Diagnostic Dilemma of Syncope: Esophageal Hiatal Hernia and High-risk Bundle-branch Block.

We herein report a complicated case of recurrent syncope accompanying bundle branch block and hiatal hernia of the esophagus. An 83-year-old woman presented with syncope. Echocardiography visualized the left atrium compressed by an esophageal hiatal hernia, which had potential to decrease the cardiac output. Although she underwent esophageal repair surgery, two months after the surgery, she presented to the emergency department again with complaints of syncope. At the return visit, her face was pale and her pulse rate was 30 beats per minute. Electrocardiography showed complete atrioventricular block. On reviewing the patient's previous electrocardiography findings, we found a record of trifascicular block. This case illustrates the importance of predicting atrioventricular blocks in patients with high-risk bundle-branch blocks. Keeping in mind high-risk bundle-branch blocks will help clinicians avoid anchoring bias due to a striking image masquerading as the true diagnosis.

A 33-Year-Old Man With Hemoptysis and Renal Dysfunction.

CASE PRESENTATION: A 33-year-old man presented with a 10-day history of fever, dry cough, and dyspnea. He reported small amounts of frank hemoptysis that occurred several times a day for the past 3 days and a reduction in urine volume. There was no joint pain, skin rash, muscle weakness, or bleeding symptoms, except for the hemoptysis. He had a medical history of childhood asthma and untreated hypertension for the past 2 years. He had no history of smoking, recent travel, medication use, or occupational inhalation.

Laryngeal edema in drug reaction with eosinophilia and systemic symptoms syndrome due to sulfasalazine.

We present a case of a 47-year-old man with drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. The patient had been diagnosed with rheumatoid arthritis and sulfasalazine was prescribed 4 weeks before admission. Initial symptoms with fever and rash worsened even after a discontinuation of the medication, and concomitant symptoms developed including typical manifestations of facial rash and edema sparing the periorbital area, as well as atypical laryngeal edema. Rheumatologists should be aware that sulfasalazine is derived from sulfonamide and can possibly induce DRESS syndrome, one of the life-threatening drug eruptions.

Performance of a pre-administration infection screening questionnaire in patients with rheumatoid arthritis administered biological disease-modifying antirheumatic drugs.

AIM: Pre-administration screening of active infections is imperative for the safe use of biological disease-modifying antirheumatic drugs (bDMARDs) in patients with rheumatoid arthritis (RA). However, a standardized screening method is lacking. We therefore implemented a novel systematic screening method with a simple predetermined questionnaire on infections and assessed its effectiveness. METHODS: We retrospectively reviewed medical records of individuals for whom intravenous bDMARDs were administered for RA from January 2016 to April 2019. We evaluated the performance of the new screening method based on physicians' assessments. In addition, a survey was administered to nurses, regarding their assessment of the usefulness of this new screening. The incidence of infections was also assessed. RESULTS: A total of 1636 cases underwent this new screening. The new screening method showed high sensitivity (0.97) and specificity (0.89) with a negative predictive value of 99.9%, as determined based on the physician's decision. Administration of bDMARDs was postponed in 37 (2.5%) patients, and there was only one case in which the screening failed to note an active infection. The nurses' survey demonstrated high agreement (87.5%) about the usefulness of this screening on the grounds of clarity, simplicity, ease, and time-saving effects. There was no significant increase in infections after implementation of this method. CONCLUSIONS: Systematic screening with a predetermined simple questionnaire is effective as an infection screening method, with a high negative predictive value. This approach contributes to high satisfaction of nurses and a time-efficient practice by focusing on screen-positive cases without increasing infections.

A Perspective from a Case Conference on Comparing the Diagnostic Process: Human Diagnostic Thinking vs. Artificial Intelligence (AI) Decision Support Tools.

Artificial intelligence (AI) has made great contributions to the healthcare industry. However, its effect on medical diagnosis has not been well explored. Here, we examined a trial comparing the thinking process between a computer and a master in diagnosis at a clinical conference in Japan, with a focus on general diagnosis. Consequently, not only was AI unable to exhibit its thinking process, it also failed to include the final diagnosis. The following issues were highlighted: (1) input information to AI could not be weighted in order of importance for diagnosis; (2) AI could not deal with comorbidities (see Hickam's dictum); (3) AI was unable to consider the timeline of the illness (depending on the tool); (4) AI was unable to consider patient context; (5) AI could not obtain input information by themselves. This comparison of the thinking process uncovered a future perspective on the use of diagnostic support tools.

Incidence of cardiovascular events in polymyalgia rheumatica and giant cell arteritis amongst an Asian population: Propensity score matched cohort study.

BACKGROUND: The hypothesis that patients with polymyalgia rheumatica (PMR) or giant cell arteritis (GCA) have a high risk for future cardiovascular diseases has not been adequately tested. The aim of this study is to evaluate this hypothesis in Japan, where the prevalence and severity of PMR and GCA are the lowest. METHODS: A propensity score matched cohort study was conducted at St. Luke's International Hospital, Tokyo, Japan, from 2003 to 2016. We included all patients who were diagnosed as PMR or GCA cases and matched comparators with a proportion of 1 : 2. Our primary outcome was newly diagnosed cardiovascular disease. The propensity score was calculated using logistic regression with forward stepwise selection in 30 variables. Kaplan-Meier curves were drawn and the log-rank test and Cox proportional hazard model were performed for survival analyses. Two types of sensitivity analyses were conducted to confirm the results. RESULTS: Among 2461 potential patients, the propensity score identified 504 (168 cases and 336 comparators) patients. During follow up (median 839.5 days), 110 (21.8%) developed cardiovascular diseases. The Kaplan-Meier curves between those with and without PMR or GCA were not significantly different (P = 0.85). The Cox proportional hazard model calculated the hazard ratio (HR) of those with PMR or GCA compared to those without as 0.96 (95% CI: 0.64-1.46). The results from sensitivity analyses were consistent (HR 0.70-1.06). CONCLUSION: Patients with PMR or GCA may not have a higher risk of future cardiovascular diseases among the Japanese population. The sensitivity analyses and sample size calculation supported the results.

Effects of quality indicator monitoring for glucocorticoid-induced osteoporosis and trends of drug treatment in a Japanese hospital.

AIMS: Globally, the appropriate prescription rate for glucocorticoid-induced osteoporosis (GIOP) is low. Thus, we aimed to examine the improvement in real-world GIOP care using a hospital-wide systematic approach with quality indicator (QI) monitoring. METHODS: We defined a novel QI for GIOP care for the prescription rate of anti-osteoporotic drugs according to 2010 American College of Rheumatology GIOP management recommendations, with the target being patients prescribed ≥7.5 mg prednisolone daily or its equivalent for ≥3 months. We monitored the glucocorticoid and osteoporotic medication dose for all patients who visited our hospital. From May 2011, we began interventions to improve QI: monthly QI monitoring providing QI-trend feedback to each department in a hospital-wide QI meeting every 3 months and organizing lectures on GIOP. We retrospectively analyzed QI trends from 2010 to 2013. We categorized groups by sex and age for subanalyses: group A, men; group B, women, aged <50 years; group C, women, aged ≥50 years. RESULTS: The numbers of participants were 401, 420, 520 and 513 in 2010, 2011, 2012 and 2013, respectively, with pooled QI rates of 45.8%, 51.3%, 55.0% and 54.8%, respectively. Changes in QI between each consecutive 2 years were statistically significant. Subanalyses showed statistically significant QI improvements in groups A and C. We observed a decreasing trend of daily bisphosphonate use throughout the study period, especially at the Immuno-Rheumatology Center. CONCLUSIONS: Quality indicator monitoring for GIOP significantly improved appropriate anti-osteoporotic drug prescriptions, especially in men and postmenopausal women.