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Volume 68, Issue 4
Displaying 1-15 of 15 articles from this issue
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ORIGINALS
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Ayano MOMOSE, Naoko USHIYAMA, Yasushi KUROBE, Junya TAMURA, Kimito MOM ...2019 Volume 68 Issue 4 Pages 443-449
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSThe objective of this study was to determine whether a decrease in the score for any of the Functional Independence Measure (FIM) domains at discharge compared to before admission (decreased FIM) is associated with increased risk of facility admission. Patients were divided into those discharged to a care facility (facility group) and those discharged home (home group). Patients in the home group were selected so as to match those in the facility group. A total of 36 patients were included in each group. Mean ages of patients in the home and facility groups were 88.9 ± 7.9 and 89.1 ± 7.6 years, respectively, and mean pre-admission total FIM scores were 77.1 ± 29.8 and 78.5 ± 30.3, respectively. When each FIM subdomain was examined for correlation between decreased score and post-discharge destination, bowel management (odds ratio, 4.5), bladder management (3.9), social interaction (3.5), problem solving (3.5), and walking (2.5) were identified as being significantly associated with increased risk of facility admission. A limitation was that this study did not consider the care-giving capacity of families. Further studies are needed to identify additional potential factors affecting post-discharge destination, including care-giving capacity of families and other social factors.View full abstractDownload PDF (701K) -
Yasuhiro NISHIMOTO, Tsuyoshi HATAD, Shuichi KOBAYASHI2019 Volume 68 Issue 4 Pages 450-459
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSInfection is a known cause of impaired consciousness. Sometimes, the absence of fever delays diagnosis and treatment of infections in patients with impaired consciousness. This study aimed to identify a better index than body temperature for detecting infection in patients with impaired consciousness by using area under the receiver operating characteristic (AUROC) curves (≥ 0.7 was significant) and stratum-specific likelihood ratios (SSLRs, ＜0.2 or ＞5 was significant) according to patients’ vital signs (blood pressure, heart rate, body temperature, respiratory rate, and SpO2) or age. Of the 1,853 consecutive patients with impaired consciousness aged ≥15 years who were transported to our hospital between 2011 and 2014, 451 (24.3％) had infection. The AUROC for body temperature was 0.701 for diagnosing infection, whereas the AUROCs for other vital signs were ＜ 0.7. Because no strata of body temperature showed values ＜ 0.2 for diagnosing infection, we could not exclude infection in patients with impaired consciousness with low body temperatures. Next, we developed a novel index called HAR/S, the product of heart rate (beats/min), age (years), and respiratory rate (breaths/min) divided by systolic blood pressure (mmHg). The AUROC for HAR/S was 0.809 for diagnosing infection; this value was higher than that for body temperature; the SSLR for HAR/S ＜700 was 0.190 for diagnosing infections, which was ＜0.2. HAR/S ≥700 can be a new index for detecting infections in patients with impaired consciousness regardless of their body temperature, with sensitivity, specificity, and negative predictive values of 0.911, 0.468, and 0.941, respectively.View full abstractDownload PDF (920K) -
Akiko TAKAI, Miho KATO, Yusuke HAYANO, Chika Chika, Rumi KISHI, Tomohi ...2019 Volume 68 Issue 4 Pages 460-467
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSMost patients on hemodialysis (HD) have left ventricular (LV) remodeling as a result of pressure and volume overload, which may lead to hypertrophy (LVH) and dilation, resulting in heart failure (HF). LV torsion by the inner and outer oblique myocardial bands may contribute in part to the ejection fraction (EF). LV dilation is associated with reduction of torsion. We assessed the hypothesis that LV dilation and decreased torsion at the sub-epicardium assessed by 3-dimensional speckle tracking echocardiography (3D-STE) may cause reduced LVEF in patients on HD. LV volume, strain, and torsion at the sub-endocardium and sub-epicardium were examined using 3D-STE in 76 patients on HD (age 64 ± 2 years) and 22 controls (age 71 ± 9 years). The HD patients were divided into 2 subgroups according to LV size (17 HD with LV end diastolic volume ≥ 70 and 59 HD with volume ＜ 70 mL/m2). Torsion (°/cm) is defined as the difference in the rotation angle between base and apex divided by the length of the LV long axis. LVEF, strain, and torsion at both layers in all HD patients (n = 76) were comparable to those in the controls (torsion at the sub-endocardium: 2.2 ± 0.7 vs 2.4 ± 1.1°/cm) despite increased LV mass and volume. In HD with dilation, LV volume increased and LVEF reduced compared to HD without dilation (LVEF: 63 ± 7, 64 ± 6, 57 ± 9％), with decreased longitudinal strain and torsion at both layers (torsion at sub-epicardium: 1.4 ± 0.7, 1.6 ± 1.0, 1.1 ± 0.6°/cm). There was no significant difference in circumferential strain at the sub-epicardium among the 3 groups. There was some correlation between torsion and EF (r = 0.34, p ＜ 0.01) and end diastolic volume (r = －0.36, p ＜ 0.01). LVEF and torsion at the sub-endocardium and sub-epicardium were reduced in HD with LV dilation, suggesting that volume control is important in HD to prevent HF with reduced EF because of reduced LVEF by LV dilation and oblique myocardial fiber damage at the sub-epicardium.View full abstractDownload PDF (1084K) -
Sota YOSHIMINE, Atsushi SEYAMA, Atsushi SUGA, Masanori MURAKAMI, Masan ...2019 Volume 68 Issue 4 Pages 468-474
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSWe treated a total of 67 patients for mamushi viper (Gloydius blomhoffii) bite during a 10-year period between 2007 and 2016. The mean age of the patients was 68 years, with those aged ≥ 60 years accounting for about 80％ of all patients. Most injuries occurred between July and September in rice fields and other cropland, or in the patients’ homes. Except for 1 severe case who developed a marked thrombocytopenia immediately after the incident, the remaining 66 patients were included in the analysis. All patients received inpatient care, with a mean hospital stay of 6.8 days. There was a significant positive correlation between the size of the swelling at the bite site and the length of hospital stay. Kidney dysfunction occurred in 3 patients, 1 of whom died. The mean time to the largest swelling was 21.8 h while the mean time to the highest creatine phosphokinase level was 2.6 days. The more severe cases were more likely to be have been treated with mamushi antitoxin while 2 of the 3 patients with kidney dysfunction, including the 1 fatality, were not, suggesting that the use of mamushi antitoxin is essential in severe cases. We also report a very rare case of mamushi viper bite complicated by thrombocytopenia.View full abstractDownload PDF (748K)
RESEARCH REPORTS
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Shigoh TAKATORI, Chinami SUZUKI, Kimihito SATO2019 Volume 68 Issue 4 Pages 475-481
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSThere have been few reports on suvorexant (SUV), a benzodiazepine-agonist hypnotic, used concomitantly with benzodiazepines (BZDs) or non-benzodiazepines (non-BZDs). Therefore, we investigated the use of SUV in patients taking BZDs and non-BZDs. Subjects were 73 individuals who were prescribed SUV while taking either BZDs or non-BZDs for 4 weeks or more from November 2015 to the end of March 2017. Subjects were divided into three groups as follows: those with no weight change compared to baseline (the non-weight loss group (n = 32)), those with some weight loss (the weight loss group n = 23)), and those who discontinued the drugs (the withdrawal group (n = 18)). Age, sex, presence or absence of antipsychotic medication, continuation rate of SUV in each week after 4 weeks, and diazepam equivalent value before and after SUV administration were compared in each group. In addition, we investigated the occurrence of side effects after SUV initiation. When comparing the SUV continuation rate at 24 weeks in each group, no significant difference was found between the 3 groups, but at 8 weeks, the weight loss group showed significantly decreased rates compared to the non-weight-loss group. When diazepam conversion values were compared before and after BZD and non-BZD administration, significant differences were found in the non-weight-loss group, weight-loss group, and withdrawal group before administration. Side effects were 18.8％ in the non-weightloss group, 13.0％ in the weight loss group, and 16.7％ in the withdrawal group; 6.3％, 8.6％, and 16.7％ were in the central nervous system. It was thought that continuation rate might fall by concomitant use of SUV with BZDs or non-BZDs. For patients using SUV when taking BZDs or non-BZDs, it is desirable not only to reduce or stop the BZDs or non-BZDs, but also to be aware of withdrawal symptoms. This is because side effects may increase following discontinuation. Despite causing weight reduction, it is also important to consider improved safety.View full abstractDownload PDF (738K) -
Junichi YAMASHITA, Yukari HORIMOTO2019 Volume 68 Issue 4 Pages 482-489
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSThis study was conducted to identify challenges experienced by chief physical therapists newly appointed as line managers and the support they require. The study included 15 chief physical therapists who had been promoted to the position in the preceding 4 years and were working at the physical therapy department of JA Shizuoka Kouseiren-affiliated hospitals. A mail-based survey was conducted using a self-administered questionnaire consisting of 7 domains. In the “worries” domain, the most common answers were “It is difficult to carry out performance evaluations of subordinates”, “I don’t know what I need to learn as chief physical therapist”, “There is too much work to do”, and “The expected achievements of chief therapists are unclear”. Regarding learning opportunities, “In-house training programs provided by the workplace (including organizations and hospitals)” was most frequently chosen, with 93.3％ of the respondents expressing a desire for a phased continuous education system focused on management/administration at their workplaces. The challenges experienced by newly appointed chief physical therapists identified in this survey included ambiguity of role sharing, heavy workload, and psychological conflict. The survey results also suggest the need for immediate response programs and support systems to promptly address problems and ensure smooth management operations.View full abstractDownload PDF (946K) -
Haruka YAGI, Yoshitaka YAMAMOTO, Ippei USUKUBO, Yuka Yuka, Asako SHIMO ...2019 Volume 68 Issue 4 Pages 490-495
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSHospitalized patients often have insomnia, and in many cases it is necessary to administer hypnotics. Although the hypnotics currently used in Japan are mainly benzodiazepine receptor agonists, there is an associated risk of falling due to muscle relaxant action, and carryover effect. It is believed that orexin receptor antagonists, which have a different mechanism of action from conventional hypnotics, have no muscle relaxant action and are thus considered to be much safer. Therefore, in this study we compared fall rate according to the class of hypnotics that the patient had been taking.
We analyzed hospitalized patients taking orexin receptor antagonists (ORB), benzodiazepines (BZDs), and non-BZDs, who had falls and were treated in our hospital from April 1, 2017 to December 31, 2017. Patients were grouped according to the drug they were taking before the fall occurred and the fall rate was calculated and compared. The total number of falls in the target patients was 45, and the total number of people prescribed hypnotics in the study period was 1682. Fall rate by classification of hypnotics was the lowest in the ORB group at 1.45％, which was significantly lower than that of the BZD group, suggesting the possibility that ORBs have minimal influence on falls. In addition, the fall rate in the non-BZD group was significantly lower than that of the BZD group.View full abstractDownload PDF (1156K) -
Kozue KATO, Shohei HASUI, Shohei KAWAGUCHI, Nami AZUCHI, Takahito IMAI ...2019 Volume 68 Issue 4 Pages 496-504
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSIn recent years, the problem of antimicrobial resistance (AMR) from inappropriate use of antimicrobial drugs has emerged, and a plan to counter AMR has been formulated. From October 2017, our hospital started interventions to guide prescribing physicians in the proper use of intravenous antibiotics for patients requiring said treatment for more than 15 days. In the present study, we investigated the status of treatment with intravenous antibiotics and considered the effects of intervention. This study targeted a total of 2627 patients, 1971 of whom were hospitalized, who started using intravenous antibiotics from June 2017 to January 2018. We assigned those who started between June and September 2017 to the pre-intervention group and those who started between October 2017 and January 2018 to the post-intervention group. The number of patients using long-term intravenous antibiotics, total number of days of treatment, antimicrobial use density (AUD), day of therapy (DOT), and rate of use by lineage of antibiotics were compared. The number of patients using long-term intravenous antibiotics decreased to 40 in the pre-intervention group and 31 in the post-intervention group. There was no significant difference in the total number of treatment days, which was 5.1 ± 5.5 days before and 4.8 ± 4 9 days after, in the intervention group. The AUD of penicillin antibiotics increased and that of aminoglycosides decreased. Furthermore, the DOT of third-generation cephems and lincomycin decreased. Penicillin had an increased lineage use ratio, while that for thirdgeneration cephems, carbapenems, and lincomycin decreased. The number of patients using long-term intravenous antibiotics as well third-generation cephem and carbapenem antibiotics, which are broad spectrum antibiotics, decreased; the overall use of penicillin, a narrow-spectrum antimicrobial, increased. This suggested that the intervention resulted in the promotion of proper use of antimicrobial drugs.View full abstractDownload PDF (1038K) -
Yoshitaka ENOMOTO, Masashi ZUGUCHI, Yosuke KUBOTA, Yasushi KAWAHARADA, ...2019 Volume 68 Issue 4 Pages 505-509
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSIn our hospital, we typically perform laparoscopic partial gastrectomy as surgical treatment for extragastric growth type of submucosal tumor (SMT), and laparoscopic intragastric surgery for intragastric growth type. In 2008, laparoscopic and endoscopic cooperative surgery (LECS) was reported for the first time by Hiki et al. Against the background of LECS as laparoscopic local gastric resection with endoscopic resection, we started LECS for gastric SMT from 2015.
We performed laparoscopic (LAP) surgery for 15 gastric SMT cases from 2009, and compared 5 cases for which LECS was performed and 10 cases for which LAP was performed. Tumor diameter was 15–21 mm (mean 19.2 mm) in the LECS group, and 20–53 mm (mean 35.5 mm) in the LAP group; the LECS group had a significantly smaller tumor diameter. Operative time was 299 ± 45 min in LECS and 222 ± 25 min in LAP. The volume of blood loss was 24 ± 13 mL in LECS and 33 ± 13 mL in LAP. Hospitalization days was 14.0 ± 3.0 days in LECS and 12.9 ±0.8 days in LAP. There was no significant difference between them.View full abstractDownload PDF (634K) -
Integration of 291 Incident ReportsMizuki SATO, Tomoko TAKAHASHI, Noritaka SAKATA, Mariko TAKAHASHI, Hiro ...2019 Volume 68 Issue 4 Pages 510-516
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSJA Omagari Kosei Medical Center is an acute hospital located in Daisen City, Akita Prefecture, and we have two comprehensive community-based care wards. Falls and fall incidents are always ranked high in acute hospitals. Injuries caused by falls such as fracture, may lead to decline in activities of daily living / quality of life in patients and / or their families, which may then prolong the hospitalization period. Therefore, prevention of falls and falling is beneficial. Previous studies have reported that the activities of the ‘falls and falling’ teams contribute to reducing the fall rate. However, few studies have been conducted in acute hospital settings. Therefore, in this study we summarized the characteristics and current status of hospitalized patients in terms of falls and falling incidents in our hospital from medical records and incident accident reports.
Among 230 patients, 291 falls and falling incidents were reported in 1 year; falls and falling accounted for 32.9％ of all incidents. In addition, the fall rate was 2.1 cases / 1,000 patients / day, average age was 77 years, and there was a higher tendency in men. Furthermore, falls and falling occurred on a median 13 days from hospitalization; in 124 cases (42.6％) within 10 days after hospitalization and in 60 cases (20.6％) from 10 days to 20 days. A similar tendency was seen in patients who were moved to the comprehensive community-based care ward. Therefore, we considered that the patient would require continuous attention after moving to that ward. Ultimately, falls and falling occurred in the late-night period (from midnight to 8 a.m.), and many were at the bedside (58.4％), and the purpose of movement was bowel motion (54.3％).View full abstractDownload PDF (851K)
CASE REPORTS
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Tomoyuki KAWAMURA, Shuntaro KAWABATA, Masatoshi YAMAOKA, Takuya ONUKI, ...2019 Volume 68 Issue 4 Pages 517-522
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSA 31-year-old pregnant woman with no remarkable past medical history presented with mild hypoxemia, which worsened after she underwent cesarean section. To determine the cause of hypoxemia, we performed chest computed tomography after the cesarean section and found a pulmonary arteriovenous fistula of the A10-V10 shunt in the lower lobe of the right lung and V10 had expanded to 12 mm. Forty-nine days after giving birth, the patient underwent thoracoscopic right lower lobectomy. The results of blood gas analysis improved after surgery; before surgery, the partial pressure of oxygen was 66.4 Torr, which increased to 98.4 Torr after surgery. The patient was discharged on the ninth day after surgery.
Pulmonary arteriovenous fistula may be exacerbated by changes in cardiac output and circulating blood volume during pregnancy. If hypoxemia progresses after pregnancy, pulmonary artery fistula must be identified.View full abstractDownload PDF (1829K) -
Koji TAKAHASHI2019 Volume 68 Issue 4 Pages 523-528
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSA man in his 80’s presented with sudden onset chest pain in the outpatient waiting room at our hospital and was diagnosed with acute myocardial infarction. Emergency coronary angiography was performed, and a drug-eluting stent was placed in the occluded right coronary artery. After the procedure, the patient developed high-grade fever (40°) with chills. Computed tomography revealed retroperitoneal and iliopsoas abscesses. The patient’s condition did not improve with the administration of antibiotics, so a drainage procedure was deemed necessary. Because of the stent, he was prescribed dual antiplatelet therapy (DAPT) with aspirin and prasugrel. Two days after stent placement, percutaneous abscess drainage was performed with the patient continuing DAPT. No bleeding occurred when a drainage tube was placed. The tube was withdrawn 19 days after insertion. He was then discharged 11 days after removal of the tube.View full abstractDownload PDF (1678K) -
Koji TAKAHASHI2019 Volume 68 Issue 4 Pages 529-534
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSA man in his 50's was referred to our hospital for hematemesis and hematochezia. He had previously presented to another hospital for ulcerative colitis that was in remission with a prescription of 11 mg prednisolone and adalimumab. He also had a history of partial gastrectomy. Although detailed information on the gastrectomy was unavailable upon arrival at our hospital, contrast-enhanced computed tomography scan suggested that he had undergone a distal gastrectomy with Billroth II reconstruction. Emergency upper gastrointestinal endoscopy revealed an ulcer with an exposed blood vessel at the Braun anastomosis; thus, clipping hemostasis was performed. However, hematemesis occurred 3 days later, and another emergency upper gastrointestinal endoscopy revealed that the clips at the Braun anastomosis had deviated from the original position; therefore, clipping hemostasis was repeated to stop the bleeding from the exposed blood vessels. Subsequently, he was provided intravenous hyperalimentation, after which he resumed oral intake 14 days after the second clipping. No bleeding was observed after the second clipping, and he was discharged 22 days after admission.View full abstractDownload PDF (2069K) -
Ayana ISHIGURO, Makoto NAKAO, Yoshiharu OZAWA, Yuto SUZUKI, Yusuke SAK ...2019 Volume 68 Issue 4 Pages 535-542
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSA 68-year-old man was admitted to our hospital with complaints of fatigue, polyuria, and loss of appetite, and was diagnosed with diabetic ketosis. Chest and abdominal computed tomography (CT) showed a pulmonary tumor on the right S3 and multiple liver tumors. Blood chemistry revealed elevated levels of amylase and hepatobiliary enzymes. Pathological examination of a biopsy specimen from the liver tumor showed a small cell carcinoma. Based on the imaging and pathological findings, we made a diagnosis of extensive disease small-cell lung cancer (ED-SCLC), cT1aN3M1b (HEP, ADR). Treatment with carboplatin and etoposide evoked partial response and the serum level of amylase decreased. Immunohistochemical staining of liver biopsy specimen was positive for amylase, leading to a diagnosis of SCLC with amylase production. About 22 months after the diagnosis of SCLC, he was admitted to our hospital with fatigue, muscular weakness, edema, and hyperpigmentation. Laboratory findings showed elevated serum levels of hepatobiliary enzymes, adrenocorticotropic hormone (ACTH), and cortisol, and a decreased serum potassium level. Urinary potassium level was elevated. Pituitary magnetic resonance imaging showed a normal morphology. We made a diagnosis of SCLC complicated by Cushing’s syndrome. We report this rare case of SCLC with amylase and ACTH production, which was detected in the course of treatment of SCLC.View full abstractDownload PDF (2039K)
SHORT REPORT
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Koki SHIRAI2019 Volume 68 Issue 4 Pages 543-548
Published: 2019
Released on J-STAGE: December 28, 2019
JOURNAL FREE ACCESSBuilding a stable profit structure is essential for hospitals to continuously provide advanced medical care. Using data analysis software for the Diagnosis Procedure Combination/Per-Diem Payment System (DPC), we compared the performance of our hospital with that of other Group II hospitals (currently, Specified Hospitals) and noted that some of the functional assessment coefficient II values were low. One of these coefficients was the emergency medical service coefficient. The coefficient of our hospital in 2016 was lower than the average of Group II hospitals and was the lowest among all JA Aichi Kouseiren-affiliated hospitals. Given this result, we reviewed our process for calculating the additional fee for emergency medical service management in an effort to increase the rate of charging the additional fee. Specifically, we changed the criteria for identifying patients eligible for the additional fee (manual preparation) and the method of calculation (systematization). These efforts resulted in an increased rate of charging an additional emergency medical service management fee without increasing the rate of assessment during insurance examination. This led to an increased emergency medical service coefficient value. These results suggest a close correlation between the rate of charging the additional emergency medical service management fee and the DPC emergency medical service coefficient.View full abstractDownload PDF (1168K)
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