[Background] Prescription is an essential medical practice, and its quality should be improved when considering medical safety. This study investigates inquiries about the prescription errors that occur in pediatric outpatients and proposes improvement measures. [Method] The participants included 594 inquiries about erroneous prescriptions for children visiting Showa University Koto Toyosu Hospital outpatient clinic from April 2017 to March 2019. The inquiries were classified into 10 categories. [Results] Of the 594 inquiries, “dosage confirmation” including inappropriate medicine dosage according to the patient's age or weight was the highest (26%, 154 cases), followed by “change of medication” (19%, 110 cases) and “typing error” (13%, 79 cases). These three inquiries accounted for more than half of the total. [Discussion] The results indicated inadequate attention toward changes in the patient's age and weight. Therefore, developing a system that alerts physicians to the change in age and weight as well as errors in prescription dosages would improve the medical safety. [Conclusions] This study highlights the issues faced in pediatric prescription. Furthermore, the content analysis of these inquiries proved useful in improving the medical safety related to prescriptions.

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Adult Growth Hormone Deficiency (AGHD) is a disease of anterior pituitary hypofunction in which growth hormone (GH) deficiency causes various metabolic disorders. Since the treatment requires self-injection of GH preparations, early diagnosis, collaboration with other professions and patients’ education are important to improve patient prognosis. Here we evaluated educational effects of lectures and practice on AGHD for medical workers and students conducted by general medicine department, leading to improvement of AGHD understanding for various medical staffs.

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[in Japanese]

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Apalutamide is an androgen receptor antagonist used for the treatment of prostate cancer. We report a case of interstitial lung disease and neutropenia following apalutamide treatment. The patient was an 82- year-old Japanese man presenting with castration-resistant prostate cancer treated with apalutamide. After apalutamide administration, the patient developed skin rash, fatigue, anorexia, and dyspnea, and was hospitalized due to respiratory failure. Interstitial lung disease, and neutropenia were observed. Both were considered to be drug-related effects, and the patient improved after discontinuation of the suspected drug, steroid therapy application, and the administration of antimicrobial agents and filgrastim. Three cases of drug-induced interstitial lung disease due to apalutamide have been reported in Japan; neutropenia has not been reported to date. Although both adverse effects are infrequent, we need to consider the possibility that they may appear as serious adverse events caused by treatment with apalutamide.

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The patient was an 89-year-old man with a 20-year history of hypertension and was undergoing outpatient treatment. About 2 weeks before visiting to our hospital, the patient came to the hospital because of feeling unsteady when walking. Although neurological findings were almost normal, a head MRI scan revealed a diagnosis of sub-acute phase right cerebellar infarction, thereby the patient was admitted to our hospital on the same day for further investigation of the underlying disease and rehabilitation. On the 5th day of hospitalization, muscle weakness was observed in the left femur, so additional examinations revealed a mass in the left iliopsoas muscle. He underwent CT-guided needle biopsy at another hospital and was diagnosed with dedifferentiated liposarcoma. Thereafter he was referred to the other hospital for proton beam therapy, and the tumor showed no worsening, which enabled him to remain ambulatory for about two years. We report a relatively rare case of dedifferentiated liposarcoma developed in the retroperitoneum, as well as a review of the diagnostic error we made in initial diagnosis.

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[Case 1] An 86-year-old woman presented to our hospital after referral from her home doctor for low blood pressure and fever. The patient had complained of general fatigue that lasted for three days. Computed tomography (CT) revealed a mass with a diameter of approximately 9 cm in her uterus. Following transvaginal echocardiography, drainage was performed and approximately 300 ml of pus was collected. [Case 2] A 74-year-old woman was rushed to our hospital due to difficulty of moving following a week of decreased food intake. We performed blood investigations which revealed an increased inflammatory response while CT scan revealed a small amount of fluid in the uterus. The patient underwent transvaginal echocardiogram and drainage which resulted in approximately 10 ml of pus collection. Pyometra among elderly women may present with a wide-range of symptoms from clinically mild loss of appetite and high fever to septic shock. Despite being an uncommon condition, we encountered two cases of pyometra in one day. Nonetheless, this disease is expected to increase in the future due to the aging population of Japan, which calls for disease familiarity among practitioners, not only among gynecologists but also general internists.

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A 58-year-old man visited the hospital with fever, cough, and bloody sputum. Thoracic computed tomography showed a space-occupying lesion within the pulmonary artery, with complete occlusion of the left pulmonary artery and severe stenosis of the right pulmonary artery. The patient was initiated on anticoagulant therapy; however, 4 days later, he developed respiratory failure and went into shock. Hence, bilateral pulmonary artery occlusion was diagnosed, and emergency surgery was conducted on the patient. Surgery revealed bilateral pulmonary artery occlusion due to tumors, and the tumor was partially removed. Further, the occlusion was relieved, and the pathological findings indicated leiomyosarcoma. Thereafter, the patient was readmitted for abdominal pain. Imaging tests showed a re-enlarged mass in the pulmonary artery and a large intra-abdominal mass. Chemotherapy was considered, but the patient experienced cardiopulmonary arrest on the third day of hospital readmission and died. Pathological autopsy showed that the cause of death was bilateral pulmonary artery occlusion caused by a tumor. Primary pulmonary artery sarcoma is rare disease and is often the initial diagnosis is pulmonary thromboembolism; hence, differential diagnosis is important. The prognosis is poor; however, long-term prognosis can be expected with surgical resection. Hence, early diagnosis and treatment are important.

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A man in his 70s reported weeding his yard 7 days prior to admission. Four days prior to admission, he developed a persistent fever as well as a petechial rash on his lower body, which developed into fused erythema and spread across his entire trunk. He was referred to our emergency department with marked inflammation and a low platelet count. Blood tests revealed a platelet count of 54, 000/μL, fibrin degradation product (FDP) level of 24.5 μg/mL, and an estimated glomerular filtration rate of 21 mL/min/1.73 m². He also had disseminated intravascular coagulation (DIC) and acute kidney injury (AKI). He was immediately started on minocycline for a suspected rickettsia infection. Despite hospitalization, the erythema and fever persisted and his renal function worsened; consequently, he was admitted to the intensive care unit. After emergent hemodialysis and levofloxacin administration, the fever resolved and the skin rash lessened. Polymerase chain reaction with a skin biopsy revealed Japanese spotted fever (JSF). However, on the 4th day of hospitalization, a sudden elevation in the ST-T wave was observed on electrocardiography. Coronary angiography revealed 90% stenosis of the right coronary artery and the left circumflex artery. We diagnosed ST-elevation myocardial infarction (STEMI) and performed Percutaneous Coronary Intervention. He was discharged on the 17th day of hospitalization with improvement of renal function, fever resolution, and erythema. Herein, we report a case of severe JSF with worsening DIC and AKI and STEMI that was difficult to treat despite relatively early intervention.

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We report a case in which the use of oxycodone significantly improved pain in a patient with spinal cord injury pain syndrome. Most neuropathic pain, initiated by cellular depolarization through ion channels, poses a challenge in management. Opioids are generally considered to have limited efficacy in treating neuropathic pain and are classified as a third-line option in neuropathic pain pharmacotherapy guidelines. However, in this case, the additional administration of oxycodone resulted in a significant improvement of symptoms. Recent studies on oxycodone suggest that, in addition to its well-known analgesic effects via intracellular signaling pathways, it hyperpolarizes neuronal cells in the central nervous system via G protein-activated inwardly rectifying potassium channels in the cell membrane, and to produce analgesic effects on neuropathic pain, as supported by our own case. The results of our own studies support this. Opioids often require careful consideration and involve complexities in prescription. However, oxycodone, known for its relatively high efficacy, should be regarded as one of the options for treating neuropathic pain. This case underscores the potential utility of oxycodone in addressing neuropathic pain, challenging the notion that opioids are uniformly less effective in such conditions.

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