Identifying Unmet Social Needs in a Patient Living in Isolation: A Case Report.

Loneliness and social isolation are common among older adults. To deliver high-quality care to older patients, healthcare professionals should know the social conditions of their patients. Addressing social determinants of health (SDH) in daily practice is beneficial to both patients and healthcare professionals. We illustrate a patient with congestive heart failure and cognitive decline whose social conditions improved through an SDH assessment. An SDH assessment has some potential advantages, which include facilitating a comprehensive understanding of patients' social conditions, visualizing how patients' social conditions have changed, deepening interprofessional collaboration, and ameliorating unnecessary negative emotions toward patients. This case report conveys two key messages. Firstly, healthcare professionals have the capability to evaluate patients' social backgrounds and enhance their health and social conditions through routine care. Secondly, the utilization of an SDH screening toolkit can support and enhance this initiative.

Early swallowing rehabilitation and promotion of total oral intake in patients with aspiration pneumonia: A retrospective study.

OBJECTIVES: To investigate the impact of early swallowing assessment and rehabilitation on the total oral intake and in-hospital mortality in patients with aspiration pneumonia. METHODS: We retrospectively analyzed the data of patients with aspiration admitted between September 1, 2015, and October 31, 2016. The inclusion criterion was total oral intake before admission. A new protocol-based intervention for appropriate early oral intake was implemented on April 1, 2016. The protocol consisted of two steps. First, a screening test was conducted on the day of admission to detect patients who were not at high risk of dysphagia. Second, patients underwent a modified water swallowing test and water swallowing test. Patients cleared by these tests immediately initiated oral intake. The primary outcome, the composite outcomes of no recovery to total oral intake at discharge, and in-hospital mortality were compared between the patients admitted pre- and post protocol intervention. RESULTS: A total of 188 patients were included in the analysis (pre-, 92; post-, 96). The primary outcome did not differ between the pre- and post-intervention periods (23/92 [25.0%] vs. 18/96 [18.8%], p = 0.30). After adjusting for other variables, the intervention was significantly associated with a lower risk of composite outcomes (odds ratio, 0.22, 95%CI, 0.08-0.61, p = 0.004). CONCLUSION: The new protocol for early swallowing assessment, rehabilitation, and promotion of oral intake in patients admitted with aspiration pneumonia may be associated with the lower risk for the composite outcomes of in-hospital mortality and no recovery to total oral intake.

Prevalence of atypical presentations among outpatients and associations with diagnostic error.

OBJECTIVES: This study aimed to assess the prevalence of atypical presentations and their association with diagnostic errors in various diseases. METHODS: This retrospective observational study was conducted using cohort data between January 1 and December 31, 2019. Consecutive outpatients consulted by physicians from the Department of Diagnostic and Generalist Medicine at a university hospital in Japan were included. Patients for whom the final diagnosis was not confirmed were excluded. Primary outcomes were the prevalence of atypical presentations, and the prevalence of diagnostic errors in groups with typical and atypical presentations. Diagnostic errors and atypical presentations were assessed using the Revised Safer Dx Instrument. We performed primary analyses using a criterion; the average score of less than five to item 12 of two independent reviewers was an atypical presentation (liberal criterion). We also performed additional analyses using another criterion; the average score of three or less to item 12 was an atypical presentation (conservative criterion). RESULTS: A total of 930 patients were included out of a total of 2022 eligible. The prevalence of atypical presentation was 21.7 and 6.7 % when using liberal and conservative criteria for atypical presentation, respectively. Diagnostic errors (2.8 %) were most commonly observed in the cases with slight to moderate atypical presentation. Atypical presentation was associated with diagnostic errors with the liberal criterion for atypical presentation; however, this diminished with the conservative criterion. CONCLUSIONS: An atypical presentation was observed in up to 20 % of outpatients with a confirmed diagnosis, and slight to moderate atypical presentation may be the highest risk population for diagnostic errors.

Relationship Between Diabetic Chorea and Timing of MRI Findings: A Systematic Review with Case Reports.

Background: Diabetic chorea is a rare complication of diabetes mellitus for which head MRI is the most common diagnostic imaging modality. Cases have been reported where CT and/or MRI findings are inconsistent or clinical symptoms and imaging findings do not appear simultaneously. We aimed to compile the cases in which imaging findings appeared on MRI retests and to examine in a systematic review whether temporal differences in the appearance of imaging findings correlate with clinical characteristics. Case Presentation: An 80-year-old man with type 2 diabetes mellitus came to a hospital with abnormal movements of the left upper and lower extremities. Two days after the first visit, his symptoms flared up, and his head MRI showed an old cerebral infarction and no new lesion. On day 14, he retested T1-weighted imaging and showed a high signal in the right putamen, which was considered diabetic chorea. Blood glucose was controlled with insulin, and the involuntary movements disappeared. Methods: PubMed and ICHUSHI were searched to identify patients with diabetic chorea who had undergone MRI retests. Patients grouped by the temporal change in the presence/absence of imaging findings were compared on age, sex, duration of diabetes mellitus, blood glucose level, HbA1c level, side of involuntary movement, time to first MRI, and follow-up MRI. Results: Of the 64 cases analyzed, 43 (67.2%) were female. The mean age was 69.0 years. 16 (25.0%) had worsening findings upon MRI retesting, 37 (57.8%) had improvement, and 10 (15.6%) had unchanged findings. There were no significant differences in age, sex, mean blood glucose level or HbA1c at onset among the groups. Conclusion: There was no association between the pattern of appearance of imaging findings over time and clinical characteristics, including glucose levels. If initial MRI findings are negative, MRI retesting after a certain time may help diagnose diabetic chorea.

EPIPERICARDIAL FAT NECROSIS.

Introduction: Epipericardial fat necrosis (EFN) is a relatively rare benign disease that causes acute chest pain. Case Description: A woman in her 20s presented with acute left shoulder and epigastric pain. One day before presentation, she had visited a cardiologist and an acute coronary syndrome had been ruled out. The pain worsened with deep inspiration. Chest computed tomography (CT) showed a soft-tissue attenuation lesion containing a fatty centre located in the epipericardial fat at the left cardiophrenic angle. Hence, EFN was diagnosed and the pain was resolved with loxoprofen. The lesion had disappeared on a follow-up chest CT scan. Discussion: EFN is a rare benign disease that causes acute chest pain. Approximately 70-90% of EFN cases are misdiagnosed by clinicians as other diseases. Conclusion: In patients with acute chest pain, the correct diagnosis of EFN avoids unnecessary invasive investigations and reassures patients. LEARNING POINTS: Patients with epipericardial fat necrosis typically present with acute pleural chest pain without any associated symptoms.Characteristic CT findings of the encapsulated fatty pericardial lesion with a surrounding inflammatory reaction are key for the diagnosis of epipericardial fat necrosis.The correct diagnosis of epipericardial fat necrosis in patients with acute chest pain reassures them and avoids unnecessary invasive investigation.

Effect of contextual factors on the prevalence of diagnostic errors among patients managed by physicians of the same specialty: a single-centre retrospective observational study.

BACKGROUND: There has been growing recognition that contextual factors influence the physician's cognitive processes. However, given that cognitive processes may depend on the physicians' specialties, the effects of contextual factors on diagnostic errors reported in previous studies could be confounded by difference in physicians. OBJECTIVE: This study aimed to clarify whether contextual factors such as location and consultation type affect diagnostic accuracy. METHODS: We reviewed the medical records of 1992 consecutive outpatients consulted by physicians from the Department of Diagnostic and Generalist Medicine in a university hospital between 1 January and 31 December 2019. Diagnostic processes were assessed using the Revised Safer Dx Instrument. Patients were categorised into three groups according to contextual factors (location and consultation type): (1) referred patients with scheduled visit to the outpatient department; (2) patients with urgent visit to the outpatient department; and (3) patients with emergency visit to the emergency room. The effect of the contextual factors on the prevalence of diagnostic errors was investigated using logistic regression analysis. RESULTS: Diagnostic errors were observed in 12 of 534 referred patients with scheduled visit to the outpatient department (2.2%), 3 of 599 patients with urgent visit to the outpatient department (0.5%) and 13 of 859 patients with emergency visit to the emergency room (1.5%). Multivariable logistic regression analysis showed a significantly higher prevalence of diagnostic errors in referred patients with scheduled visit to the outpatient department than in patients with urgent visit to the outpatient department (OR 4.08, p=0.03), but no difference between patients with emergency and urgent visit to the emergency room and outpatient department, respectively. CONCLUSION: Contextual factors such as consultation type may affect diagnostic errors; however, since the differences in the prevalence of diagnostic errors were small, the effect of contextual factors on diagnostic accuracy may be small in physicians working in different care settings.

Case of bilateral Bell's palsy.

A man in his 70s presented with a 4-day history of bilateral frontal headache and heaviness of the face. He was unable to close either of his eyes, to wrinkle his forehead bilaterally and to raise either corner of his mouth. The patient was admitted with a diagnosis of bilateral facial palsy. From history, epidemiology, physical and laboratory findings, Bell's palsy was considered more probable than viral infection, Guillain-Barré syndrome and sarcoidosis. Oral administration of prednisolone, valacyclovir and mecobalamin were initiated promptly, which improved his symptoms. In areas in which Lyme disease is not endemic, we believe that Bell's palsy is the most probable cause of isolated bilateral facial palsy. Patients with bilateral facial paralysis under the suspicion of Bell's palsy should be immediately started on steroid therapy.

Social vital signs for improving awareness about social determinants of health.

We, Team SAIL, have held sessions introducing social vital signs (SVS). SVS is a useful tool for evaluating patient's social determinants of health (SDH).

Hydronephrosis associated with antiurothelial and antinuclear autoantibodies in BALB/c-Fcgr2b-/-Pdcd1-/- mice.

Because most autoimmune diseases are polygenic, analysis of the synergistic involvement of various immune regulators is essential for a complete understanding of the molecular pathology of these diseases. We report the regulation of autoimmune diseases by epistatic effects of two immunoinhibitory receptors, low affinity type IIb Fc receptor for IgG (FcgammaRIIB) and programmed cell death 1 (PD-1). Approximately one third of the BALB/c-Fcgr2b(-/-)Pdcd1(-/-) mice developed autoimmune hydronephrosis, which is not observed in either BALB/c-Fcgr2b(-/-) or BALB/c-Pdcd1(-/-) mice. Hydronephrotic mice produced autoantibodies (autoAbs) against urothelial antigens, including uroplakin IIIa, and these antibodies were deposited on the urothelial cells of the urinary bladder. In addition, approximately 15% of the BALB/c-Fcgr2b(-/-)Pdcd1(-/-) mice produced antinuclear autoAbs. In contrast, the frequency of the autoimmune cardiomyopathy and the production of anti-parietal cell autoAb, which were observed in BALB/c-Pdcd1(-/-) mice, were not affected by the additional FcgammaRIIB deficiency. These observations suggest cross talk between two immunoinhibitory receptors, FcgammaRIIB and PD-1, on the regulation of autoimmune diseases.