Marked gallbladder wall thickening caused by Epstein-Barr virus-induced infectious mononucleosis.

Key Clinical Message: In patients with symptoms of viral infection and marked thickening of the gallbladder wall, it is important to suspect acalculous cholecystitis due to Epstein-Barr virus-induced infectious mononucleosis. Abstract: A 35-year-old Japanese man presented with fever, abdominal right upper quadrant pain, and liver dysfunction. Positive immunoglobulin M and -G antibodies and negative nuclear antigen for Epstein-Barr virus were observed. Abdominal ultrasonography revealed a markedly thickened gallbladder wall. Acalculous cholecystitis due to Epstein-Barr virus-induced infectious mononucleosis was diagnosed.

Potential Indicators of Intestinal Necrosis in Portal Venous Gas: A Case Report of an 82-Year-Old Woman on Long-Term Hemodialysis with Ascites and Pneumatosis Coli.

BACKGROUND Several factors have been reported as possible predictors of intestinal necrosis in patients with portal venous gas (PVG). We describe potential indicators of intestinal necrosis in PVG identified by contrasting 3 episodes of PVG in a patient on hemodialysis against previously verified factors. CASE REPORT An 82-year-old woman undergoing hemodialysis was admitted to our hospital thrice for acute abdominal pain. On first admission, she was alert, with a body temperature of 36.3°C, blood pressure (BP) of 125/53 mmHg, pulse rate of 60/min, respiratory rate of 18/min, and 100% oxygen saturation on room air. Computed tomography (CT) revealed PVG, intestinal distension, poor bowel wall enhancement, bubble-like pneumatosis in the intestinal wall, and minimal ascites. PVG caused by intestinal ischemia was diagnosed, and she recovered after bowel rest and hydration. Three months later, she had a second episode of abdominal pain. BP was 115/56 mmHg. CT revealed PVG and a slight accumulation of ascites, without pneumatosis in the intestinal wall. She again recovered after conservative measures. Ten months later, the patient experienced a third episode of abdominal pain, with BP of 107/52 mmHg. CT imaging indicated PVG, considerable ascites, and linear pneumatosis of the intestinal walls. Despite receiving conservative treatment, the patient died. CONCLUSIONS A large accumulation of ascites and linear pneumatosis in the intestinal walls could be potential indicators of intestinal necrosis in patients with PVG caused by intestinal ischemia. As previously reported, hypotension was further confirmed to be a reliable predictor of intestinal necrosis.

Validation and Improvement of the Saga Fall Risk Model: A Multicenter Retrospective Observational Study.

Purpose: We conducted a pilot study in an acute care hospital and developed the Saga Fall Risk Model 2 (SFRM2), a fall prediction model comprising eight items: Bedriddenness rank, age, sex, emergency admission, admission to the neurosurgery department, history of falls, independence of eating, and use of hypnotics. The external validation results from the two hospitals showed that the area under the curve (AUC) of SFRM2 may be lower in other facilities. This study aimed to validate the accuracy of SFRM2 using data from eight hospitals, including chronic care hospitals, and adjust the coefficients to improve the accuracy of SFRM2 and validate it. Patients and Methods: This study included all patients aged ≥20 years admitted to eight hospitals, including chronic care, acute care, and tertiary hospitals, from April 1, 2018, to March 31, 2021. In-hospital falls were used as the outcome, and the AUC and shrinkage coefficient of SFRM2 were calculated. Additionally, SFRM2.1, which was modified from the coefficients of SFRM2 using logistic regression with the eight items comprising SFRM2, was developed using two-thirds of the data randomly selected from the entire population, and its accuracy was validated using the remaining one-third portion of the data. Results: Of the 124,521 inpatients analyzed, 2,986 (2.4%) experienced falls during hospitalization. The median age of all inpatients was 71 years, and 53.2% were men. The AUC of SFRM2 was 0.687 (95% confidence interval [CI]:0.678-0.697), and the shrinkage coefficient was 0.996. SFRM2.1 was created using 81,790 patients, and its accuracy was validated using the remaining 42,731 patients. The AUC of SFRM2.1 was 0.745 (95% CI: 0.731-0.758). Conclusion: SFRM2 showed good accuracy in predicting falls even on validating in diverse populations with significantly different backgrounds. Furthermore, the accuracy can be improved by adjusting the coefficients while keeping the model's parameters fixed.

Polybacterial Iliopsoas Muscle Abscess as an Indication for Early Diagnosis of Crohn's Disease.

BACKGROUND Crohn disease (CD) is a chronic, relapsing inflammatory bowel disease characterized by penetrations or fistulae in the gastrointestinal tract and abscesses in the surrounding tissues. Diagnosis of CD is difficult with an iliopsoas muscle abscess (IMA) as an initial presentation. CASE REPORT A 22-year-old Japanese man had right hip pain 17 days prior to admission. Because of worsening pain, he was admitted to our hospital. Physical examination revealed limitation of his right hip motion and a positive right psoas sign. Abdominal contrast-enhanced computed tomography (CT) revealed a large right IMA. Continuous drainage, which revealed polymicrobial pus, with intravenous administration of antibiotics dramatically decreased the size of the IMA. The drainage tube was removed on hospitalization day 9 because barium enema and contrast radiography of the abscess through the drainage tube showed no fistula. However, on day 19 of hospitalization, the IMA was redetected by abdominal CT. Continuous abscess drainage was resumed, and the third contrast radiograph of the abscess revealed contrast medium flow into the small intestine. Colonoscopy detected stenoses and circumferential ulceration of the terminal ileum. Histopathological examination of the ileum biopsy showed histocyte aggregation with lymphocyte or plasmacyte infiltration of the lamina propria, compatible with a CD diagnosis. Laparoscopic ileocecal resection was performed on day 64 of hospitalization. CONCLUSIONS Penetration of the intestinal tract caused by CD should be suspected in a patient with a polymicrobial IMA. It is essential to identify the fistula and subsequently perform surgical resection of the affected intestinal area.

Acute abdominal pain due to atypical bilateral adrenal infarction in acute myeloid leukemia with alterations related to myelodysplasia: A case report.

Key Clinical Message: Acute myeloid leukemia (AML) can cause acute abdomen following adrenal insufficiency or adrenal infarction. Therefore, when diffusely enlarged adrenal glands and adrenal insufficiency of unknown cause are seen in a patient presenting with acute abdomen, adrenal infarction due to AML, or other hematologic diseases should be ruled out. Abstract: A 49-year-old man developed acute abdominal pain following adrenal insufficiency and was diagnosed with acute myeloid leukemia (AML) with myelodysplasia-related changes. Because AML can cause acute abdominal pain due to adrenal infarction following adrenal insufficiency, a patient with these conditions should be ruled out adrenal infarction due to AML or other hematologic diseases.

Higher power achieves greater local impedance drop, shorter ablation time, and more transmural lesion formation in comparison to lower power in local impedance guided radiofrequency ablation of atrial fibrillation.

BACKGROUND: Since the local impedance (LI) of the ablation catheter reflects tissue characteristics, the efficacy of higher power (HP) compared to lower power (LP) in LI-guided ablation may differ from other index-guided ablations. OBJECTIVE: This study aimed to assess the efficacy of HP ablation in LI-guided ablation of atrial fibrillation (AF). METHODS: A prospective observational study was conducted, enrolling patients undergoing de novo ablation for AF. Pulmonary vein isolation was performed using point-by-point ablation with a RHYTHMIA HDxTM Mapping System and an open-irrigated ablation catheter with mini-electrodes (IntellaNav MIFI OI). Ablation was stopped when the LI drop reached 30 ohms, three seconds after the LI plateaued, or when ablation time reached 30 s. To balance the baseline differences, a unique method was used in which the power was changed between HP (45 W to anterior wall/40 W to posterior wall) and LP (35 W/30 W) alternately for each adjacent point. RESULTS: A total of 551 ablations in 10 patients were analyzed (HP, n = 276; LP, n = 275). The maximum LI drop was significantly larger (HP: 28.3 ± 5.4 vs. LP: 24.8 ± 6.3 ohm), and the time to minimum LI was significantly shorter (HP: 15.0 ± 6.3 vs. LP: 19.3 ± 6.6 s) in the HP setting. The unipolar electrogram analysis of three patients revealed that the electrogram indicating transmural lesion formation was observed more frequently in the HP setting. CONCLUSION: In LI-guided ablation, the HP could achieve a larger LI drop and shorter time to minimum LI, which may result in more transmural lesion formation compared to a LP setting.

A Simple and Accurate Model for Predicting Fall Injuries in Hospitalized Patients: Insights from a Retrospective Observational Study in Japan.

BACKGROUND While several predictive models for falls have been reported such as we reported in 2020, those for fall "injury" have been unreported. This study was designed to develop a model to predict fall injuries in adult inpatients using simple predictors available immediately after hospitalization. MATERIAL AND METHODS This was a single-center, retrospective cohort study. We enrolled inpatients aged ≥20 years admitted to an acute care hospital from April 2012 to March 2018. The variables routinely obtained in clinical practice were compared between the patients with fall injury and the patients without fall itself or fall injury. Multivariable analysis was performed using covariables available on admission. A predictive model was constructed using only variables showing significant association in prior multivariable analysis. RESULTS During hospitalization of 17 062 patients, 646 (3.8%) had falls and 113 (0.7%) had fall injuries. Multivariable analysis showed 6 variables that were significantly associated with fall injuries during hospitalization: age (P=0.001), sex (P=0.001), emergency transport (P<0.001), medical referral letter (P=0.041), history of falls (P=0.012), and abnormal bedriddenness ranks (all P≤0.001). The area under the curve of this predictive model was 0.794 and the shrinkage coefficient was 0.955 using the same data set given above. CONCLUSIONS We developed a predictive model for fall injuries during hospitalization using 6 predictors, including bedriddenness ranks from official Activities of Daily Living indicators in Japan, which were all easily available on admission. The model showed good discrimination by internal validation and promises to be a useful tool to assess the risk of fall injuries.

A novel catheter ablation strategy for non-paroxysmal atrial fibrillation combining cryoballoon, radiofrequency, and Marshall-vein ethanol ablations.

BACKGROUNDS: Catheter ablation for non-paroxysmal atrial fibrillation (non-PAF) remains challenging and more effective strategy has been required to reduce postoperative arrhythmia recurrences. This study aims to investigate the efficacy and safety of a novel extensive ablation strategy for non-PAF, that is based on a combination of cryoballoon (CBA), radiofrequency (RFA), and Marshall-vein ethanol ablations (EA-VOM). METHODS: The study was a single-center, retrospective observational study. We enrolled 171 consecutive patients who underwent de-novo catheter ablation for non-PAF under conscious sedation with a novel extensive ablation strategy that included CBA for pulmonary vein isolation (PVI) and left atrial roof ablation (LARA), RFA for mitral isthmus (MI) ablation, superior vena cava isolation, and other linear ablations and EA-VOM. Recurrence of atrial arrhythmias over 1 year, procedure outcomes, and procedure-related complications were investigated. RESULTS: A total of 139 (81.3%) patients remained in sinus rhythm during 1-year follow-up. Of the 139 patients, 51 patients (29.8%) received antiarrhythmic drugs. The mean procedure time was 204 ± 45 min. PVI and LARA ablation by CBA and MI block by RFA and EA-VOM were completed in 171 (100%) and 166 (97.1%) patients, respectively. No serious procedure-related complications were observed except for one case of delayed pericardial effusion. CONCLUSION: Approximately 80% of the study patients were AF-free during 1-year follow-up period after a single procedure based on the novel extensive ablation strategy combining CBA, RFA, and EA-VOM. This strategy for non-PAF may be preferred in terms of maintenance of sinus rhythm, safety even in high-risk patients, and relatively short procedure time.

Clinical Clerkships in General Medicine Enable Students to Acquire Basic Medical Competencies and Experience in Community-Based Integrated Care: A Descriptive Questionnaire-Based Study.

Background No previous research has targeted educators regarding educational practice and the achievements of students in terms of the learning objectives of clinical clerkships in university general medicine departments of Japan. We aimed to clarify the characteristics of clinical clerkships in Japanese general medicine departments using a questionnaire administered to chairpersons of university general medicine departments. Methods This was a descriptive questionnaire-based study using Google Forms (Google, Inc., Mountain View, CA, USA). We asked the chairpersons of general medicine departments in Japanese universities the following questions, with responses given on a 5-point Likert scale: Question 1: How well are primary symptoms in the national model core curriculum for undergraduate medical education taught in clinical clerkships in university general medicine departments? Question 2: How successfully can students achieve the learning objectives of the national model core curriculum for undergraduate medical education through clinical clerkships in general medicine departments of university hospitals? Question 3: How successfully can students achieve the learning objectives of the national model core curriculum for undergraduate medical education through clinical clerkships in other community clinics or hospitals? The results of the questionnaire responses are described as mean±standard deviation. Results Of the 71 Japanese universities with general medicine departments, 43 were included in the analysis. For Question 1, the symptoms and pathophysiologies with a mean score of 4 points or higher were fever, general malaise, anorexia, weight loss or gain, edema, abdominal pain, lymphadenopathy, and headache. All those symptoms require basic medical competencies. For Questions 2 and 3, the intramural clinical clerkship of general medicine departments had a higher mean score than the extramural clinical clerkship for diagnostic reasoning that emphasizes medical history and physical examination and a comprehensive approach to patients with multiple health problems. In contrast, the extramural clinical clerkship, in which medical students can build experience with community-integrated care, had a mean score of 3 points or higher for all items. Conclusions The clinical clerkship in general medicine departments of Japanese universities provides students with chances to acquire clinical competencies regarding primary symptoms and pathophysiologies. Additionally, the extramural clinical clerkship provides experience in community-based integrated care, including home medical care, collaboration, health and welfare, and long-term care.

Evaluation of a Previously Developed Predictive Model for Infective Endocarditis in 320 Patients Presenting with Fever at 4 Centers in Japan Between January 2018 and December 2020.

BACKGROUND In our previous single-center study, we developed an infective endocarditis (IE) prediction model among patients with undiagnosed fever (UF) based on 5 factors that can be obtained on admission: ambulance transfer, presence of cardiac murmur or pleural effusion, blood neutrophil percentage, and platelet count. The present study aimed to retrospectively evaluate the prediction model for IE in 320 patients presenting with fever at 4 university hospitals in Japan from January 2018 to December 2020. MATERIAL AND METHODS Patients aged ≥20 years admitted to 4 hospitals with I-330 (IE) or R-50-9 (UF) according to the International Statistical Classification of Diseases and Related Health Problems-10 were enrolled. More than 2 physicians at each hospital reviewed the patient diagnoses using the modified Duke criteria, allocating "definite IE" to IE group (n=119) and "non-definite IE" to UF group (n=201). Five factors on admission were analyzed by multivariate logistic regression. The discriminative ability and calibration of the model were evaluated using the area under the curve (AUC) and the shrinkage coefficient, respectively. RESULTS A total of 320 patients were enrolled. The odds ratios (95% confidence intervals) were as follows: ambulance transfer 1.81 (0.91-3.55); cardiac murmur 13.13 (6.69-27.36); pleural effusion 2.34 (0.62-2.42); blood neutrophil percentage 1.09 (1.06-1.14); and platelet count 0.96 (0.93-0.99). The AUC was 0.783 (0.732-0.834) with a shrinkage coefficient of 0.961. CONCLUSIONS The IE prediction model is useful to estimate the probability of IE immediately after admission for fever in patients aged ≥20 years.

Heidenhain Variant of Sporadic Creutzfeldt-Jakob Disease with a Variety of Visual Symptoms: A Case Report with Autopsy Study.

BACKGROUND Sporadic Creutzfeldt-Jakob disease (sCJD) is a fatal disease caused by the change of prion protein (PrP). Affected patients present with rapidly progressive cognitive dysfunction, myoclonus, or akinetic mutism. Diagnosing the Heidenhain variant of sCJD, which initially causes various visual symptoms, can be particularly difficult. CASE REPORT A 72-year-old woman presented with a 2- to 3-month history of photophobia, blurring vision in both eyes. Seven days previously, she showed visual impairment of 20/2000 in both eyes. Left homonymous hemianopia and restricted downward movement of the left eye were observed with an intact pupillary light reflex and normal fundoscopy. On admission, her visual acuity was light perception. Cranial magnetic resonance imaging revealed no abnormality, and electroencephalography showed no periodic synchronous discharges. Cerebrospinal fluid examination on the sixth hospital day revealed tau and 14-3-3 protein with a positive result of real-time quaking-induced conversion. She thereafter developed myoclonus and akinetic mutism and died. Autopsy revealed thinning and spongiform change of the cerebral cortex of the right occipital lobe. Immunostaining showed synaptic-type deposits of abnormal PrP and hypertrophic astrocytes. Consequently, she was diagnosed with the Heidenhain variant of sCJD with both methionine/methionine type 1 and type 2 cortical form based on the western blot of cerebral tissue and PrP gene codon 129 polymorphism. CONCLUSIONS When a patient presents with various progressive visual symptoms, even without typical findings of electroencephalography or cranial magnetic resonance imaging, it is essential to suspect the Heidenhain variant of sCJD and perform appropriate cerebrospinal fluid tests.

The angle of the tines before the pull and hold test predicts engagement of the tines in Micra leadless pacemaker implantation.

Background: Micra leadless pacemaker is secured to the myocardium by engagement of at least 2/4 tines confirmed with pull and hold test. However, the pull and hold test is sometimes difficult to assess. This study was performed to evaluate whether the angle of the tines before the pull and hold test predicts engagement of the tines in Micra leadless pacemaker implantation. Methods: We retrospectively enrolled 93 consecutive patients (52.7% male, age 82.4 ± 9.4 years), who received Micra implantation from September 2017 to June 2020 at our institution. After deployment and before the pull and hold test, the angle of the visible tines to the body of the pacemaker was measured using the RAO view of the fluoroscopy image. The engagement of the tines was then confirmed with the pull and hold test. Results: A total of 326 tines were analyzed. The angle of the engaged tines was significantly lower than the non-engaged tines (9.2 degrees [4.0-14.0] vs. 16.6 degrees [14.2-18.8], p < .0001). All tines with angles <10 degrees were engaged. In higher angles, engagement could not be predicted. Conclusion: A low angle of the tines before the pull and hold test can predict engagement of the tines in Micra leadless pacemaker implantation. The tines which are already open after deployment may be presumed that they are engaged.

Effects of Caregiver's Gender or Distance Between Caregiver and Patient's Home on Home Discharge from Hospital in 285 Patients Aged ≥75 Years in Japan.

BACKGROUND Many hospitalized aged patients in Japan, the most super-aged society, are unable to be discharged home. This study was performed to clarify the factors associated with home discharge, not to a long-term care (LTC) facility or another hospital, among inpatients aged ≥75 years. MATERIAL AND METHODS A single-center prospective cohort study was performed for inpatients aged ≥75 years in a rural acute-care hospital in Japan, from November 2017 to October 2019. We divided the patients into 2 groups: those who resided at home or had died at home by 30 days after discharge, and others. We obtained data from medical charts and questionnaires given to patients and their caregivers. For each factor shown to be statistically significant by the univariable analysis, a multivariable analysis with adjustment was conducted. RESULTS In all, 285 patients agreed to participate. With adjustment by where the patient was admitted from, residing with other family members, cognitive function scores, and Barthel index, multivariable analysis using each factor identified as relevant by univariable analysis identified the following as associated with home discharge: being less informed about LTC insurance; cost of home-visit medical, nursing, or LTC services; shorter hospital stays; close proximity between patient and caregiver; main caregiver being female; and life expectancy of over 6 months (P<0.05). CONCLUSIONS Male gender and a long distance between the caregiver and patient's home significantly hindered home discharge in patients aged ≥75 years, suggesting the need to provide information regarding home-visit services under Japan's LTC insurance system for such caregivers.

Pulmonary Veno-occlusive Disease that Developed Following Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia.

We herein report a case of pulmonary veno-occlusive disease (PVOD) induced by allo-hematopoietic stem cell transplantation (HSCT) in a 48-year-old man who was diagnosed with acute myeloid leukemia. Five months after transplantation, he developed dyspnea and was diagnosed with pulmonary hypertension based on right heart catheterization. Although he received treatment with pulmonary vasodilators, diuretics, and corticosteroids, his pulmonary artery pressure did not decrease, and his pulmonary edema worsened. Based on the clinical course, hypoxemia, diffusion impairment, and computed tomography findings, the patient was diagnosed with HSCT-related PVOD. Critical attention should be paid to dyspnea after HSCT for the early diagnosis of PVOD.

Hands-on Clinical Clerkship at the Department of General Medicine in a University Hospital Improves Medical Students' Self-Evaluation of Skills of Performing Physical Examinations and Informed Consent: A Questionnaire-Based Prospective Study.

Introduction: The educational effects of a hands-on clinical clerkship on medical students at the Department of General medicine of Japanese university hospitals remain to be clarified. This study aimed to determine how such education affects medical students' self-evaluation of their clinical skills. Methods: We enrolled 5th-year-grade students at the Department of General Medicine, Saga University Hospital, Japan in 2017. The students were divided into those who were going to have Japanese traditional-style observation-based training mainly in the outpatient clinic (Group O) and those in the 2018, new-style, hands-on clinical clerkship as one of the group practice members in outpatient and inpatient clinics (Group H). A questionnaire survey using the 4-point Likert scale for self-evaluation of the students' clinical skills at the beginning and the end of their training was conducted in both groups. The pre- and post-training scores of each item in both groups were compared and analyzed using the Mann-Whitney test. Results: All 99 students in Group O and 121 of 123 students in Group H answered the questionnaires. The response rate was 99%. Two items regarding the abilities of "can perform a systemic physical examination quickly and efficiently" and "can clearly explain the current medical condition, therapeutic options, or risks associated with treatment, and discuss the process for obtaining informed consent" showed higher scores in the post-training survey in Group H than in Group O. There were no differences in these scores in the pre-training survey between the two groups. Conclusion: A hands-on clinical clerkship at the Department of General medicine in a university hospital in Japan provided medical students with higher self-confidence in their skills of performing a physical examination and better understanding of patients' treatment options and the process of informed consent than observation-based training.

Criterion-related validity of Bedriddenness Rank with other established objective scales of ADLs, and Cognitive Function Score with those of cognitive impairment, both are easy-to-use official Japanese scales: A prospective observational study.

AIM: Bedriddenness Rank (BR) and Cognitive Function Score (CFS), issued by the Ministry of Health, Labour and Welfare, Japan, are easy-to-use and widely used in the medical and long-term care insurance systems in Japan. This study aims to clarify the criterion-related validity of the CFS with the Mini-Mental State Examination (MMSE) and ABC Dementia Scale (ABC-DS), and to re-evaluate the criterion-related validity of BR with the Barthel Index (BI) or Katz Index (KI) in more appropriate settings and a larger population compared with the previous study. METHODS: A single-center prospective observational study was conducted in an acute care hospital in a suburban city in Japan. All inpatients aged 20 years or older admitted from October 1, 2018 to September 30, 2019. The relationship between BR and the BI and KI, and the relationship between CFS and the MMSE and ABC-DS were analyzed using Spearman's correlation coefficients. RESULTS: We enrolled 3,003 patients. Of these, 1,664 (56%) patients exhibited normal BR. The median (interquartile range) values of the BI and KI were 100 (65-100) and 6 (2-6), respectively. Spearman's rank correlation coefficients between BR and the BI and KI were -0.891 (p < 0.001) and -0.877 (p < 0.001), respectively. Of the patients, 1,967 (65.5%) showed normal CFS. The median (interquartile range) MMSE of 951 patients with abnormal CFS and ABC-DS of all patients were 15 (2-21) and 117 (102-117), respectively. Spearman's rank correlation coefficients between CFS and MMSE and ABC-DS were -0.546 (p < 0.001) and -0.862 (p < 0.001), respectively. CONCLUSIONS: BR and CFS showed significant criterion-related validity with well-established but complicated objective scales for assessing activities of daily living and cognitive functions, respectively. These two scales, which are easy to assess, are reliable and useful in busy clinical practice or large-scale screening settings.

Late-Onset Ornithine Transcarbamylase Deficiency Complicated with Extremely High Serum Ammonia Level: Prompt Induction of Hemodialysis as the Key to Successful Treatment.

BACKGROUND Ornithine transcarbamylase deficiency (OTCD) is an X-linked semi-dominant disorder, causing possible fatal hyperammonemia. Late-onset OTCD can develop at any time from 2 months after birth to adulthood, accounting for 70% of all OTCDs. CASE REPORT A 35-year-old man with chronic headaches stated that since childhood he felt sick after eating meat. Fourteen days before hospital admission, he began receiving 60 mg/day of intravenous prednisolone for sudden deafness. The prednisolone was stopped 5 days before hospital admission. Four days later, he was transferred to our hospital because of confusion. On admission, he had hyperammonemia of 393 µmol/L. Because he became comatose 7 hours after admission, and his serum ammonia increased to 1071 µmol/L, we promptly started hemodialysis. Because his family history included 2 deceased infant boys, we suspected late-onset OTCD. On day 2 of hospitalization, we began administering ammonia-scavenging medications. Because he gradually regained consciousness, we stopped his hemodialysis on day 6. After his general condition improved, he was transferred to the previous hospital for rehabilitation on day 32. We definitively diagnosed him with late-onset OTCD due to the low plasma citrulline and high urinary orotic acid levels found during his hospitalization. CONCLUSIONS Clinicians should suspect urea cycle disorders, such as OTCD, when adult patients present with marked hyperammonemia without liver cirrhosis. Adult patients with marked hyperammonemia should immediately undergo hemodialysis to remove ammonia, regardless of causative diseases.

History of Falls and Bedriddenness Ranks are Useful Predictive Factors for in-Hospital Falls: A Single-Center Retrospective Observational Study Using the Saga Fall Risk Model.

Introduction: In our former study, we had validated the previously developed predictive model for in-hospital falls (Saga fall risk model) using eight simple factors (age, sex, emergency admission, department of admission, use of hypnotic medications, history of falls, independence of eating, and Bedriddenness ranks [BRs]), proving its high reliability. We found that only admission to the neurosurgery department, history of falls, and BRs had significant relationships with falls. In the present study, we aimed to clarify whether each of these three items had a significant relationship with falls in a different group of patients. Methods: This was a single-center based, retrospective study in an acute care hospital in a rural city of Japan. We enrolled all inpatients aged 20 years or older admitted from April 2015 to March 2018. We randomly selected patients to fulfill the required sample size. We performed multivariable logistic regression analysis using forced entry on the association between falls and each of the eight items in the Saga fall risk model 2. Results: A total of 2932 patients were randomly selected, of whom 95 (3.2%) fell. The median age was 79 years, and 49.9% were men. Multivariable analysis showed that female sex (odds ratio [OR] 0.6, 95% confidence interval [CI] 0.39-0.93, p = 0.022), having a history of falls (OR 1.9, 95% CI 1.16-2.99, p = 0.010), requiring help with eating (OR 1.9, 95% CI 1.12-3.35, p = 0.019), BR of A (OR 6.6, 95% CI 2.82-15.30, p < 0.001), BR of B (OR 7.5, 95% CI 2.95-19.06, p < 0.001), and BR of C (OR 4.1, 95% CI 1.53-11.04, p = 0.005) were significantly associated with falls. Conclusion: History of falls and BRs were independently associated with in-hospital falls.

A Prospective Observational Study Conducted at a Single Center in Japan to Validate a Previously Developed Predictive Formula of In-Hospital Mortality for Patients Aged ≥65 Years with Endogenous Diseases Transported by Ambulance.

BACKGROUND In 2019, we developed a predictive formula of in-hospital mortality for inpatients aged ≥65 years transported by ambulance for endogenous diseases. In this study, we aimed to validate this previously developed predictive formula. MATERIAL AND METHODS In this single-center prospective observational study, we enrolled all patients aged ≥65 years who were transported by ambulance and admitted to an acute care hospital in Japan for endogenous diseases. We calculated the score according to our developed formula using age, disturbance of consciousness, the shock index, and amount of oxygen administered, with each item scoring 1 point and then totaling them. We subsequently evaluated the in-hospital mortality rate, stratum-specific likelihood ratio, and area under the receiver operating characteristic curve (AUC) of the formula, using in-hospital mortality as the primary outcome. RESULTS In total, 325 patients were included in this study. Forty-two patients died during hospitalization. Multivariable logistic regression analysis (forced-entry method) revealed that disturbance of consciousness and oxygen administration 5 L/min or more were significantly associated with mortality during hospitalization. In contrast, aged ≥90 years and shock index of 1 or higher were not significant. The mortality and stratum-specific likelihood ratios for scores in the predictive formula of 3 and 4 were 40.9% and 4.66, and 66.7% and 13.48, respectively. The AUC of the predictive formula for in-hospital mortality was 0.670 (95% confidence interval: 0.574-0.767). CONCLUSIONS This study showed that our predictive formula, consisting of factors available immediately after ambulance transport in older patients, is feasible with sufficient discrimination ability and reliability.

Willingness to Select Initial Clinical Training Hospitals Among Medical Students at a Rural University in Japan: A Single-Center Cross-Sectional Study.

Purpose: Many countries will be aged societies by 2060. As a super-aged society, Japan may offer a valuable reference point. The number of medical residents and doctors working at university hospitals in Japan has halved since 2004, resulting in serious shortages of doctors in rural areas. This study clarified factors influencing medical students to choose university hospitals as facilities for their initial training or to only choose community hospitals. Methods: This single-center cross-sectional study was conducted in a typical rural city in Japan from February to March 2021. Data were collected using a questionnaire developed from a narrative review and discussion among four researchers. The participants were divided into those who chose university hospitals and those chose only community hospitals for logistic regression analysis. Results: Of the 300 students who answered the questionnaire (46.4% response rate), 291 agreed to participate in the study. At the time, 93 students had not decided where to undertake initial training, and were excluded. Of the 198 analyzed students, 113 (57.1%) had chosen university hospitals. Significant factors affecting students' choices were "good salary or fringe benefits" (odds ratio [OR] 2.6, 95% confidence interval [CI]: 1.3-5.2) in the community hospital group, and "desire to have contact with doctors practicing in a medical setting before starting hospital training in the fifth and sixth grade" (OR 0.4, 95% CI: 0.2-0.8) and "prefer Saga Prefecture for initial training" (OR 0.2, 95% CI: 0.1-0.4) among the university hospital group. Conclusion: University hospitals could offer a good salary or fringe benefits to secure residents. Other useful measures include preferential admission of students who pledge to work in the prefecture of their medical school after graduation and facilitating contact between motivated students and senior doctors before starting hospital training.