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Risa Hirata,1 Naoko E Katsuki,1 Hitomi Shimada,2 Eiji Nakatani,3 Kiyoshi Shikino,4,5 Chihiro Saito,6 Kaori Amari,7 Yoshimasa Oda,8 Midori Tokushima,1 Masaki Tago1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Shimada Hospital of Medical Corporation Chouseikai, Saga, Japan; 3Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka, Japan; 4Department of General Medicine, Chiba University Hospital, Chiba, Japan; 5Department of Community-Oriented Medical Education, Chiba University Graduate School of Medicine, Chiba, Japan; 6Shizuoka General Hospital, Shizuoka, Japan; 7Department of Emergency Medicine, Saga-Ken Medical Centre Koseikan, Saga, Japan; 8Department of General Medicine, Yuai-Kai Foundation and Oda Hospital, Saga, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jpPurpose: There has been no large-scale investigation into the association between the use of lemborexant, suvorexant, and ramelteon and falls in a large population. This study, serving as a pilot investigation, was aimed at examining the relationship between inpatient falls and various prescribed hypnotic medications at admission.Patients and Methods: This study was a sub-analysis of a multicenter retrospective observational study conducted over a period of 3 years. The target population comprised patients aged 20 years or above admitted to eight hospitals, including chronic care, acute care, and tertiary hospitals. We extracted data on the types of hypnotic medications prescribed at admission, including lemborexant, suvorexant, ramelteon, benzodiazepines, Z-drugs, and other hypnotics; the occurrence of inpatient falls during the hospital stay; and patients’ background information. To determine the outcome of inpatient falls, items with low collinearity were selected and included as covariates in a forced-entry binary logistic regression analysis.Results: Overall, 150,278 patients were included in the analysis, among whom 3,458 experienced falls. The median age of the entire cohort was 70 years, with men constituting 53.1%. Binary logistic regression analysis revealed that the prescription of lemborexant, suvorexant, and ramelteon at admission was not significantly associated with inpatient falls.Conclusion: The administration of lemborexant, suvorexant, and ramelteon at admission may not be associated with inpatient falls.Keywords: lemborexant, hypnotics, in-hospital falls, risk factor

Masaki Tago,1 Risa Hirata,1 Naoko E Katsuki,1 Eiji Nakatani,2 Midori Tokushima,1 Tomoyo Nishi,1 Hitomi Shimada,3 Shizuka Yaita,1 Chihiro Saito,4 Kaori Amari,5 Kazuya Kurogi,6 Yoshimasa Oda,7 Kiyoshi Shikino,8,9 Maiko Ono,10 Mariko Yoshimura,11 Shun Yamashita,1 Yoshinori Tokushima,1 Hidetoshi Aihara,1 Motoshi Fujiwara,1 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka, Japan; 3Shimada Hospital of Medical Corporation Chouseikai, Saga, Japan; 4Shizuoka General Hospital, Shizuoka, Japan; 5Department of Emergency Medicine, Saga-Ken Medical Centre Koseikan, Saga, Japan; 6Department of General Medicine, National Hospital Organization Ureshino Medical Center, Saga, Japan; 7Department of General Medicine, Yuai-Kai Foundation and Oda Hospital, Saga, Japan; 8Department of General Medicine, Chiba University Hospital, Chiba, Japan; 9Department of Community-Oriented Medical Education, Chiba University Graduate School of Medicine, Chiba, Japan; 10Department of General Medicine, Karatsu Municipal Hospital, Saga, Japan; 11Safety Management Section, Saga University Hospital, Saga, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jpPurpose: 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.Keywords: accidental falls, inpatients, validation study, accident prevention

Masaki Tago,1 Risa Hirata,1 Naoko E Katsuki,1 Yuki Otsuka,2 Taro Shimizu,3 Yosuke Sasaki,4 Kiyoshi Shikino,5 Takashi Watari,6 Hiromizu Takahashi,7 Kazunobu Une,8 Toshio Naito,7 Fumio Otsuka,2 Rachel Thompson,9 Susumu Tazuma8,10 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan; 3Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, Tochigi, Japan; 4Department of General Medicine and Emergency Care, Toho University School of Medicine, Tokyo, Japan; 5Department of General Medicine, Chiba University Hospital, Chiba, Japan; 6General Medicine Center, Shimane University Hospital, Izumo, Japan; 7Department of General Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan; 8Department of Critical Care and General Medicine, Onomichi General Hospital, Hiroshima, Japan; 9Executive Team, Snoqualmie Valley Hospital, Snoqualmie, WA, USA; 10JR Hiroshima Hospital, Hiroshima, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jpIntroduction: Hospitalists in Japan have been at the forefront of the COVID-19 pandemic. However, contributions of Japanese hospitalists during the COVID-19 pandemic and hospitalists’ awareness of crisis management education remain unclear.Material and Methods: We conducted a questionnaire survey to investigate the role of Japanese hospitalists during the COVID-19 pandemic. The questionnaire was conducted using email and Google Forms targeting the chairpersons of facilities certified by the Japanese Society of Hospital General Medicine (JSHGM). Members of the academic committee of the JSHGM and several hospitals conducted a narrative review and determined the questions for the survey in a discussion.Results: We conducted descriptive statistics based on the responses of 97 hospitals that agreed to participate in this survey. In total, 91.8% of general medicine departments in the included hospitals were involved in the medical care of COVID-19 patients. Furthermore, in 73.2% of hospitals, hospitalists were involved in infection control for COVID-19 inside or outside the hospital. Our survey revealed that Japanese hospitalists were responsible for COVID-19 treatment in over 60% of hospitals and contributed to hospital management, infection control, and vaccination. In total, 79.4% of hospitals answered that “training of personnel who can provide practical care for emerging infectious diseases is necessary”, 78.4% indicated that “the establishment of an infection control system in advance to prepare emerging infectious diseases in the hospital is necessary”, and 74.2% stated that “the establishment of an educational system for responding to emerging infectious diseases is necessary.”.Conclusion: In conclusion, during the pandemic, in addition to inpatient care, Japanese hospitalists provided outpatient care for COVID-19, which is the role of primary care physicians in other countries. Furthermore, Japanese hospitalists who experienced the COVID-19 pandemic expressed the need for personnel development and education to prepare for future emerging infectious disease pandemics.Keywords: COVID-19 pandemic, hospitalist, hospital management

Yoshinori Tokushima,1,2 Masaki Tago,1,2 Midori Tokushima,1,3 Shun Yamashita,1 Yuka Hirakawa,1 Hidetoshi Aihara,1 Naoko E Katsuki,1 Motoshi Fujiwara,1 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Community Medical Support Institute, Faculty of Medicine, Saga University, Saga, Japan; 3Saga Medical Career Support Center, Saga University Hospital, Saga, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81 952 34 3238, Fax +81 952 34 2029, Email tagomas@cc.saga-u.ac.jpIntroduction: 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.Keywords: general medicine, hands-on clinical clerkship, medical education, observation-based training

Risa Hirata,1 Masaki Tago,1 Naoko E Katsuki,1 Yoshimasa Oda,2 Midori Tokushima,1 Yoshinori Tokushima,1 Yuka Hirakawa,1 Shun Yamashita,1 Hidetoshi Aihara,1 Motoshi Fujiwara,1 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Department of General Medicine, Yuai-Kai Foundation and Oda Hospital, Saga, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81-952-34-3238, Fax +81-952-34-2029, Email tagomas@cc.saga-u.ac.jpIntroduction: 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.Keywords: bedridden, Bedriddenness ranks, fall, predictive model, validation, Saga fall risk model 2

Masaki Tago,1 Kiyoshi Shikino,2 Risa Hirata,1 Takashi Watari,3 Shun Yamashita,1 Yoshinori Tokushima,1 Midori Tokushima,1 Hidetoshi Aihara,1 Naoko E Katsuki,1 Motoshi Fujiwara,1 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Department of General Medicine, Chiba University Hospital, Chiba, Japan; 3General Medicine Center, Shimane University Hospital, Shimane, JapanCorrespondence: Masaki Tago, Department of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Email tagomas@cc.saga-u.ac.jpBackground: It is unclear how much effort Japanese university general medicine (GM) departments, which teach basic medical skills and have a high affinity for clinical practice, devote to medical education, particularly undergraduate education. This study aimed to clarify the contribution of GM departments of Japanese universities to medical education.Patients and Methods: This was a questionnaire-based descriptive study of GM departments of Japanese universities. We sent the questionnaire created using Google Forms by email, and the universities responded by Internet. The department chairperson of the universities’ main hospital was responsible for completing the questionnaire. It covered the number of staff, inpatients over the previous 3 years, affiliated hospitals, classroom lectures, and practical training sessions per year for each academic year in medical faculty and students accepted for clinical clerkship. Items also included the effort for clinical training, research, and education and the effort for undergraduate, initial clinical residency, and specialty program training.Results: In all, 46 of 71 universities responded, and we included 43 in our analysis. The median number of medical staff was 7; the median number of inpatients over the previous 3 years was 76. The median number of classroom lectures of the GM department was 1 for 1st-year, 5 for 3rd-year, 9 for 4th-year, and 0 for 2nd-, 5th-, and 6th-year students. The median total number of accepted students for clinical clerkship was 120. The median educational effort of the GM department was 30. With total educational effort set at 100, the median effort for undergraduate education was 45, for postgraduate residency 30, and for specialty program training 20.Conclusion: The undergraduate medical education by GM departments of Japanese universities was provided mainly in clinical settings for almost all medical students. A focus on exposing students to GM in early academic years would improve the educational environment.Keywords: clinical clerkship, general medicine, medical education, specialty program, university

Shun Yamashita, Masaki Tago, So Motomura, Satsuki Oie, Hidetoshi Aihara, Naoko E Katsuki, Shu-ichi Yamashita Department of General Medicine, Saga University Hospital, Saga, JapanCorrespondence: Shun YamashitaDepartment of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, JapanTel +81952343238Fax +81952342029Email sy.hospitalist.japan@gmail.comPurpose: Infective endocarditis (IE) may be diagnosed as fever of unknown origin due to its delusively non-descriptive clinical features, especially in outpatient clinics. Our objective is to develop a prediction model to discriminate patients to be diagnosed as “definite” IE from “non-definite” by modified Duke criteria among patients with undiagnosed fever, using only history and results of physical examinations and common laboratory examinations.Patients and Methods: The study was a single-center case–control study. Inpatients at Saga University Hospital diagnosed with IE from 2007 to 2017 and patients with undiagnosed fever from 2015 to 2017 were enrolled. Patients diagnosed with definite IE according to the modified Duke criteria, except those definitely diagnosed with other disorders responsible for fever, were allocated to the IE group. Patients without IE among those defined as non-definite according to the modified Duke criteria were allocated to the undiagnosed fever group. We developed a prediction model to pick up patients who would be “definite” by modified Duke criteria, which was subsequently assessed by area under the curve (AUC).Results: A total of 144 adult patients were included. Of these, 59 patients comprised the IE group. We developed the prediction model using five indicators, including transfer by ambulance, cardiac murmur, pleural effusion, neutrophil count, and platelet count, with a sensitivity 84.7%, a specificity 84.7%, an AUC 0.893 (95% confidence interval 0.828– 0.959), a shrinkage coefficient 0.635, and a stratum-specific likelihood ratio 0.2– 50.4.Conclusion: Our prediction model, which uses only indicators easy to gain, facilitates prediction of patients with IE. These indicators can be acquired even at common hospitals and clinics, without requiring advanced medical equipment or invasive examinations.Trial Registration Number: UMIN000041344.Keywords: infective endocarditis, undiagnosed fever, case–control study, prediction model, area under the curve

Takashi Watari,1,2,* Masaki Tago,3,* Kiyoshi Shikino,4 Shun Yamashita,3 Naoko E Katsuki,3 Motoshi Fujiwara,3 Shu-ichi Yamashita3 1General Medicine Center, Shimane University Hospital, Shimane, Japan; 2Master of Healthcare Quality and Patient Safety, Harvard Medical School, Boston, MA, USA; 3Department of General Medicine, Saga University Hospital, Saga, Japan; 4Department of General Medicine, Chiba University Hospital, Chiba, Japan*These authors contributed equally to this workCorrespondence: Masaki TagoDepartment of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga, 849-8501, JapanTel +81 952 34 3238Fax +81 952 34 2029Email tagomas@cc.saga-u.ac.jpPurpose: The training of generalist physicians in university hospitals needs to emphasize development of their research role in order to continue improving their research capacity and their standing in academic hospitals in Japan. This cross-sectional descriptive study aimed to survey departments of general medicine (GM) in university hospitals in Japan to identify the research areas and themes pursued by academic generalist physicians.Patients and Methods: The heads of the departments of GM from 71 university hospitals in Japan were enrolled. The main outcomes studied were the identification of the main research areas and themes in academic departments of GM, based on the classification of the National Grants-in-Aid for Scientific Research (KAKENHI): clinical research, public health, preventive medicine, medical education, basic science, health services and safety and quality.Results: We received 47 of 71 replies (66.2% response rate). Clinical research was the most common area of research (62%), followed by public health and preventive medicine (14%), medical education (11%), and basic sciences (9%). Only one department identified health services and safety and quality as a research area (2%). There was marked variability in research areas across the different departments, with 23% of the research targeting the highest specialties, particularly organ-specific research in the fields of gastroenterology, cardiology, immunology, neurology, metabolic endocrinology, and hematology-oncology.Conclusion: The training of generalist physicians in university hospitals needs to emphasize development of their research role in order to continue improving the research capacity and the standing generalist physicians in academic hospitals in Japan.Keywords: general medicine, research, academic activity

Yoshinori Tokushima,1,* Masaki Tago,1,* Midori Tokushima,1 Naoko E Katsuki,1 Shinji Iwane,2 Yuichiro Eguchi,3 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Fujioka Hospital, Saga, Japan; 3Eguchi Hospital, Saga, Japan*These authors contributed equally to this workCorrespondence: Masaki TagoDepartment of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga 849-8501, JapanTel +81 952 34 3238Fax +81 952 34 2029Email tagomas@cc.saga-u.ac.jpObjective: To investigate effects of an altered medical environment between 2010 and 2015 on viral hepatitis treatment behaviors of doctors who were not hepatology specialists.Methods: Charts of patients who were identified as hepatitis B surface antigen (HBs-Ag)-positive or hepatitis C virus antibody (HCV-Ab)-positive by university hospital departments not specializing in hepatology from January to December 2015 were retrospectively reviewed. Patients were assigned to a “referred” group or a “non-referred” group based on whether they were subsequently referred to the Hepatology Department. Age, sex, type of department visited (one of various internal medicine departments, or a different department), and blood test results were compared in the two groups.Results: Among 7,824 patients screened for HBs-Ag, 82 were positive. Twenty-nine (35.4%) had subsequently been referred to the Hepatology Department, which was higher than the 2010 referral rate (20.6%). In multivariate analysis, patients in the referred group were significantly more likely to have visited one of various internal medicine departments, and they had higher levels of platelet count and γ-glutamyl transpeptidase. Among 7,778 patients screened for HCV-Ab, 279 were positive. Only 33 (11.8%) had subsequently been referred to the Hepatology Department, which was lower than the 2010 referral rate (18.7%). In multivariate analysis, patients in the referred group were significantly more likely to have visited an internal medicine department.Conclusion: HCV-antibody-positive patients screened by departments not specializing in hepatology were not managed adequately in 2015. This suggests a need for education of doctors not specializing in hepatology, particularly those not working in internal medicine departments.Keywords: hepatitis B virus, hepatitis C virus, hepatitis B, hepatitis C, referral, department

Shun Yamashita,1 Masaki Tago,1 Midori Tokushima,1 Tomotaro Nakashima,1 Naoko E Katsuki,1 Keizo Anzai,2 Shu-ichi Yamashita1 1Department of General Medicine, Saga University Hospital, Saga, Japan; 2Division of Metabolism and Endocrinology, Faculty of Medicine, Saga University, Saga, JapanCorrespondence: Masaki TagoDepartment of General Medicine, Saga University Hospital, 5-1-1 Nabeshima, Saga 849-8501, JapanTel +81952343238Fax +81952342029Email tagomas@cc.saga-u.ac.jpBackground: Our hospital’s department of general medicine is often involved in the diagnosis and treatment of diseases that are considered by other hospitals or other departments in our hospital to be difficult to diagnose correctly.Objective: The aim of this study was to clarify how patients with infective endocarditis (IE) being admitted to our hospital’s department of general medicine were examined and treated and to elucidate their prognosis compared with patients admitted to other departments.Materials and Methods: Inpatients of Saga University Hospital with definite IE from September 2007 to August 2017 were divided into 2 groups: those admitted to the general medicine department (the GM group) and those admitted to other departments (the non-GM group).Results: Seventy-four patients were included; 17 (23%) were admitted to the general medicine department. In the GM group, the percentage of patients diagnosed with definite or suspected IE was lower (0% vs 32%, p=0.008), as was the rate of patients with echocardiographic findings that fulfilled the major modified Duke’s criteria (71% vs 98%, p≤ 0.001), preadmission. The GM group had higher percentages of patients with back or joint pain (41% vs 9%, p=0.001) and complications, including pyogenic spondylitis (35% vs 2%, p≤ 0.001), deep-seated abscesses (24% vs 5%, p=0.024), pyogenic arthritis (18% vs 0%, p=0.001), and glomerulonephritis (77% vs 37%, p=0.004) than did the non-GM group. Mortality within 30 days of admission to our hospital (12% vs 14%, p=0.753) and overall in-hospital mortality (12% vs 18%, p=0.570) did not significantly differ.Conclusion: The general medicine department could have accurately diagnosed IE, given appropriate treatments, and obtained similar prognoses to those of IE patients treated by other departments, including cardiology and cardiovascular surgery, even in patients for whom diagnosing IE was more difficult or who had less typical echocardiographic findings preadmission.Keywords: infective endocarditis, echocardiographic findings of infective endocarditis, general medicine, cardiology, cardiovascular surgery

Tokushima Y, Tago M, Tokushima M, et al. Int J Gen Med. 2020;13:743—750. The authors have advised there are errors in Table 1 on page 746 in the Hbs-Ag positive patients’ data. The errors were introduced during the creation of the Table. The correct Table 1 is shown below: The errors were only in the patients’ background and do not affect the main results (consultation rate, comparison of RF and non-RF groups), discussion, or conclusion of the paper. The authors apologize for these errors. Read the original article

Introduction: The cognitive function score (CFS) is a public scale for assessing the activities of daily living (ADL) in older adults with dementia in Japan. In contrast, the scores of the revised Hasegawa's dementia scale (HDS-R), an easy-to-use dementia screening tool developed in Japan, are significantly correlated with mini-mental state examination scores and are widely utilized in various countries. This novel study aimed to elucidate the previously unexplored criterion-related validity of the CFS and HDS-R and the Bedriddenness Rank (BR), Barthel index (BI), and Katz index (KI)., Methods: This was a multicenter retrospective study and a secondary analysis of our previous study. The study included patients aged ≥20 years hospitalized in chronic care settings between April 1, 2018, and March 31, 2021. We collected data from medical charts on admission, including age, sex, the BR, CFS, BI, KI, and HDS-R scores. Correlations between the CFS and HDS-R score, as well as between the BR and BI or KI, were analyzed using Spearman's rank correlation coefficients., Results: A total of 749 participants were included in the analysis of criterion-related validity between the CFS and HDS-R. In the CFS cohort analysis, 202 patients (27.0%) were categorized as having a normal CFS, and the median HDS-R score was 18 (range: 6-26). The correlation coefficient between the CFS and HDS-R scores was -0.834 ( p < 0.001). The correlation coefficient between BR and BI was -0.741 ( p < 0.001), BR and KI was -0.740 ( p < 0.001)., Conclusion: The CFS revealed significant criterion-related validity compared with the established cognitive assessment scale, the HDS-R. The BR also demonstrated significant criterion-related validity with the BI and KI., Competing Interests: Masaki Tago is supported by grants from the Japan Society for the Promotion of Science, JSPS KAKENHI (Grant No. JP21H03166)., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Background: Predicting fall injuries can mitigate the sequelae of falls and potentially utilize medical resources effectively. This study aimed to externally validate the accuracy of the Saga Fall Injury Risk Model (SFIRM), consisting of six factors including age, sex, emergency transport, medical referral letter, Bedriddenness Rank, and history of falls, assessed upon admission. Methods: This was a two-center, prospective, observational study. We included inpatients aged 20 years or older in two hospitals, an acute and a chronic care hospital, from October 2018 to September 2019. The predictive performance of the model was evaluated by calculating the area under the curve (AUC), 95% confidence interval (CI), and shrinkage coefficient of the entire study population. The minimum sample size of this study was 2,235 cases. Results: A total of 3,549 patients, with a median age of 78 years, were included in the analysis, and men accounted for 47.9% of all the patients. Among these, 35 (0.99%) had fall injuries. The performance of the SFIRM, as measured by the AUC, was 0.721 (95% CI: 0.662-0.781). The observed fall incidence closely aligned with the predicted incidence calculated using the SFIRM, with a shrinkage coefficient of 0.867. Conclusions: The external validation of the SFIRM in this two-center, prospective study showed good discrimination and calibration. This model can be easily applied upon admission and is valuable for fall injury prediction., Competing Interests: Competing Interests: Masaki Tago is supported by grants from the Japan Society for the Promotion of Science, JSPS KAKENHI (Grant Number JP18K17322 and JP21H03166). Naoko E. Katsuki is supported by grants from the Japan Society for the Promotion of Science, JSPS KAKENHI (Grant Number JP23K16257). The sponsor of the study had no role in the preparation of the manuscript., (© The author(s).)

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.

Introduction: The danger of diagnostic errors exists in daily medical practice, and doctors are required to avoid such errors as much as possible. Although various factors, including cognitive, system-related, and patient-related factors, are involved in the occurrence of diagnostic errors, the percentage of doctors with insufficient medical knowledge among those factors is extremely low. Therefore, lectures on diagnostic errors might also be useful for medical students without experience working as doctors. This study investigated whether a 60-minute lecture on diagnostic errors would enable Japanese medical students to consider the factors involved in diagnostic errors and how their perceptions of diagnostic errors change., Methods and Materials: This single-center interventional study was conducted in October 2022 among fourth-year medical students at the Faculty of Medicine, Saga University. A questionnaire survey was conducted before and immediately after the lecture to investigate changes in the perceptions of medical students regarding diagnostic errors. One mock case question was given on an exam the day after the lecture, and the number of responses to cognitive biases and system-related and patient-related factors involved in diagnostic errors were calculated., Results: A total of 83 students were analyzed. After the lecture, medical students were significantly more aware of the existence of the concept of diagnostic error, the importance of learning about it, their willingness to continue learning about it, and their perception that learning about diagnostic errors improves their clinical skills. They were also significantly less likely to feel blame or shame over diagnostic errors. The mean numbers of responses per student for cognitive bias, system-related factors, and patient-related factors were 1.9, 3.4, and 0.9, respectively. The mean number of responses per student for all factors was 5.6., Conclusion: A 60-minute lecture on diagnostic errors among medical students is beneficial because it significantly changes their perception of diagnostic errors. The results of the present study also suggest that lectures may enable Japanese medical students to consider the factors involved in diagnostic errors., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Yamashita et al.)

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.

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., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2023, Tago et al.)

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.

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.

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 &lt; 0.001) and -0.877 (p &lt; 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 &lt; 0.001) and -0.862 (p &lt; 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., Competing Interests: "The authors have declared that no competing interests exist", (Copyright: © 2022 Tago et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Several reliable predictive models for falls have been reported, but are too complicated and time-consuming to evaluate. We recently developed a new predictive model using just eight easily-available parameters including the official Japanese activities of daily living scale, Bedriddenness ranks, from the Ministry of Health, Labour and Welfare. This model has not yet been prospectively validated. This study aims to prospectively validate our new predictive model for falls among inpatients admitted to two different hospitals., Methods: A double-centered prospective cohort study was performed from October 1, 2018, to September 30, 2019 in an acute care hospital and a chronic care hospital. We analyzed data from all adult inpatients, for whom all data required by the predictive model were evaluated and recorded. The eight items required by the predictive model were age, gender, emergency admission, department of admission, use of hypnotic medications, previous falls, independence of eating, and Bedriddenness ranks. The main outcome is in-hospital falls among adult inpatients, and the model was assessed by area under the curve., Results: A total of 3,551 adult participants were available, who experienced 125 falls (3.5%). The median age (interquartile range) was 78 (66-87) years, 1,701 (47.9%) were men, and the incidence of falls was 2.25 per 1,000 patient-days and 2.06 per 1,000 occupied bed days. The area under the curve of the model was 0.793 (95% confidence interval: 0.761-0.825). The cutoff value was set as - 2.18, making the specificity 90% with the positive predictive value and negative predictive value at 11.4% and 97%., Conclusions: This double-centered prospective cohort external validation study showed that the new predictive model had excellent validity for falls among inpatients. This reliable and easy-to-use model is therefore recommended for prediction of falls among inpatients, to improve preventive interventions., Trial Registration: UMIN000040103 (2020/04/08)., (© 2022. The Author(s).)

A cross-sectional questionnaire-based study was conducted to examine whether the educational performance and achievements are appropriately recognized and contribute to their promotion in university hospitals. We found that the chairpersons of those general medicine departments believed that educational performance had not been appropriately evaluated; educational achievements did not receive sufficient consideration for promotion compared with the performance and achievements related to clinical and research activities., Competing Interests: The authors have stated explicitly that there are no conflicts of interest in connection with this article., (© 2022 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.)

Background: Few studies have focused on research practice in Japanese university general medicine (GM) departments., Methods: This is a questionnaire-based cross-sectional study to clarify the research achievement and associated factors of Japanese university GM department. Univariate analysis was performed to compare the number of English-language research publications and explanatory variables., Results: Forty-seven universities responded. Over a 3 years period, the median number of English-language research publications was 6. Perceived degree of research necessity, staff numbers, collaborative research, conference presentations, and obtaining research grants were significantly associated with a higher number of English-language research publications., Conclusions: While GM research output was found to be limited, numerous associated factors can potentially change Japanese GM departments' research environments., Competing Interests: The authors have stated explicitly that there are no conflicts of interest in connection with this article., (© 2021 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.)

We herein report three cases of group A Streptococcus (GAS) infection in a family. Patient 1, a 50-year-old woman, was transferred to our hospital in shock with acute respiratory distress syndrome, swelling in the right neck and erythemata on both lower extremities. She required intubation because of laryngeal oedema. At the same time, patient 2, a 48-year-old man, was admitted because of septic shock, pneumonia and a pulmonary abscess. Five days later, patient 3, a 91-year-old woman, visited our clinic with bloody stool. All three patients were cured by antibiotics, and GAS was detected by specimen cultures. During these patients' clinical course, an 84-year-old woman was found dead at home after having been diagnosed with type A influenza. All four patients lived in the same apartment. The GAS genotypes detected in the first three patients were identical. When treating patients with GAS, appropriate management of close contacts is mandatory., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

BACKGROUND The portal vein thrombosis caused by a carcinoma of the pancreas or liver could be a diagnostic challenge. There are some cases which could be diagnosed only by observing changes in patients' clinical manifestations or imaging studies over time. CASE REPORT A 63-year-old man experienced exacerbation of chronic low back pain for 1 month, with abdominal distention. He was admitted to our hospital because abdominal ultrasonography and abdominal contrast-enhanced computed tomography performed at another hospital revealed an extensive thrombus in the portal, splenic, and superior mesenteric veins. Anticoagulation therapy with warfarin was started immediately on admission. Although no baseline disease, such as malignancies, coagulopathies, infections, or collagen diseases were revealed during the 12 days of his hospitalization, the thrombus gradually expanded, with the appearance of obstructive jaundice 8 months after admission. He was readmitted at that time for biopsy of intrahepatic tumors detected by abdominal computed tomography, which diagnosed metastasis of a carcinoma of unknown origin. Although chemotherapy was started, he died 11 months after his initial admission to our hospital. Autopsy revealed a tumorous lesion in the pancreatic head with almost complete replacement of the portal venous thrombus with a similar-appearing tumor. We confirmed the diagnosis of portal venous metastatic infiltration by undifferentiated pancreatic carcinoma, using histopathological examinations. CONCLUSIONS It is essential to consider portal venous metastatic infiltration of undiagnosed malignancy inducing local hypercoagulopathy as a possible cause of expansive portal venous thrombosis.

A 75-year-old woman developed redness and swelling on her truncal skin, spreading from the lower abdomen to left thigh, 2 months before being admitted to our hospital. She was urgently hospitalised because of her worsening respiratory condition. On admission, she had reticular telangiectasia, diffuse skin induration on the lower abdomen and panhypopituitarism. She was diagnosed with intravascular large B-cell lymphoma (IVLBCL) by the third random abdominal skin biopsy. After histopathological examination at autopsy, we made a final diagnosis of IVLBCL causing respiratory failure and panhypopituitarism. This is the rare case of IVLBCL-induced panhypopituitarism showing visible skin lesions., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The statistical validities of the official Japanese classifications of activities of daily living (ADLs), including bedriddenness ranks (BR) and cognitive function scores (CFS), have yet to be assessed. To this aim, we evaluated the ability of BR and CFS to assess ADLs using inter-rater reliability and criterion-related validity., Methods: New inpatients aged ≥75 years were enrolled in this hospital-based prospective observational study. BR and CFS were assessed once by an attending nurse, and then by a social worker/medical clerk. We evaluated inter-rater reliability between different professions by calculating the concordance rate, kappa coefficient, Cronbach's α, and intraclass correlation coefficient. We also estimated the relationship of the Barthel Index and Katz Index with the BR and CFS using Spearman's correlation coefficients., Results: For the 271 patients enrolled, BR at the first assessment revealed 66 normal, 10 of J1, 15 of J2, 18 of A1, 31 of A2, 37 of B1, 35 of B2, 22 of C1, and 32 of C2. The concordance rate between the two BR assessments was 68.6%, with a kappa coefficient of 0.61, Cronbach's α of 0.91, and an intraclass correlation coefficient of 0.83, thus showing good inter-rater reliability. BR was negatively correlated with the Barthel Index (r = - 0.848, p < 0.001) and Katz Index (r = - 0.820, p < 0.001), showing justifiable criterion-related validity. Meanwhile, CFS at the first assessment revealed 92 normal, 47 of 1, 19 of 2a, 30 of 2b, 60 of 3a, 8 of 3b, 8 of 4, and 0 of M. The concordance rate between the two CFS assessments was 70.1%, with a kappa coefficient of 0.62, Cronbach's α of 0.87, and an intraclass correlation coefficient 0.78, thus also showing good inter-rater reliability. CFS was negatively correlated with the Barthel Index (r = - 0.667, p < 0.001) and Katz Index (r = - 0.661, p < 0.001), showing justifiable criterion-related validity., Conclusions: BR and CFS could be reliable and easy-to-use grading scales of ADLs in acute clinical practice or large-scale screening, with high inter-rater reliabilities among different professions and significant correlations with well-established, though complicated to use, instruments to assess ADLs., Trial Registration: UMIN000041051 (2020/7/10).

An 81-year-old woman who underwent percutaneous endoscopic gastrostomy (PEG) a year before, after cerebral infarction was receiving home medical care. The first accidental PEG tube removal occurred after clinic hours, and the home-care doctor visited her home to quickly reinsert the tube. After the narrowed fistula was dilated, the tube was reinserted with a guide wire. An X-ray taken with a CALNEO Xair, which is an easily portable X-ray system launched in 2018, confirmed that the tip of the PEG tube was successfully placed in the stomach. A similar accidental removal occurred 2 months later, and we managed it in the same way. Both events were resolved with a single radiograph without significant difficulty. With in-home medical care, PEG tube replacement can be performed easily and safely with a handy portable X-ray system., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: Most predictive models for falls developed previously were awkward to use because of their complexity. We developed and validated a new easier-to-use predictive model for falls of adult inpatients using easily accessible information including the public ADL scale in Japan., Methods: We retrospectively analyzed data from Japanese adult inpatients in an acute care hospital from 2012 to 2015. Two-thirds of cases were randomly extracted to the test set and one-third to the validation set. Data including age, sex, activity of daily living (ADL), public scales in Japan of ADL "bedriddenness rank," and cognitive function in daily living, hypnotic medications, previous falls, and emergency admission were derived from hospital records. Falls during hospitalization were identified from incident reports. Two predictive models were created by multivariate analysis, each of which was assessed by area under the curve (AUC) from the validation set., Results: A total of 7,858 adult participants were available. The AUC of model 1, using 13 factors-age, sex (male), emergency admission, use of ambulance, referral letter, admission to Neurosurgery, admission to Internal Medicine, use of hypnotic medication, permanent damage by stroke, history of falls, visual impairment, independence of eating, and bedriddenness rank-with low mutual collinearity and showing significant relationship by multivariate logistic regression analysis, was 0.789 in the validation set. The AUC of parsimonious model 2, using age and seven factors-sex (male), emergency admission, admission to Neurosurgery, use of hypnotic medication, history of falls, independence of eating, and bedriddenness rank-showing statistical significance by multivariate analysis in model 1, was 0.787 in the validation set., Conclusions: We proposed new predictive models for inpatients' fall using the public ADL scales in Japan, which had a higher degree of usability because of their use of simpler and fewer (8 or 13) predictors, especially parsimonious model 2., Competing Interests: The authors declare that no competing interests exist.

Objectives: Abdominal pain is one of the most frequent chief complaints in primary care settings. The aim of the present study was to determine the positive likelihood ratios (PLRs) and negative likelihood ratios (NLRs) of the relationships between the sites of abdominal pain and the organs involved., Design: Prospective observational study., Setting: A single tertiary centre, a university hospital in Japan., Participants: A total of 2591 new outpatients visited the Department of General Medicine at a university hospital from April 2017 to March 2018. Of these, 326 patients aged ≥20 years with abdominal pain were enrolled., Results: Sites of abdominal pain were classified into 11 categories including nine different abdominal sections, 'generalised abdomen' and 'site-indeterminate'. The PLRs between 'right subcostal' and 'liver and biliary tract'; between 'right subcostal' and 'musculoskeletal' ; between 'epigastric' and 'oesophagus, stomach and duodenum'; between 'right or left flank' and 'urinary tract'; between 'left flank' and 'dermatological'; and between 'mid-lower' and 'intestinal' ranged from 2.17 to 4.14. The PLRs between 'epigastric' and 'urinary tract'; between 'mid-lower' and 'liver and biliary tract'; between 'periumbilical' and 'urinary tract'; and between 'generalised abdomen' and 'oesophagus, stomach and duodenum' were low, ranging from 0.17 to 0.25. The NLR ranged from 0.5 to 1.5, excluding the relationship between 'left flank' and 'dermatological'., Conclusion: The presence of pain at right subcostal, epigastric, right or left flank and mid-lower sites might be useful for identifying the organs involved. Additionally, the presence of pain at mid-lower, epigastric, periumbilical and generalised abdominal sites might be helpful for denying the involvement of some organs. Some sites of abdominal pain can be indicative of the organs involved. Trial registration number UMIN000037686., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Clinicians should be alert to traumatic fourth nerve palsy in patients with double vision after head injury. In most cases with traumatic fourth nerve palsy, the imaging tests fail to show abnormal findings. In the cases of bilateral superior oblique paresis, the sensitivity of Bielschowsky head-tilt test is 40%., Competing Interests: The authors have stated explicitly that there are no conflicts of interest in connection with this article., (© 2020 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.)

Competing Interests: Competing interests: None declared.

BACKGROUND Proliferative fasciitis/myositis is a benign disease that can be treated conservatively. However, some patients are mistakenly treated surgically because of a misdiagnosis of the condition as a malignant tumor. CASE REPORT A 50-year-old Japanese man developed swelling in his left cheek 12 days before admission; he developed a fever and trismus 3 days later. He was admitted to our hospital because of worsening of his condition despite treatment with sitafloxacin for 5 days and needle-aspiration drainage. On admission, he had a fever of 38.1°C, swelling in his left cheek spreading to the lower jaw, and several dental caries. Although ceftriaxone and clindamycin were administered for 7 days because an odontogenic infection was suspected, his condition did not improve. T2-weighted magnetic resonance imaging of the facial muscles on Day 5 of hospitalization showed swelling and high-intensity signals in the left masseter, temporalis, and pterygoid muscles. Macroscopic findings from a biopsy of the left temporalis muscle performed on Day 17 showed white and thickened fascia. Histopathological examination revealed fibrous hyperplasia of the fascia, increased fibrous connective tissue between muscle fibers, and infiltration of inflammatory cells, providing not a definite but a compatible diagnosis of proliferative fasciitis/myositis. Beginning on Day 18, the patient's fever lessened with gradual improvement of his facial swelling and trismus. CONCLUSIONS It is imperative to include proliferative fasciitis/myositis as a possible diagnosis when patients present with facial swelling and trismus of unknown cause.

A 64-year-old Japanese woman developed fatigue, dyspnea, and wheezing in July. Although she had been undergoing treatment for chronic obstructive pulmonary disease for six days, she was transferred to our hospital with delirium and diarrhea. On admission, she had an eschar of 3 mm in diameter on her anterior chest. Polymerase chain reaction of her blood and eschar specimens led to the diagnosis of severe fever with thrombocytopenia syndrome. Chest computed tomography showed ground-glass opacities, suggesting noncardiogenic pulmonary edema or viral pneumonia. This is the first case report of severe fever with thrombocytopenia syndrome beginning with dyspnea and wheezing.

Competing Interests: Competing interests: None declared.

BACKGROUND Intravascular large B-cell lymphoma (IVLBCL) is characteristically diagnosed by histological examination of biopsies of bone marrow or randomly harvested skin specimens in the absence of any diagnostic abnormalities on imaging studies, including computed tomography (CT). In particular, diagnosis of IVLBCL with pulmonary manifestations is challenging, because even in patients with severe respiratory failure, there are rarely abnormalities on standard imaging studies. CASE REPORT A 75-year-old female presented with fatigue, weight loss, and high fever with chills for 3 months. Blood examinations on her initial visit to her primary physician showed high concentrations of C-reactive protein, lactate dehydrogenase, and soluble interleukin-2 receptor. There were no abnormalities on imaging studies. She was subsequently admitted to our hospital because of development of dyspnea over time (4 months after symptom onset). Although she was suspected of having IVLBCL, repeated biopsies from bone marrow, skin, liver, and lung did not result in a diagnosis. Finally, a lung biopsy obtained by video-associated thoracic surgery (VATS) from the right lung base, where fluorine-18 fluorodeoxyglucose positron emission tomography had shown high uptake, resulted in a definite diagnosis of IVLBCL. CONCLUSIONS Highly invasive procedures such as thoracoscopic lung resection may be required to diagnose IVLBCL with pulmonary manifestations which can cause severe respiratory failure in the absence of any abnormalities on standard imaging studies.

When patients develop destructive osteomyelitis, clinicians must always consider the possibility of SAPHO syndrome because even extremely destructive osteomyelitis can be cured by NSAIDs., Competing Interests: The authors state that they have no conflict of interest.

Competing Interests: Competing interests: None declared.

BACKGROUND Infective endocarditis is prevalent worldwide and the modified Duke criteria have been used universally to diagnose this condition. However, making the correct diagnosis is rather difficult because the clinical presentation and findings of blood tests are non-specific. CASE REPORT A 70-year-old female complaining of dyspnea for 5 days with acute mitral regurgitation was transferred to our hospital. She had acute heart and respiratory failure and disseminated intravascular coagulation. Although infective endocarditis was suspected, repeated blood cultures and transesophageal echocardiography could not reveal any findings of infective endocarditis. Because the etiology of her condition was not determined by various examinations, mitral annuloplasty was required to treat her mitral regurgitation, and was performed for definitive diagnosis and treatment revealing the presence of vegetation on the mitral valve. Enterococcus faecalis was detected by cultures of the mitral valve and blood after the surgery. CONCLUSIONS It can be very difficult to diagnose infective endocarditis correctly, especially when a case fails to fulfill the modified Duke criteria. In such a case, only cardiac surgery might enable us to make an accurate diagnosis and save a patient's life.

BACKGROUND Although diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma in adults, isolated cardiac recurrence of DLBCL which can cause fatal heart failure via various mechanisms is extremely rare. Furthermore, the frequency of recurrence of DLBCL more than 5 years after attaining complete remission is as low as 3.6%. The rate of complete remission and partial remission of DLBCL that have recurred 5 or more years after attaining the initial remission are reported to be 61% and 29%, respectively. CASE REPORT A 79-year-old female with a history of DLBCL at the age of 63 years was transferred to our hospital because of cardiogenic shock. Although cardiac tamponade was suspected, her hemodynamics did not improve with pericardiocentesis. Thoracotomy showed an elastic to hard tumor occupying most of the right ventricular wall. Cytological examination of the pericardial effusion and histological examination of a biopsy of the tumor yielded a diagnosis of DLBCL; this information was available only post mortem. Immunostaining of a biopsy specimen suggested that her cardiac tumor was a recurrence of her lymphoma diagnosed 16 years previously. Bone marrow aspiration was not performed; no recurrences were detected in any other site. This patient thus appeared to have an isolated cardiac recurrence of DLBCL. CONCLUSIONS When managing a patient with a cardiac tumor and a past history of DLBCL, albeit more than a decade previously, establishing a histological diagnosis as early as possible would facilitate possible successful treatment and a good prognosis.