MAY 2023 Volume5-3

ISSN 2436-018X

JOURNAL OF HOSPITAL GENERAL MEDICINE

Original Articles

Impact of exercise on pulmonary hemodynamics in patients
with hypertension・・・・・・・・・・・・・・・・・・・・・・・・ Reiko Mizuno　　45
Validation of a Predictive Model for Inpatient Falls (Saga Fall Risk Model 2)
in a University Hospital：A Retrospective Single-Center Study・・・ Masaki Tago　　53

Short Original Articles

Spontaneous Retroperitoneal Hematoma and Rectus Sheath Hematoma
in Older COVID-19 Patients Under Anticoagulation Therapy：
A Single-Center Case Series ・・・・・・・・・・・・・・・・・Tomohiro Hosoda　　62

Case Reports

JHGM 2023：5(3)：45-52

Original Articles

Impact of exercise on pulmonary hemodynamics
in patients with hypertension

Reiko Mizuno※　　Yasuyuki Okamoto　　Masaharu Yamazaki

Central Clinical Laboratory, Nara Medical University

Key Words：exercise, heart failure, hypertension, pulmonary hemodynamics

[Background] Heart failure with preserved ejection fraction (HFPEF) causes pulmonary hypertension (PH) in association with left ventricular diastolic dysfunction. Recent studies suggested that exercise-induced PH precedes the development of HEFPEF. Hypertension is one of the major risk factors for HFPEF. There are few studies regarding the impact of exercise on pulmonary artery pressure (PAP) in hypertensive patients. [Aim] The present study investigated the impact of exercise on pulmonary hemodynamics in hypertensive patients.
[Methods and Results] We used exercise stress echocardiography to study 41 consecutive asymptomatic patients with essential hypertension and 30 healthy volunteers as controls. Resting PAP was similar between hypertensive patients and controls and was normal in both groups. PAP at peak exercise was significantly increased compared with resting PAP in both groups and was significantly higher in hypertensive patients compared with controls. None in either group had exercise-induced PH. PAP at peak exercise was significantly correlated with left ventricular diastolic dysfunction in hypertensive patients.
[Conclusions] The present study suggests that an exercise-induced increase in PAP is exaggerated in its association with left ventricular diastolic dysfunction in asymptomatic patients with hypertension. Such an exaggerated response to exercise may be related to the future development of exercise-induced PH, and furthermore to HEFPEF. Further investigation is needed.

JHGM 2023：5(3)：53-61

Original Articles

Validation of a Predictive Model for Inpatient Falls
(Saga Fall Risk Model 2) in a University Hospital：
A Retrospective Single-Center Study

Masaki Tago※　　Risa Hiratai 1)　　Naoko E. Katsuki 1)　　Yoshimasa Oda 2)　　Masahiko Ezoe 1)
So Motomura1)　　Midori Tokushima 1)　　Yoshinori Tokushima 1)　　Yuka Hirakawa 1)
Shun Yamashita1)　　Hidetoshi Aihara 1)　　Motoshi Fujiwara 1)　　Shu-ichi Yamashita 1)

1) Department of General Medicine, Saga University Hospital
2) Department of General Medicine, Yuai-Kai Foundation and Oda Hospital

Key Words：fall, predictive model, validation, Saga Fall Risk Model 2 (SFRM-2), Bedriddenness rank

[Background]We developed an inpatient fall predictive model (Saga Fall Risk Model 2 [SFRM-2]) based on eight items (age, sex, emergency admission, inpatient department, use of hypnotic medications, history of falls, independence of eating, and Bedriddenness rank) at an acute care community hospital. The SFRM-2 has not been validated in a highly acute care hospital； therefore, the purpose of this study was to evaluate the accuracy of the model in a university hospital.
[Methods] This single-center retrospective study involved patients aged ≥ 20 years who were admitted to a university hospital from April 2017 to March 2019. The required information for validation was collected from the electronic medical records, and the model’s accuracy was evaluated using the area under the curve.s.
[Results] In total, the data of 16,025 patients were analyzed, and 194 (1.2%) fell. The median age was 68 years, and 49.4% were men. The area under the curve of the model was 0.703 (95% confidence interval：0.669-0.737, p ＜ 0.001).
[Conclusions]The SFRM-2 showed high accuracy in external validation at a university hospital.

JHGM 2023：5(3)：62-66

Short Original Articles

Spontaneous Retroperitoneal Hematoma and Rectus
Sheath Hematoma in Older COVID-19 Patients Under
Anticoagulation Therapy：A Single-Center Case Series

Tomohiro Hosoda1)※　　Hiroki Soma 2)

1) Department of Infectious Disease, Kawasaki Municipal Kawasaki Hospital
2) Department of Internal Medicine, Kawasaki Municipal Kawasaki Hospital

Key Words：coronavirus disease 2019, spontaneous retroperitoneal hematoma, rectus sheath hematoma

　　Spontaneous retroperitoneal hematoma and rectus sheath hematoma (SRH/RSH) are rare
hemorrhagic events. Some of the risk factors for SRH/RSH are similar to those of the severity of
coronavirus disease 2019 (COVID-19) or associated with the management of COVID-19. Among
201 COVID-19 patients aged over 65 years who received anticoagulant therapy for COVID-19
between March 2020 and February 2022, 4 patients developed SRH/RSH during hospitalization.
SRH/RSH occurred 6–14 days after the initiation of anticoagulation therapy. All 4 patients
developed SRH/RSH while under administration of a prophylactic dose of unfractionated heparin
(UFH) and dexamethasone for severe COVID-19, within the target range of the activated partial
thromboplastin time (APTT). All 4 patients discontinued UFH, 3 underwent transfusion therapy,
and 1 underwent angiographic intervention with embolization；2 died：1 from disseminated
intravascular coagulation and the other from respiratory failure due to COVID-19. The other 2
were discharged 66 and 38 days after the onset of SRH/RSH. SRH/RSH can occur even within the
expected range of APTT and can contribute to poor outcomes in COVID-19 patients.

JHGM 2023：5(3)：67-70

Case Reports

Hashimoto’s thyroiditis with macro-CPK type 1
but without subjective symptoms

Takashi Akimoto1)※　　Tadashi Kobayashi 1)　　Hiroki Maita2)
Hiroshi Osawa1)　　Hiroyuki Kato 1)2)3)

1) Department of General Medicine, Hirosaki University School of Medicine and Hospital
2) Development of Community Healthcare, Hirosaki University Graduate School of Medicine
3) General Medicine, Hirosaki University Graduate School of Medicine

Key Words：autoimmune thyroiditis, immunoglobulin, hypothyroidism

　　Autoimmune hypothyroidism (Hashimoto’s thyroiditis) is a common disease in primary care. A 58-year-old woman with a history of gastric cancer was referred to our department with a 12-month history of high serum creatine phosphokinase (CPK) concentrations and dyslipidemia without subjective symptoms. Her voice had been hoarse for ＞ 10 years；however, she considered this an effect of smoking. Her vital signs were within normal ranges, and her physical examination findings were unremarkable, except for the hoarseness. Her blood test results showed that her anti-thyroid peroxidase antibody levels and macro-CPK type 1 exceeded the upper limit of the reference range. Other blood tests and whole-body contrast-enhanced computed tomography scan results showed no abnormal findings. She underwent hormone replacement therapy (HRT). Six months later, her serum CPK concentration had normalized, and macro-CPK type 1 was negative. Hashimoto’s thyroiditis with macro-CPK can become negative after HRT. When Hashimoto’s thyroiditis is diagnosed, prioritizing thyroid function treatment may be necessary, even in the presence of macro-CPK. Physicians should confirm thyroid function in patients with high serum CPK concentrations or dyslipidemia with no subjective symptoms.

JHGM 2023：5(3)：71-75

Case Reports

Hip arthritis due to
Salmonella enterica Subspecies arizonae
in a Japanese immunocompetent patients

Fumitaka Yoshimura ※　　Junko Kubosaki 　　Kotaro Kunitomo　　Takahiro Tsuji

Department of General Medicine, National Hospital Organization Kumamoto Medical Center

Key Words：Salmonella enterica Subspecies arizonae, hip arthritis, immunocompetent patient

　　A 79-year-old Japanese immunocompetent woman was admitted with high fever and left hip pain. T2-weighted magnetic resonance imaging showed fluid retention around the left hip. Salmonella enterica subspecies arizonae (S. arizonae) was detected in the puncture fluid of the left hip joint. After treatment with antimicrobials, the patient recovered well. Human infections with S. arizonae have been reported mostly in the southern United States, where contact with reptiles is common. Since 2000, only 6 cases of S. arizonae infection have been reported in Japan, nonendemic area. Although the patient had a history of reptile-contaminated food intake, the relation between the history of reptile-contaminated food intake and S. arizonae infection was unclear. Further accumulation of cases is important to elucidate the pathogenesis of S. arizonae infection in non-endemic areas..

JHGM 2023：5(3)：76-82

Case Reports

A case of a centenarian in whom complete
atrioventricular block that had persisted for 3 months
disappeared after treatment for heart failure

Tetsuya Kawabe 1)※　　 Kazumi Kawabe 2)　　Yoshiaki Minakata 2)

1) Department of Cardiovascular Medicine, National Hospital Organization Wakayama Hospital
2) Department of Respiratory Medicine, National Hospital Organization Wakayama Hospital

Key Words：complete atrioventricular block, centenarian, polypharmacy

　　A 104-year-old man was admitted to our hospital with a complaint of dyspnea. He was diagnosed as having congestive heart failure associated with complete atrioventricular (AV) block and had a heart rate (HR) of 40 beats/min. Pacemaker implantation was offered but declined by the patient. Cilostazol was started in addition to oxygen and diuretics to increase his HR. Although the dyspnea improved, diuresis and HR elevation were inadequate. On day 14 after admission, dl-isoprenaline hydrochloride was added to increase HR further. HR increased to 50- 60 beats/min with an increase in ventricular escape beats. The heart failure gradually improved and administration of oxygen was discontinued on hospital day 38. On day 81, due to low blood pressure, we discontinued amlodipine, which the patient had been taking before admission. Complete AV block persisted thereafter, but on day 87, first-degree AV block with HR of 80-100 beats/min was observed. The first-degree AV block persisted even after discontinuation of cilostazol. The patient was discharged on day 101. This report describes our experience in this case of a very elderly patient who recovered to first-degree AV block after approximately 3 months of complete AV block.

HGM 2023：5(3)：83-87

Case Reports

A case of purulent facet joint arthritis and omarthritis
by invasive pneumococcal infection

Kazuo Eguchi 1)※　　Tomotaka Nishizawa 2)　　Youhei Koushima 3)

1) Department of General Internal Medicine, Saitama Red Cross Hospital
2) Department of Respiratory Medicine, Saitama Red Cross Hospital
3) Hepatobiliary Pancreatic Department

Key Words：invasive pneumococcal infection, purulent facet joint arthritis, omarthritis

　　A 65-year-old woman was transferred to our hospital with fever, shoulder pain, and back pain. She was diagnosed as purulent facet joint arthritis (L1-2 spine) and omarthritis. Streptococcus pneumoniae was detected from the blood, and a diagnosis of invasive pneumococcal disease (IPD) was made. Ceftriaxone 4 g/day was used for 4 weeks and the condition improved. IPD can occur even in immunocompetent persons.

JHGM 2023：5(3)：88-93

Case Reports

Diffuse Fasciitis Preceding the Onset
of Ulcerative Colitis

Kazunari Aoki 1)※　　Mizune Tamaki 1)　　Shogo Kitahata 2)

1) Department of General Medicine, Ehime Prefectural Central Hospital
2) Department of Gastroenterology, Ehime Prefectural Central Hospital

Key Words：Diffuse fasciitis, ulcerative colitis, extraintestinal manifestation

　　Diffuse fasciitis is a disease associated with scleroderma-like induration and thickening of the skin. We report herein a case of diffuse fasciitis associated with ulcerative colitis. The patient was a 19-year-old woman with no underlying diseases. She presented with acute pain and purpura in both lower extremities. There was no obvious history of exercise or trauma, but physical examination revealed induration of the skin on both lower extremities. There was no induration of the skin of the fingers or toes, and a simple MRI of both lower legs showed inflammatory findings in the adipose tissue and fascia, leading to a diagnosis of diffuse fasciitis. A colonoscopy led to a diagnosis of a severe form of ulcerative colitis. High-dose prednisolone was administered, and induration of the skin, pain, and purpura improved. Both diffuse fasciitis and purpura were considered possible extraintestinal complications of ulcerative colitis. In diffuse fasciitis and its analog, eosinophilic fasciitis, immune abnormalities are involved in their pathogenesis. In such cases, complications associated with immune abnormalities, such as ulcerative colitis, should be considered.

JHGM 2023：5(3)：94-96

Short Case Reports

A case of infected abdominal aortic aneurysm
with chronic DIC successfully treated
with a single agent administration of Tranexamic Acid

Takayuki Yamaki

Department of General medical surgery, Independent Administrative Institution National Hospital Organization Miyagi Hospital

Key Words：Chronic DIC with Enhanced Fibrinolysis, Infected Abdominal Aortic Aneurysm, Tranexamic Acid

JHGM 2023：5(3)：97-102

Reviews

Narrative review of predictive models of the prognosis
of emergency inpatients in acute care hospitals

Masaki Tago 1)※　　Risa Hirata 1)　　Motoshi Fujiwara 1)　　Shun Yamashita 1)

Naoko E Katsuki1)　　Noriko Ide 1)2)　　Tomoyo Nishi 1)2)

Yoshimasa Oda 2)　　Midori Tokushima 1)　　Yuka Hirakawa 1)

Yoshinori Tokushima 1)　　Hidetoshi Aihara 1)　　 Shu-ichi Yamashita 1)

1) Department of General Medicine, Saga University Hospital
2) Department of General Medicine, Yuai-Kai Foundation and Oda Hospital

　　Early recognition of high-risk patients whose conditions could deteriorate rapidly in acute emergency care settings is critical to provide appropriate care. This article aimed to compare previous predictive models of the prognosis of emergency inpatients in acute care hospitals with our predictive model and to clarify the characteristics of the models. Using PubMed, we performed a narrative review of previous studies of the prediction of the prognosis of emergency inpatients admitted to acute care hospitals. We investigated the outcomes, subjects’ backgrounds, and methods of evaluation of the models. We also compared our original predictive model for emergency patients with other models and discussed the characteristics of the models. The predictive models for outcomes of emergency inpatients in numerous previous studies involved issues such as variable background of the subjects, lengthy evaluation time, and low accuracy. In contrast, our predictive model for emergency inpatients aged ≥ 65 years with endogenous diseases was easy to use and beneficial；the model includes only four items, which can be assessed on admission.

JHGM 2023：5(3)：103

Letters To The Editor

Comments on “Sudden onset and rapid resolution of
swelling in the head and neck region：angioedema”

Hiroki Isono

Department of General Medicine, HITO Medical Center

JHGM 2023：5(3)：104

Letters To The Editor

Sudden onset and rapid resolution of swelling
in the head and neck region：angioedema

Masashi Nishiyama1)　　 Tatsuya Fujikawa 1)※　　Tetsuya Nakamura2)

1) Department of General Internal Medicine, Mitoyo General Hospital
2) Department of Radiology, Mitoyo General Hospital

JHGM 2023：5(3)：105-106

Key Images

A Case of Simple Adhesive Ileus Identified
by Abdominal Computed Tomography Imaging
Findings Resembling Whirlpool Sign

Haruhiko Egawa

Internal Medicine, Sakai Wakabakai Hospital

Key Words：whirlpool sign, computed tomography imaging

JHGM 2023：5(3)：107-108

Key Images

Calcium sign triggers diagnosis of aortic dissection

Yuki Chiko

Department of General Medicine, Okinawa Prefectural Yaeyama Hospital

Key Words：calcium sign, aortic dissection, chest pain

JHGM 2023：5(3)：109-110

Key Images

Inverted V sign due to subacute combined
spinal cord degeneration

Ryuichi Ito　　Toshinori Nishizawa ※　　Hiroko Arioka

Department of General Internal Medicine, St. Luke’s International Hospital

Key Words：MRI, Subacute combined degeneration of spinal cord, Vit B12 deficiency, anemia, neurodegenerative disease