impairment, and adequate use of antibiotics is important.

JHGM 2021：3(6)：209-212

Case report

A case of atypical chest pain caused
by thoracic vertebral fracture

Maoka Yamada 1)　　Hiroki Isono 2)※

1) Ehime University School of Medicine
2) Department of General Medicine, HITO Medical Center

Key Words：Vertebral fracture, chest pain, magnetic resonance imaging

　　A 91-year-old woman presented to our emergency room with a complaint of left-sided chest pain and difficulty walking after a backward fall. After admission, the cause remained unidentified. She described the painful area by rubbing back and forth around the left costal region, but no tenderness was observed. The fall was the trigger, and she complained of banded pain at the 7th to 8th thoracic vertebral level on dermatome, suggesting a nerve root symptom. A fracture of the eighth thoracic vertebra was found on magnetic resonance imaging (MRI). A paraspinal nerve block was performed and her pain improved. She is now able to walk. Thoracic vertebral body fractures rarely cause left-sided chest pain. Clinical reasoning based on careful history-taking and physical examination is important for diagnosis. If the diagnosis cannot be made using radiography or computed tomography, MRI should be considered.

JHGM 2021：3(6)：213-216

Case report

Warfarin-induced development
of an acquired factor V inhibitor

Yuichi Sesumi ※　　Yasushi Terada　　Wataru Kaino
Toshihiro Yamagata　　Shungo Nishimura

Department of Internal Medicine, Shounai Amarume Hospital

Key Words：acquired factor V inhibitor, warfarin

　　Acquired factor V (FV) deficiency is characterized by bleeding tendency owing to the development of FV inhibitors. We encountered a case of this disease in a 90-year-old male patient who had been taking warfarin for more than 10 years. He had received antibiotic therapy for a urinary tract infection and developed an FV inhibitor. After normalization of his coagulation function, warfarin re-administration reduced FV coagulation activity. Warfarin was the causative drug for the development of the FV inhibitor. Acquired coagulation factor deficiency should be considered when both the prothrombin time and activated partial thromboplastin time are prolonged during warfarin therapy.

JHGM 2021：3(6)：217-223

Case report

Fulminant Clostridioides difficile infection
in a dialysis outpatient with no history
of antibiotic use

Shokin Shigemitsu 1)　　Kosuke Nomura 1)2)　　Shigeo Toda3)
Shunichiro Matoba 3)　　Shunsaku Matsuoka 4)　　Naoki Sawa 4)
Futoshi Yoshino 1)　　Naoki Saegusa 1)　　Daisuke Kikuchi 1)2)※

1) Department of Gastroenterology, Toranomon Hospital Kajigaya
2) Department of Gastroenterology, Toranomon Hospital
3) Department of Digestive Surgery, Toranomon Hospital
4) Department of Nephrology, Toranomon Hospital Kajigaya

Key Words：Fulminant Clostridium difficile infection, dialysis, antibiotic

　　There are few reports on fulminant Clostridium difficile infection (CDI) in patients on dialysis with no history of antibiotic use. The patient was a 66-year-old woman with a 15-year history of dialysis due to end-stage renal failure. She was diagnosed with fulminant CDI, but her general condition improved with conservative treatment. Fulminant CDI has a high fatality rate, even with surgical treatment. Here, we describe a case of fulminant Clostridium difficile enteritis during dialysis, with no history of antibiotic use, in which a favorable survival outcome was achieved with conservative treatment.

JHGM 2021：3(6)：224

Brief report

Campylobacter jejuni enteritis mimicking colon cancer

Masayuki Kagota 1)　　Kosuke Oka 2)※　　Hideharu Hagiya 2)　　Fumio Otsuka 2)

1) Okayama University Medical School
2) Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences

Key Words：Campyrobacter jejuni enteritis and colon cancer

JHGM 2021：3(6)：225-227

LETTERS TO THE EDITOR

Research trends of general hospitalists in Japan：
a cross-sectional questionnaire-based personal survey

Masaki Tago 1)※　Takashi Watari 2)　Kiyoshi Shikino 3)　Shun Yamashita 1)
Yosuke Sasaki 4)　Hiromizu Takahashi 5)　Taro Shimizu 6)

1) Department of General Medicine, Saga University Hospital
2) General Medicine Center, Shimane University Hospital
3) Department of General Medicine, Chiba University Hospital
4) Department of General Medicine and Emergency Care, Toho University School of Medicine
5) Department of General Medicine, Faculty of Medicine, Juntendo University
6) Department of Diagnostic and Generalist Medicine, Dokkyo Medical University

Key Words：Clinical research, General hospitalists, Hospital General Medicine, Research topics

JHGM 2021：3(6)：228-231

LETTERS TO THE EDITOR

Emergency hospitalization of COVID-19 patients
at a non-COVID-19 specialty hospital

Ken Johkura ※
Yokohama Brain and Spine Center COVID-19 Emergency Response Team 1)

1) Contributors：
Noriko Nara, Yosuke Kudo, Ryoo Yamamoto, Hideyuki Kikyo, Yu Amano, Masahiro Shibuya, Hiroyuki Otaki, of the Department of Neurology；Junko Suzuki, Yuiko Kameyama, Kimiko Yamamoto, Masumi Umeki, Hitomi Jibe, Miho Takano, Yuko Ohara, Maki Kamiya, Minako Uesugi, Chigusa Soma, Megumi Kobayashi, Akiko Koizumi, Rieko Mori, Hiroshi Ide, Hiroko Mitsui, Remi Nakamura, Yuko Saito, Rika Suzuki, Ayako Uchiyama, Chisato Urai, Mayuko Togashi, Misaki Ikeda, Kana Honda, Kumiko Kurosawa, Chika Kudo, Takashi Kurosawa, Aira Nakayama, Yuka Nagoya, Miki Kimura, Minori Yazaki, of the Nursing Division

Department of Neurology, Yokohama Brain and Spine Center

Key Words：COVID-19, non-specialty hospital, hospital beds, Japanese standard medical care