Factors in Avoidable Emergency Visits for Ambulatory Care-sensitive Conditions among Older Patients Receiving Home Care in Japan: A Retrospective Study.

Objective Older adults have many health conditions that do not require hospitalization, such as cognitive decline and progression of frailty, so it is necessary to prevent avoidable emergency visits for ambulatory care-sensitive conditions (ACSCs) in this population. We therefore examine Freund's classification of reasons for hospitalization owing to ACSCs to identify factors involved in elderly patients visiting emergency departments in Japan. Methods This retrospective case-control study included patients who received emergency transport for medical treatment at Yushoukai Home Care Clinic Shinagawa in Japan between January 1, 2016, and April 30, 2019. We examined patients' medical records and categorized the reasons for emergency visit by ambulance in accordance with Freund's categories (physician related level, medical causes, patient level, and social level). In addition, we classified and compared patients who lived at home (Group A) with those living in a care facility for older adults (Group B). Results A total of 365 patients visited the emergency department (298 in Group A and 67 in Group B). Among these, we determined that emergency visits were potentially avoidable in 135 patients from Group A and 28 from Group B. The patient and social level categories accounted for 81% of potentially avoidable emergency visits. Confirmed advanced care planning (ACP) was significantly associated with avoidable emergency visit by ambulance in multivariate analyses. Conclusion To prevent emergency visits for ACSCs among older people, ACP should be encouraged.

[Anti-atherosclerotic effects of etanercept in rheumatoid arthritis patients].

Epidemic studies have shown that rheumatoid arthritis (RA) patients have shorter life expectancy than healthy persons, primarily due to cardiovascular events. The aim of our study was to explore inhibitory effects on atherosclerosis of RA patients by TNF-inhibitor etanercept (ETN). We studied six RA patients with moderate or high disease activity as defined by the European League Against Rheumatism (EULAR) disease activity score (DAS28-ESR) in spite of treatment with methotrexate (MTX) 8 mg/week. We measured their pulse wave velocity (PWV) before and after treatment with ETN 25 mg/week for one year. There were no additional medications other than ETN that might influence on atherosclerosis. Their PWV decreased in five of six patients and the average decreased from 1474.8 cm/sec to 1432.5 cm/sec. The average of DAS28-ESR score was significantly decreased from 5.56 to 2.87 and they achieved good response by the EULAR criteria. There were no significant changes in the blood pressure, serum lipid (total cholesterol and triglyceride) and HbA1c ; all values were within normal limits before and after ETN treatment. It is suggested that the improvement of PWV is due to anti-inflammatory effects, leading inhibition of atherosclerosis, of ETN in RA patients.

Polyarthritis and posterior interosseous nerve palsy associated with gastric carcinoma.

Cancer polyarthritis is a very rare condition. Here, we present a case of cancer polyarthritis, who also had mononeuritis simplex as a manifestation of paraneoplastic neuralgic syndrome. A 71-year-old man, who initially presented symmetrical polyarthritis and unilateral posterior interosseous nerve palsy, was subsequently diagnosed to have gastric cancer. Total gastrectomy was performed, and his polyarthritis and the palsy simultaneously disappeared within 2 weeks after the resection. His gastric cancer was found to be metastasized to his liver 16 months after the total gastrectomy; however, the polyarthritis and the palsy did not recurrent throughout his course. The polyarthritis in this case was diagnosed as a cancer polyarthritis from its features. On the other hand, the isolated posterior interosseous nerve palsy in this case met the diagnostic criteria for paraneoplastic neurological syndrome. This case was also unique in that the manifestations of paraneoplastic syndromes did not recur even after the metastasis of the primary cancer, suggesting that some specific clones in the cancer were responsive to the manifestations of paraneoplastic syndromes. Our case suggested that relapse of the manifestations of paraneoplastic syndromes may not always herald the recurrence of primary or metastatic tumour, and other tumour markers and signs should be periodically followed to search for the recurrence of the tumours.

Spontaneous anterior interosseous nerve palsy with Churg-Strauss syndrome.

A 74-year-old woman diagnosed with Churg-Strauss syndrome (CSS) complained of difficulty in flexing her left thumb and index finger. Electromyography demonstrated isolated anterior interosseous nerve (AIN) palsy, with no other peripheral neuropathy. We diagnosed this case as spontaneous AIN palsy complicated with CSS, the first case of this kind. Surgical treatment should be considered if no sign of recovery is seen within six months of onset.

[Two severe tetanus cases infected in an urban area of Kawasaki City].

We report two cases of severe tetanus infection. Case 1: A 73-year-old non-vaccinated man who fell in a local park developed a wound on the left little finger. The wound was debrided and a tetanus toxin shot given on day 4 following the injury. He developed trismus on day 6 requiring deep sedation and mechanical ventilation in the intensive care unit (ICU), with human anti-tetanus immune globulin (TIG) and antibiotics administered. Despite a very severe autonomic dysfunction, he recovered and was discharged mobile after 2 months of rehabilitation. Case 2: A 37-year-old woman fully vaccinated against tetanus in her childhood had apparently had booster vaccine for at least 20 years and was being treated for hyperthyroidism with thiamazole. She sustained two lacerations on the fingers of her right hand in her backyard. She noticed difficulty in opening her mouth on day 3 following the injury and was seen on day 7, for high fever and difficulty in speaking. She was diagnosed clinically as having tetanus and underwent wound debridement, and a shot of tetanus toxin, TIG, and antibiotics. On hospital admission day 2, she developed spasms and her blood pressure dropped drastically. She died the next day due to endotoxin shock caused by other bacteria. C. tetani is widely distributed in Japan, and these cases underscore the importance of maintaining adequate tetanus antibody levels through booster administration every 10 years in immune adults and appropriate post-exposure treatment with tetanus toxin and/or prophylactic TIG administration.

Reversible focal neurological deficits in systemic lupus erythematosus: report of 2 cases and review of the literature.

We report two cases presenting focal neurological deficits with high intensity lesions in fluid attenuated inversion recovery (FLAIR) images on brain magnetic resonance imaging (MRI), which almost completely improved by corticosteroid therapy. Marked elevation of cerebrospinal fluid IL-6 was also noted when these patients showed neurological deficits. As far as we explored, there have been thirteen published case reports of systemic lupus erythematosus patients with reversible focal neurological deficits. The neurological symptoms varied from case to case, but could be attributed to the lesions on MRI scans. The completely reversible feature of neurological manifestations as well as MRI findings on corticosteroid therapy is distinct from any other disorder, including cerebrovascular disease and demyelinating syndrome, in the 1999 American College of Rheumatology nomenclature. Therefore, we propose that reversible focal neurological deficits should be added to the 1999 nomenclature and classification and case definitions.

[A case of primary HIV infection presenting as meningoencephalitis].

A 23-year-old man presented with disturbance of consciousness and convulsion. Two weeks prior to his admission, he had general arthralgia, retro-orbital pain, and body temperature increase to 40 degrees C. These symptoms persisted for two weeks. He was admitted to the hospital because of general convulsion, followed by disturbance of consciousness. On admission, he was deeply lethargic. Cerebrospinal fluid obtained on admission showed pleocytosis (247/mm3) and an increased level of protein. Electroencephalogram obtained on admission disclosed diffuse slow waves. Enhanced cranial MR image did not show any abnormal lesions in the cerebral parenchyma. The patient was diagnosed as having meningoencephalitis and the treatment consisting of aciclovir, CTRX, and methylprednisolone was undertaken. A test for human immunodeficiency virus (HIV) antibody was found to be positive on the second day of hospitalization. A Western blot was positive with bands at gp160 and P24 confirming HIV infection. Antibody titers of paired acute and convalescent sera including HSV, EBV, CMV, mumps, measles, and Japanese encephalitis did not show any significant increase. The patient became alert on the 3rd day of hospitalization. Electroencephalogram obtained on the 10th day of hospitalization was normal. Western blot, which was obtained 4 months later, was positive with bands at gp120, p68, p55, p52, gp41, p40, p34, p18, including gp160 and P24. He was diagnosed as having primary HIV infection. Meningoencephalitis was attributed to acute primary HIV infection. Acute HIV infection should be considered as an etiology of meningoencephalitis.