Clinically defined aspiration pneumonia is an independent risk factor associated with long-term hospital stay: a prospective cohort study.

BACKGROUND: Long-term hospital stay is associated with functional decline in patients with pneumonia, especially in the elderly. Among elderly patients with pneumonia, aspiration pneumonia is a major category. Clinical definition is usually used because it can occur without apparent aspiration episodes. It is still not clear whether a long-term hospital stay is due to aspiration pneumonia itself caused by underlying oropharyngeal dysfunction or simply due to functional decline in elderly patients with multiple comorbidities during acute infection. The aim of this study is to identify whether clinically defined aspiration pneumonia itself was associated with a long-term hospital stay. METHODS: A prospective observational study on community-acquired (CAP) or healthcare-associated pneumonia (HCAP) was conducted from January 2012 through January 2014. Aspiration pneumonia was clinically defined as pneumonia not only occurring in patients after documented aspiration episodes, but also occurring in those with underlying oropharyngeal dysfunction: chronic disturbances of consciousness and/or chronic neuromuscular diseases. We defined thirty-day hospital stay as a long-term hospital stay and compared it with logistic regression analysis. Potential confounders included age, sex, HCAP, body mass index (BMI), long-term bed-ridden state, heart failure, cerebrovascular disorders, dementia, antipsychotics use, hypnotics use, and CURB score which is a clinical prediction tool used to assess the severity, standing for; C (presence of Confusion), U (high blood Urea nitrogen level), R (high Respiratory rate), and B (low Blood pressure). In a sub-analysis, we also explored factors associated with long-term hospital stay in patients with aspiration pneumonia. RESULTS: Of 2,795 patients, 878 (31.4%) had aspiration pneumonia. After adjusting potential confounders, the aspiration pneumonia itself was significantly associated with long-term hospital stay (adjusted odds ratio 1.44; 95% confidence interval 1.09-1.89, p < 0.01), as were higher age, male sex, high CURB score, HCAP, low BMI, heart failure, cerebrovascular disease, and antipsychotics use. Sub-analysis revealed factors associated with long-term hospital stay in the aspiration pneumonia, which included male sex, and multi-lobar chest X-ray involvement. CONCLUSIONS: Clinically defined aspiration pneumonia itself was independently associated with long-term hospital stay. This result could potentially lead to specific rehabilitation strategies for pneumonia patients with underlying oropharyngeal dysfunction.

Self-assessment scale for the community-based and emergency practice.

BACKGROUND: For current medical education, community-based primary care for the elderly is an essential topic. This study aimed to establish a scale of community-based assessment for clinical and emergency practice (C-CEP). METHODS: A self-assessment scale for C-CEP was developed according to four steps. Initially, we reviewed publications from the societies of the United States, British, and Japan regarding educational goals. In addition, we searched MEDLINE for educational goals regarding attitude, skills, and knowledge. Getting together, we established 23 items as the educational goals of the C-CEP. Second, we collected responses for these 23 items from 5th-grade medical students (n = 195). Third, we conducted an exploratory factor analysis (EFA) using their responses to determine the fundamental structure of the self-assessment scale. Finally, a confirmatory factor analysis (CFA) was performed to assess the fitness of the self-assessment scale developing the EFA, resulting in modification of the items. RESULTS: In EFA and CFA results, C-CEP Scale consisted of four factors with 15 items: "Attitude and communication in emergency care," Basic clinical skills," "Knowledge of community healthcare," and "Knowledge of evidence-based medicine perseverance." The model fit indices were acceptable (Goodness of Fix Index = 0.928, Adjusted Goodness of Fit Index = 0.900, Comparative Fit Index = 0.979, and Root Mean Square Error of Approximation = 0.045). The values of McDonald's omega as an estimate of scale reliability were more than 0.7 in all four factors. As for test-retest reliability, the intraclass correlation coefficients were ≥ 0.58 for all factors. All four factors of the C-CEP Scale correlated positively with the Medical Professionalism Evaluation Scale subscales. CONCLUSIONS: We developed a valid and reliable self-assessment scale to assess student competence.

Six underlying health conditions strongly influence mortality based on pneumonia severity in an ageing population of Japan: a prospective cohort study.

BACKGROUND: Mortality prediction of pneumonia by severity scores in patients with multiple underlying health conditions has not fully been investigated. This prospective cohort study is to identify mortality-associated underlying health conditions and to analyse their influence on severity-based pneumonia mortality prediction. METHODS: Adult patients with community-acquired pneumonia or healthcare-associated pneumonia (HCAP) who visited four community hospitals between September 2011 and January 2013 were enrolled. Candidate underlying health conditions, including demographic and clinical characteristics, were incorporated into the logistic regression models, along with CURB (confusion, elevated urea nitrogen, tachypnoea, and hypotension) score as a measure of disease severity. The areas under the receiver operating characteristic curves (AUROC) of the predictive index based on significant underlying health conditions was compared to that of CURB65 (CURB and age ≥ 65) score or Pneumonia severity index (PSI). Mortality association between disease severity and the number of underlying health conditions was analysed. RESULTS: In total 1772 patients were eligible for analysis, of which 140 (7.9%) died within 30 days. Six underlying health conditions were independently associated: home care (adjusted odds ratio, 5.84; 95% confidence interval, CI, 2.28-14.99), recent hospitalization (2.21; 1.36-3.60), age ≥ 85 years (2.15; 1.08-4.28), low body mass index (1.99, 1.25-3.16), neoplastic disease (1.82; 1.17-2.85), and male gender (1.78; 1.16-2.75). The predictive index based on these conditions alone had a significantly or marginally higher AUROC than that based on CURB65 score (0.78 vs 0.66, p = 0.02) or PSI (0.78 vs 0.71, p = 0.05), respectively. Compared to this index, the AUROC of the total score consisting of six underlying health conditions and CURB score (range 0-10) did not improve mortality predictions (p = 0.3). In patients with one or less underlying health conditions, the mortality was discretely associated with severe pneumonia (CURB65 ≥ 3) (risk ratio: 7.24, 95%CI: 3.08-25.13), whereas in patients with 2 or more underlying health conditions, the mortality association with severe pneumonia was not detected (risk ratio: 1.53, 95% CI: 0.94-2.50). CONCLUSIONS: Mortality prediction based on pneumonia severity scores is highly influenced by the accumulating number of underlying health conditions in an ageing society. The validation using a different cohort is necessary to generalise the conclusion.

Clinical features of eosinophilic esophagitis: ten Japanese cases.

AIM: We studied eosinophilic esophagitis (EE) to clarify the clinical and endoscopic features of a Japanese case series. METHODS: Records of 10 patients diagnosed with EE at our hospital between May 2010 and December 2011 were examined for age, sex, symptoms, allergic disorder, endoscopic findings, and treatment received. Esophageal wall thickness was measured by endoscopic ultrasonography (EUS). RESULTS: Patients were seven males and three females with a mean age of 48 years. Symptoms included dysphagia, heartburn, food impaction, and chest pain. Nine patients had a history of allergic diseases. Increased peripheral eosinophil count was observed in one patient whereas increased immunoglobulin E level was observed in eight patients. Endoscopic findings included longitudinal furrows in all patients, mucosal edema in nine patients, loss of vascular pattern in nine patients, white exudates in six patients, cobblestone-like appearance in five patients, and concentric rings in three patients. EUS revealed thickening of the esophageal wall in one patient. Histopathological examination revealed eosinophilic infiltration (≥15 eosinophils/high-powered field) in the esophageal epithelium of all patients. Treatment was required in six patients. Proton pump inhibitor (PPI) therapy was given as the first-line treatment but was ineffective in four patients and effective in two patients. Steroid therapy was given to three patients unresponsive to PPI therapy and was effective. CONCLUSIONS: EE was common among relatively young men and was associated with allergic diseases. Longitudinal furrows were observed as the most characteristic endoscopic finding. Esophageal wall thickening was not commonly observed by EUS.

The Clinical Utility of Relative Bradycardia for Identifying Cases of Coronavirus Disease 2019 Pneumonia: A Retrospective Pneumonia Cohort Study.

Objective Both coronavirus disease 2019 (COVID-19) pneumonia and relative bradycardia are common conditions among clinicians; however, the association between these has not been well studied. The present study assessed whether or not relative bradycardia on admission was more predominant in patients with COVID-19 pneumonia than in those with other infectious pneumonia. Methods For this single-center, retrospective cohort study, we collected data through electronic medical records and examined the occurrence of relative bradycardia on admission. We used logistic regression analyses to compare outcomes with and without relative bradycardia on admission. The primary outcome was COVID-19 pneumonia. The secondary outcome was hypoxemia during the hospital stay. We performed multivariable regression with adjusting for the effects of age, sex, healthcare-associated pneumonia, body mass index, Charlson comorbidity index, and bilateral infiltration on computed tomography (CT) as confounding factors. Patients Adult patients with new-onset hospitalized infectious pneumonia confirmed by CT between January 1, 2020, and July 31, 2021. Results This study included 395 participants. On admission, 87 (22.0%) participants exhibited relative bradycardia, and 302 (76.5%) participants had COVID-19. Relative bradycardia on admission was not significantly associated with COVID-19 pneumonia [adjusted odds ratio (OR) 1.32; 95% confidence interval (CI) 0.49-3.54, p=0.588] but was associated with hypoxemia (adjusted OR 4.74; 95%CI 2.64-8.52, p<0.001). Conclusion The study results showed that relative bradycardia on admission was not associated with COVID-19 in cases of infectious pneumonia. However, relative bradycardia may be associated with the incidence of hypoxemia in pneumonia.

The dawn of directed acyclic graphs in primary care research and education.

Dramatical increase in articles mentioning "directed acyclic graph."

The Clinical Significance of Otolaryngology Manifestations in COVID-19 Pneumonia: A Single-center Retrospective Cohort Study.

Objective Although the absence of a runny nose and sore throat, both ear-nose-throat (ENT) symptoms, suggests community-acquired pneumonia (CAP), the association between ENT symptoms and coronavirus disease 2019 (COVID-19) pneumonia remains unclear. We therefore investigated the association between ENT symptoms and COVID-19 pneumonia. Methods We retrospectively recruited consecutive confirmed COVID-19 inpatients with and without pneumonia admitted to a single institution from April 1, 2020, to July 31, 2021. After a descriptive analysis, we implemented univariable and multivariable regression analyses to assess the association between ENT symptoms and COVID-19 pneumonia. Results The present study included 385 patients. Pneumonia patients exhibited lower rates of positive runny nose and sore throat than non-pneumonia patients. Univariable analyses found mean odds ratios of 0.59 and 0.61 and 95% confidence intervals (CIs) of 0.30-1.16 and 0.32-1.17 for runny nose and sore throat, respectively, and multivariable analyses found mean odds ratios of 0.73 and 0.70 and 95% CIs of 0.34-1.56 and 0.34-1.46, respectively. Conclusion Our study found no statistically significant association between ENT symptoms and COVID-19 pneumonia. Clinicians should be aware that, unlike CAP, there is no correlation between ENT symptoms and pneumonia among patients with COVID-19, so it is necessary to consider the possibility of pneumonia even in the presence of ENT symptoms.

[Guideline of prevention and treatment for NSAIDs induced ulcer].

The guideline for peptic ulcer treatment was reported by Japanese Society of Gastroenterology in 2009. In the guideline, 23 clinical questions were chosen for NSAIDs induced ulcer. Nine questions out of them were related to the prevention, eight were low dose aspirin, three were COX-2 inhibitors and three were the treatment. The recommendations were made for these questions according to evidence-based medicine. In the recommendations, the grade of recommendation, the evidence level of literatures and the applications to Japanese medical insurance were mentioned.

Outcome, diagnosis, and microbiological profile comparison of community- and hospital-acquired bacteremia: A retrospective cohort study.

BACKGROUND: Although bacteremia is one of the most pressing situation in the field of hospital medicine, little is known about the differences between community- and hospital-acquired bacteremia (CAB and HAB, respectively). METHODS: Objective is to know the epidemiologic characteristics of CAB and HAB. Study design is a single-center retrospective cohort study. Participants were all patients over the age of 16 years who were blood cultures positive at single acute care hospital from April 2013 to March 2018. HAB was defined as positive culture acquired at least 48 h after admission or blood culture-positive patients transferred from other hospital. The primary outcome was 30 day mortality, and the secondary outcome was 1 year mortality. We compared the primary and secondary outcomes between HAB and CAB using logistic regression analyses. RESULTS: There were 325 participants in this study. The number of patients with CAB was 189 (58.1%). HAB was associated with a higher 30 day mortality rate than CAB (n = 31, 22.8% vs. n = 9, 4.8%, adjusted odds ratio (AOR) 2.60; 95% confidence interval (CI) 1.04-6.53, p < 0.05). In the secondary outcome, HAB was also associated with a higher 1 year mortality rate (n = 61/110, 55.5% vs. n = 32/143, 22.4%, AOR 2.27; 95% CI: 1.12-4.58). CONCLUSIONS: Our study showed that HAB was associated with higher mortality than CAB in 30 day mortality and in 1 yr mortality. Thus, we confirmed that HAB is distinct from CAB concerning the differences of outcomes.

Importance of nutritional status in recovery from acute cholecystitis: benefit from enteral nutrition supplementation including medium chain triglycerides.

This study was undertaken to clarify the importance of nutritional status in patients with acute cholecystitis, and also evaluate whether they benefited from enteral nutrition supplementation, including medium-chain triglycerides (MCT), during the convalescent stage. Patients with acute cholecystitis admitted to our hospital between April 1994 and March 2002 were classified into a poor nutrition group (n=40; total serum protein<5.0 g/dl) or a fair nutrition group (n=71; >5.0 g/dl). Patients with poor nutrition were significantly more elderly than those with fair nutrition, and had significantly higher serum C-reactive protein (CRP) concentrations. The two groups did not differ significantly with respect to other laboratory data, gender distribution, or medical treatment. We supplemented ordinary meals with enteral nutrition including MCT in 16 patients during the convalescent stage (MCT group). We compared their length of hospital stay and days required to recovery to pre-admission functional status for activities of daily living (ADL) with the same intervals in 16 patients without supplementation (non-MCT group) selected to match for age, gender, and fair or poor nutritional status from among 111 patients. Hospitalizations were significantly longer in the poor nutrition group (43.0+/-2.2 days) than in the fair nutrition group (27.0+/-8.2 days). Significantly more days were required to recover ADL status in the poor nutrition group (12.0+/-7.2 days) than in the fair group (9.4+/-5.2 days). Hospitalizations were significantly shorter in the MCT group (20.1+/-15 days) than in the non-MCT group (35.4+/-12.8 days). Significantly fewer days were required to recover ADL status in the MCT group (10.9+/-7 days) than in the non-MCT group (13.1+/-6.8 days). Administration of enteral nutrition including MCT during convalescence from acute cholecystitis thus appears to promote functional recovery shorten hospital stay.

Impact of lipoprotein lipase gene polymorphisms on ulcerative colitis.

AIM: To examine the influence of lipoprotein lipase (LPL) gene polymorphism in ulcerative colitis (UC) patients. METHODS: Peripheral blood was obtained from 131 patients with UC and 106 healthy controls for DNA extraction. We determined LPL gene polymorphisms affecting the enzyme at Ser447stop, as well as Hind III and Pvu II polymorphisms using PCR techniques. PCR products were characterized by PCR-RFLP and direct sequencing. Polymorphisms were examined for association with clinical features in UC patients. Genotype frequencies for LPL polymorphisms were also compared between UC patients and controls. RESULTS: In patients with onset at age 20 years or younger, C/G and G/G genotypes for Ser447stop polymorphism were more prevalent than C/C genotype (OR = 3.13, 95% CI = 0.95-10.33). Patients with H(+/-) or H(-/-) genotype for Hind III polymorphism also were more numerous than those with H(+/+) genotype (OR = 2.51, 95% CI = 0.85-7.45). In the group with H(+/+) genotype for Hind III polymorphism, more patients had serum triglyceride concentrations over 150 mg/dL than patients with H(+/-) or H(-/-) genotype (P < 0.01, OR = 6.46, 95% CI = 1.39-30.12). Hypertriglycemia was also more prevalent in patients with P(+/+) genotypes for Pvu II polymorphism (P < 0.05, OR = 3.0, 95% CI = 1.06-8.50). Genotype frequency for LPL polymorphism did not differ significantly between UC patients and controls. CONCLUSION: Ser447stop and Hind III LPL polymorphisms may influence age of onset of UC, while Hind III and Pvu II polymorphisms influence serum triglyceride in UC patients.

[Fluctuation of the fibrosis markers with aging].

Actual age and biological age are not always proportional. To find out indices of aging, other than actual age, we investigated relationship between aging and four hepatic fibrosis markers: hyaluronates, type IV collagen, type IV collagen 7s and P III P. The subject of this study were 78 patients of inpatients and outpatients of our hospital. They were divided into four groups of very elderly (over 80-year-old), elderly (70-79-year-old), non-elderly (50-69-year-old), and non-elderly (20-49-year-old), and these four groups were compared. The results were as follows: regarding hyaluronates value were 86.3 +/- 46.7 ng/ml in the patients in the very elderly group, 58.9 +/- 37.4 ng/ml in the elderly group, 48.7 +/- 71.9 ng/ml in patients aged between 50 and 69 years old, and 22.6 +/- 26.1 ng/ml in patients aged between 20 and 49 years old. Regarding type IV collagen value were 134.6 +/- 27.8 ng/ml in the very elderly group, 131.1 +/- 46.5 ng/ml in the elderly group, 135.1 +/- 102.1 ng/ml in patients aged between 50 and 69 years old and 92.8 +/- 21.8 ng/ml in patients aged between 20 and 49 years old. Type IV collagen 7s value were 4.4 +/- 0.9 ng/ml in the very elderly group, 4.4 +/- 0.6 ng/ml in the elderly group, 4.8 +/- 1.6 ng/ml in patients of between 50 and 69 years old, and 4.3 +/- 0.6 ng/ml in patients between 20 and 49 years old. P III P value were 0.70 +/- 0.31 U/ml in the very elderly group, 0.64 +/- 0.34 U/ml in the elderly group, 0.59 +/- 0.43 U/ml in patients aged between 50 and 69 years old, and 0.46 +/- 0.14 U/ml in patients aged between 20 and 49 years old. The results indicated that three markers: hyaluronates, type IV collagen, P III P increased with the aging. Especially, hyaluronates were remarkably increased. Next, we studied 159 patients (78 patients added to 81 patients who visited our hospital for health checkup), and investigated the fluctuation of hyaluronate values by the aging. The results showed a definite increase of hyaluronate values with age. A correlation was recognized between ages and hyaluronate values (correlation coefficient: r = 0.64, p < 0.001). Furthermore we investigated effect on aging of various items including fibrosis markers, immunoglobulin or serum albumin by using multiple factor analysis, and found that hyaluronates influenced most strongly on aging (p < 0.0002, p < 0.00002). Thus, hyaluronates could be considered to be an index other than actual ages to evaluate progress of aging.

Clinical study using novel endoscopic system for measuring size of gastrointestinal lesion.

AIM: To verify the performance of a lesion size measurement system through a clinical study. METHODS: Our proposed system, which consists of a conventional endoscope, an optical device, an optical probe, and a personal computer, generates a grid scale to measure the lesion size from an endoscopic image. The width of the grid scale is constantly adjusted according to the distance between the tip of the endoscope and lesion because the lesion size on an endoscopic image changes according to the distance. The shape of the grid scale was corrected to match the distortion of the endoscopic image. The distance was calculated using the amount of laser light reflected from the lesion through an optical probe inserted into the instrument channel of the endoscope. The endoscopist can thus measure the lesion size without contact by comparing the lesion with the size of the grid scale on the endoscopic image. (1) A basic test was performed to verify the relationship between the measurement error eM and the tilt angle of the endoscope; and (2) The sizes of three colon polyps were measured using our system during endoscopy. These sizes were immediately measured by scale after their removal. RESULTS: There was no error at α = 0°. In addition, the values of eM (mean ± SD) were 0.24 ± 0.11 mm (α = 10°), 0.90 ± 0.58 mm (α = 20°) and 2.31 ± 1.41 mm (α = 30°). According to these results, our system has been confirmed to measure accurately when the tilt angle is less than 20°. The measurement error was approximately 1 mm in the clinical study. Therefore, it was concluded that our proposed measurement system was also effective in clinical examinations. CONCLUSION: By combining simple optical equipment with a conventional endoscope, a quick and accurate system for measuring lesion size was established.

Involvement of NAD(P)H:quinone oxidoreductase 1 and superoxide dismutase polymorphisms in ulcerative colitis.

Inflammatory bowel disease is a multifactorial disease. Oxidative stress has been thought to be one of etiologic factor for inflammatory bowel disease. The genes superoxide dismutase (SOD2) and NAD(P)H:quinone oxidoreductase 1 (NQO1) are involved in inflammation and oxidative stress. The purpose of the present case-control study with 134 patients with ulcerative colitis (UC) and 125 healthy controls was to determine whether polymorphisms of these genes, the NQO1 C609T and the SOD2 Ala-9Val, are associated with the risk of UC and influence the clinical characteristics. These polymorphisms were examined by polymerase chain reaction-restriction fragment length polymorphisms and direct sequencing. In patients showing steroid resistance, the number with the NQO1 T/T genotype was significantly higher than other genotypes (odds ratio 9.45, 95% confidence interval 2.46-41.6, p = 0.002). In the patients whose onset of UC was age 20 years or younger, more patients had SOD2 T/T genotype than the other genotypes (odds ratio 6.46, 95% confidence interval 0.82-51.0). No association between these polymorphisms and UC risk was apparent. The NQO1 C609T polymorphism may influence steroid resistance of UC patients, while the SOD2 Ala-9Val polymorphism may influence age of onset of UC. Oxidative stress may influence the clinical features of UC.