Evaluation of the usefulness of costovertebral angle tenderness in patients with suspected ureteral stone.

Background: The usefulness of costovertebral angle (CVA) tenderness for the diagnosis of a suspected ureteral stone remains controversial. Methods: This single-center, retrospective, observational study included patients aged 16-64 years with acute-onset unilateral lower back pain or abdominal pain. The diagnostic accuracy of CVA tenderness was investigated. Results: In total, 132 patients met the criteria; 80 were diagnosed with ureteral stones. The sensitivity and specificity of CVA tenderness were 0.65 and 0.50, respectively; positive and negative likelihood ratios were 1.3 and 0.7, respectively. Conclusions: CVA tenderness cannot be used as a single diagnostic indicator to confirm or exclude ureteral stone diagnosis.

Factors associated with delayed diagnosis of appendicitis in adults: A single-center, retrospective, observational study.

Appendicitis is one of the most common causes of acute abdominal pain; yet the risk of delayed diagnosis remains despite recent advances in abdominal imaging. Understanding the factors associated with delayed diagnosis can lower the risk of diagnostic errors for acute appendicitis. These factors, including physicians' specialty as a generalist or non-generalist, were evaluated through a retrospective, observational study of adult acute appendicitis cases at a single center, between April 1, 2014, and March 31, 2021. The main outcome was timely diagnosis, defined as "diagnosis at the first visit if the facility had computed tomography (CT) capability" or "referral to an appropriate medical institution promptly after the first visit for a facility without CT capability," with all other cases defined as delayed diagnosis. The frequency of delayed diagnosis was calculated and associated factors evaluated through multivariate and exploratory analyses. The overall rate of delayed diagnosis was 26.2% (200/763 cases). Multivariate analysis showed that tenderness in the right lower abdominal region, absence of diarrhea, a consultation of ≤6 h after symptom onset, and consultation with a generalist were associated with a decreased risk of delayed diagnosis of acute appendicitis. Exploratory analysis found that generalists performed more physical findings related to acute appendicitis, suggesting that this diagnostic approach may be associated with timely diagnosis. Future studies should adjust for other potential confounding factors, including patient complexity, consultation environment, number of physicians, diagnostic modality, and physician specialties.

Relationship Between the Use of Preprinted Physician Orders for Hospital-Acquired Fever and Time to Blood Culture Collection: A Single-Center Retrospective Cross-Sectional Study.

Purpose: Fever is relatively common in patients admitted to general wards. There is no standardized approach, and little is known about how physicians respond to fever. Additionally, preprinted physician orders are routinely used clinically in hospital medicine, and it is not clear how preprinted physician orders for fever affect the care of patients with fever. Therefore, we aimed to determine whether preprinted physician orders for inpatients have an effect on the time from fever measurement to blood culture collection. Patients and Methods: This was a single-center, retrospective, cross-sectional study of patients with bacteremia. Between January 1, 2015 and December 31, 2019, 137 hospitalized febrile patients diagnosed with bacteremia by blood culture prepared from blood collected 72 h after hospitalization were included. Results: Preprinted physician orders with instructions to call the physician if the patient has a fever were present for 59 patients. For preprinted physician orders with instructions to notify the physician about fever onset, 62.7% of the blood cultures were collected within 1 h of fever observation; when preprinted orders were not used, only 23.1% met the 1-h collection criterion. Multivariate analysis showed that preprinted physician orders were significantly associated with blood culture collection within 1 h from the reporting of fever (odds ratio, 4.94; 95% confidence interval, 2.27-10.70). Conclusion: Preprinted physician orders with instructions to notify the physician about fever onset were present for only 40% of our sample, and this was related to the time of blood culture collection.

Single-center observation of direct impact of the Tokyo 2020 Games on ambulance emergency response.

The burden of the 2020 Tokyo Olympic and Paralympic Games on the local emergency medical system was limited. In addition to the Games were held without spectators, this was due to advance preparation by various organizations and the efforts of local staff, including primary care physicians.

Misdiagnosis Due to False-Positive Detection of Pneumococcal Urinary Antigen.

Introduction: The detection of pneumococcal antigens in urine is an alternative to gram staining, and their culture is central to the diagnosis of pneumococcal pneumonia. We present a case of the false-positive detection of urinary Streptococcus species pneumococcal antigen with a BinaxNOW test. This resulted in delayed diagnosis of a liver abscess. Case description: A 70-year-old woman presented to the emergency department with a 1-day history of chills and difficulty walking. She had a fever and her physical examination was normal. Non-contrast chest computed tomography (CT) revealed a slight ground-glass opacity in the left lower lobe. Laboratory tests revealed liver injury and elevated C-reactive protein levels. A urinary pneumococcal antigen test was positive, and she was diagnosed with acute bronchopneumonia caused by Streptococcus pneumoniae. She was treated with ceftriaxone. However, abdominal contrast-enhanced CT performed the next day revealed portal vein thrombus and a left lobe liver abscess. Streptococcus constellatus was detected in a puncture specimen of the liver abscess. It was concluded that the positive urinary pneumococcal antigen test was a false-positive owing to Streptococcus infection. Discussion: False-positive results might be explained by the presence of C-polysaccharide antigens in the cell wall of S. pneumoniae. The positive urinary antigen test together with the finding of slight ground-glass opacity in the left lung on chest CT initially led to misdiagnosis. False positives may result in misdiagnosis and unnecessary antimicrobial therapy. Conclusion: The overuse of the pneumococcal urinary antigen tests can lead to false positives and misdiagnosis. LEARNING POINTS: False-positive pneumococcal urinary antigen results may lead to the misdiagnosis of pneumococcal pneumonia caused by Streptococcus pneumoniae and unnecessary antimicrobial therapy.False-positive results can occur in patients with infections caused by other Streptococcus species (e.g., liver abscess caused by Streptococcus constellatus).The optimal use of pneumococcal urinary antigen tests needs to be studied in clinical practice settings.

Diagnostic error rates and associated factors for lower gastrointestinal perforation.

Lower gastrointestinal perforation is rare and challenging to diagnose in patients presenting with an acute abdomen. However, no study has examined the frequency and associated factors of diagnostic errors related to lower gastrointestinal perforation. This large-scale multicenter retrospective study investigated the frequency of diagnostic errors and identified the associated factors. Factors at the level of the patient, symptoms, situation, and physician were included in the analysis. Data were collected from nine institutions, between January 1, 2015 and December 31, 2019. Timely diagnosis was defined as diagnosis at the first visit in computed tomography (CT)-capable facilities or referral to an appropriate medical institution immediately following the first visit to a non-CT-capable facility. Cases not meeting this definition were defined as diagnostic errors that resulted in delayed diagnosis. Of the 439 cases of lower gastrointestinal perforation identified, delayed diagnosis occurred in 138 cases (31.4%). Multivariate logistic regression analysis revealed a significant association between examination by a non-generalist and delayed diagnosis. Other factors showing a tendency with delayed diagnosis included presence of fever, absence of abdominal tenderness, and unavailability of urgent radiology reports. Initial misdiagnoses were mainly gastroenteritis, constipation, and small bowel obstruction. In conclusion, diagnostic errors occurred in about one-third of patients with a lower gastrointestinal perforation.

Lateral tongue bite in patient with transient loss of consciousness.

The finding of a tongue bite is infrequent since it is a physical finding that is often overlooked, but it has a very high diagnostic value. It is important to check for tongue bites when examining any patient with a transient loss of consciousness.

Changes in influenza vaccination coverage associated during the COVID-19 pandemic in Japan.

Changes in influenza vaccination coverage during the COVID-19 pandemic in Japan were limited. Not only changes in individual behavior and the threat of disease, but also vaccine dissemination policy based on system-based interventions, including behavioral economic approaches, is desirable.

18F-Fluorodeoxyglucose positron emission tomography computed tomography detection of single organ vasculitis of the breast: A case report.

RATIONALE: Although single organ vasculitis (SOV) is a rare occurrence and it is difficult to diagnose, its possibility as a cause of fever of unknown origin (FUO) must be considered. Recently, the usefulness of 18F-fluorodeoxyglucose positron emission tomography computed tomography (FDG PET/CT) in the diagnosis of unknown fevers due to vasculitis, especially in cases of small and medium-sized vasculitis, has begun to be pointed out. PATIENT CONCERNS: We report the case of an 84-year-old woman with persisting fever for more than 2 weeks. She had no accompanying symptoms, other than fever, and the physical examination, echocardiography, and contrast-enhanced CT did not reveal any diagnostic clue. DIAGNOSES: The FDG PET/CT revealed positive uptakes of FDG in the left breast, with a standardized uptake value (SUV) of 2.9. The biopsy specimen of the left breast lesion revealed rupture of the elastic plate and evidence of fibrinoid necrosis of arteries, leading to the diagnosis of polyarteritis (PAN). Further angiographic examination and additional imaging did not reveal the presence of other lesions. Therefore, the diagnosis was established as a PAN-SOV of the left breast. INTERVENTIONS: This patient has improved with follow-up only. OUTCOMES: There has been no evidence of a relapse of PAN over a 5-year follow-up period. LESSONS: SOV presenting with unspecific local symptoms is difficult to diagnose based on the medical history and clinical examination. Our findings show that early "Combination of PET-CT and biopsy" can be a powerful diagnostic tool in patients with FUO for whom diagnosis of the underlying cause is difficult despite appropriate clinical examination.

COVID Blindness: Delayed Diagnosis of Aseptic Meningitis in the COVID-19 Era.

Diagnostic errors are a serious problem in healthcare. The diagnostic process is highly susceptible to cognitive bias and the current COVID-19 pandemic may cause normally accurate healthcare workers to make incorrect decisions. We report a case of aseptic meningitis that required five healthcare visits before it was correctly diagnosed. This case highlights the risk of anchoring bias and the importance of carefully assessing diagnostic processes during the COVID-19 pandemic. LEARNING POINTS: COVID-19 can disrupt the healthcare system and clinical environment and affect diagnosis due to anchoring bias.Healthcare providers should carefully check the COVID-19 illness script to reduce diagnostic errors.Healthcare providers should prepare and practice a diagnostic debiasing strategy during the COVID-19 pandemic.

Usefulness of bounce-back admission in monitoring the quality of practice in the emergency department.

Background: Recently, unscheduled readmissions after discharge from the emergency department (ED) (bounce-back admissions, BBAs) have been monitored as a hospital performance measure in countries other than Japan. It has been suggested that BBAs may be caused by errors in diagnoses or treatments. Purpose: This retrospective cohort study aimed to evaluate BBAs and improve the quality of medical care in the ED of Showa University Hospital by analyzing the data of adult patients (≥18 years) with index visits to the ED of Showa University Hospital between June 2011 and May 2013 (n=15,069). Patients and methods: Patients were registered and followed up for unscheduled admissions to this hospital within 7 days. In order to understand the reasons for BBAs, individual diagnoses upon BBA were compared to the corresponding diagnoses upon discharge. Results: Among the 11,669 discharged patients, 180 patients were admitted within 3 days after discharge (3-day BBAs), and 257 were admitted within 7 days after discharge (7-day BBAs). The main diagnoses upon admission (BBA) were pneumonia or exacerbation of chronic obstructive pulmonary disease (COPD) or asthma (n=40, 16%), cholecystitis or cholangitis (n=21, 8.2%), and urinary tract infection (n=16, 6.2%). Among the 7-day BBA cases, 117 patients had similar and 110 patients had different diagnoses upon discharge and admission; in the remaining 30 cases, the results could not be ascertained owing to incomplete diagnostic data. In the cases of pneumonia, exacerbation of COPD or asthma, and colitis or enterocolitis, there was a significantly higher "similar" diagnoses than "different", while the reverse was true for cases of stroke, ileus or bowel obstruction, and meningitis. These results were shared with the ED staff, and similar surveillances were periodically conducted. The frequency of admission within 7 days after discharge continuously declined from 2013 to 2016. Conclusion: Analyzing the discharge and admission diagnoses may help ED staff to understand the reasons for common errors in order to follow the plan-do-check-act cycle of medical care in the ED.