Background: The current study aimed to investigate factors associated with the prognosis of activities of daily living (ADL) in elderly patients with pneumonia who had undergone rehabilitation during their hospitalization.
Methods: The study included patients of age ≥65 years who were hospitalized due to pneumonia and had undergone rehabilitation for disuse syndrome at Tsukuba Memorial Hospital. The main outcome was measured using the functional independence measure (FIM) scores to assess ADL. The participants were divided into a high-recovery group (≥80%) and a low-recovery group (<80%) based on the FIM recovery rate score. Further, factors associated with the prognosis of ADL were evaluated using multivariate logistic regression analysis. Basic characteristics, consciousness, usual mode of transportation, FIM score, grip strength, range of motion, orthostatic hypotension, exercise tolerance (6-minutes walking distance), respiratory disorder (Hugh–Jones classification), constipation, malnutrition (mini-nutritional assessment), cognitive (mini-mental state examination), depression (geriatric depression scale), balance (functional balance scale), urinary incontinence, and pressure ulcers were included as the evaluation items.
Results: Among the 51 elderly patients with pneumonia (average age ± SD; 82.0 ± 11.3), 34 patients were classified in the high-recovery group and 17 in the low-recovery group. In multivariate logistic regression analysis, it was revealed that the number of days from the onset until the initiation of rehabilitation (days of inactivity) and nutritional status were factors associated with a high-recovery FIM score.
Conclusions: The study results suggest that days of inactivity and early management of nutritional status after hospitalization are important for elderly patients with pneumonia to return to their ADL.

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Background: Japanese medical student education lacks emphasis on teaching clinical reasoning skills. To partially remedy this situation, we developed a prototypic web-based module for tutors to teach clinical reasoning. We report the medical students’ opinions of this module.
Methods: Twenty-four students from two Japanese medical universities were randomly assigned to the two tutored virtual classrooms, each classroom with six students, or to the self-study group, 12 students, after taking the Internet-based Sequential Question and Answer pretest. After four weeks, each of the 24 students took the Sequential Question and Answer posttest. The entire 24 students answered a questionnaire about the Sequential Question and Answer tests; all 12 tutored students answered a questionnaire about the web-based tutored module.
Results: Although both tutored and self-study Sequential Question and Answer posttest scores increased, the increases of the tutored group’s posttest compared to the self-study posttest group were not statistically significant (p = 0.066). Ninety-two percent of the students rated the Sequential Question and Answer tests as an improved way to learn case presentation and clinical reasoning. Moreover, 79% of students felt that the Sequential Question and Answer tests were an effective way to learn clinical information. The tutored students rated the web-based tutored seminars as an ‘excellent to fair’ method to learn clinical reasoning using a five-point ‘excellent to poor’ scale.
Conclusions: We developed a prototypic web-based module for tutors to teach clinical reasoning to medical students. The students’ opinion supported the modular components of the web-based seminar format, Sequential Question and Answer test, and the tutoring syllabus as an effective way to improve learning clinical reasoning, case presentation, and medical information. Students also suggested refinements of the prototypic module.

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Background: New onset fever is a common symptom among hospitalized patients and it may be a manifestation of fatal illnesses such as infection. However, its epidemiology and predictors for mortality have not been fully determined in a Japanese teaching hospital.
Methods: We investigated adult patients with new onset elevated temperature of 37.5 degrees Celsius or greater the 3^rd day after admission during a 4-month study period. Only the first, single episode per patient was analyzed. We determined the causes of fever among these patients with new onset fever. We also analyzed predictors for in-hospital mortality among these patients. These predictors were based on multivariable adjusted logistic regression using demographics, vital signs at the time of fever onset, baseline diseases, and basic laboratory data.
Results: From a total of 2,271 admitted patients, 126 patients (5.6%) developed fever. Among these febrile patients, 98 (78%) had infectious diseases with a prevalence of 4.3% in all admitted patients. The most common cause of infection among those patients was respiratory tract infection, followed by urinary tract infection. Causes for non-infectious fever included neoplastic diseases, inflammatory diseases, and drug fever. In-hospital mortality was associated with lower mean blood pressure <60 mmHg with odds ratio (OR) of 12.7 (95% CI, 1.3–121), tachycardia >90/min with OR 4.1 (95% CI, 1.2–13.5), tachypnea >20/min with OR 10.0 (95% CI, 2.8–35.2), and neoplastic disease with OR 4.1 (95% CI, 1.3–13.1). Infection as a cause of fever was not associated with mortality.
Conclusion: The majority of inpatients with new onset fever had infectious diseases, however fever was also caused by neoplastic diseases, inflammatory diseases and drug fever. Abnormality of vital signs and neoplastic disease were related to in-hospital mortality.

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Background: There is limited information available on zinc (Zn) or copper (Cu) deficiency during total enteral nutrition treatment. With more patients surviving long term while on enteral nutrition, these deficiencies may be more common.Methods: In our prospective study, 53 patients who received total enteral nutrition were admitted to our hospital for periodic replacement of gastrostomy catheters from March 1, 2013 to August 31, 2013. We measured the serum Zn and Cu levels on admission, and investigated the relationships of the levels on gender, the period after percutaneous endoscopic gastrostomy, the daily dosage of Zn or Cu, age, white blood cell count, hemoglobin (Hb) level, platelet count, and serum albumin (Alb) level.Results: The rate of low serum Zn level (43%) was significantly higher than that of low serum Cu level (9%) [Zn (23/53) vs. Cu (5/53), p = 0.0002]. None of the patients had high serum Zn level, whereas 26% of the patients had high serum Cu level [Zn (0/53) vs. Cu (14/53), p = 0.0002]. There was a significant positive correlation between serum Zn and Hb levels (r = 0.515, p = 0.00008), and a significant, weak positive correlation between serum Zn and Alb levels (r = 0.357, p = 0.009).Conclusions: Enteral nutrition may be an independent risk factor for Zn deficiency, and the Zn deficiency is associated with the decrease in the Hb level.

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We report on a case of the altered mental status from hyperammonemia due to a urinary tract infection of urease-producing (urea-splitting) bacteria. A 98-year-old Japanese woman, who had no history of liver cirrhosis or portal hypertension, presented with altered mental status. The cause of the altered mental status was attributed to an elevation of ammonia in her blood. The urine culture grew Proteus vulgaris. Complete recovery occurred with the use of an antibiotic for the urinary tract infection. Among patients with urinary tract infections, but without liver cirrhosis or portal hypertension, production by urea-splitting bacteria and the subsequent tubular reabsorption of ammonia, may result in hyperammonemic encephalopathy.

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Eosinophillic glanuromatosis with polyangitis (EGPA) usually occurs in patients with a recent history (usually less than 10 years) of uncontrolled bronchial asthma. Here we describe a case of EGPA that occurred in a 68-year-old female who had well-controlled bronchial asthma for 17 years. A leukotriene receptor antagonist that had been prescribed one week before onset might have triggered the disease. Our case shows that there is a wide spectrum of clinical characteristics of EGPA, making diagnosis difficult in a primary care setting.

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We report two cases of retroperitoneal fibrosis that emerged during a clinical course of moderate chronic kidney disease. In both cases, we observed an elevation in the serum CRP and IgG4 levels without an increase in the white blood cell count. The patients were treated with prednisolone. Their clinical conditions improved with a decrease in the serum IgG4 to total IgG ratio. The present cases suggest the importance of a differential diagnosis of retroperitoneal fibrosis in the medical care of chronic kidney disease patients, and we propose a useful biomarker for retroperitoneal fibrosis, which we suspect is associated with IgG4-related disease.

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We report a case of a 75-year-old female, with a known history of Hashimoto’s disease, who was admitted with anorexia, nausea and vomiting. Laboratory data revealed hyponatremia and hypothyroidism. Despite thyroid hormone replacement with synthetic thyroxine, the patient had persistent hyponatremia. Further investigations revealed secondary adrenal insufficiency but otherwise normal pituitary function, based on a rapid adrenocorticotrophic hormone (ACTH) test as part of a combined anterior pituitary stimulation test. She was diagnosed with isolated ACTH deficiency (IAD) with concomitant Hashimoto’s disease. Adrenal insufficiency should be considered in patients with hypothyroidism and persistent hyponatremia. In patients with Hashimoto’s disease who are found to have concomitant hypoadrenalism, IAD should also be suspected after primary adrenal insufficiency is ruled out.

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A 64-year-old female was admitted due to iliopsoas abscess caused by misplacement of a central venous catheter (CVC) into the ascending lumbar vein (ALV). Despite removing the CVC and administering an antimicrobial agent, her general condition did not improve. Therefore, we performed a contrast-enhanced head computed tomography (CT) scan. The CT scan revealed a cerebellum abscess. Surgical cerebellum abscess drainage was thus performed urgently. We recommend using anteroposterior radiographs, J-guide wire catheter and ultrasound guidance to prevent misplacement. If misplacement of the CVC is suspected, it should be removed and a CT scan performed without hesitation as soon as possible.

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