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Objective The hospitalist system in the United States has been considered successful in terms of the quality of care and cost effectiveness. In Japan, however, its efficacy has not yet been extensively examined. This study examined the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population using treatment of urinary tract infection as an example. Methods We analyzed 271 patients whose most resource-consuming diagnosis at admission was urinary tract infection between April 2017 and March 2019. Propensity-matched analyses were performed to compare health care economics and the quality of care between the hospitalist system and the conventional system. Results In matched pairs, care by the hospitalist system was associated with a significantly shorter length of stay than that by the conventional system. The quality of care (oral antibiotics switch rate, rate of appropriate antibiotics change based on urine or blood culture results, detection rate of urinary tract infection etiology and the number of laboratory tests) was also considered to be favorably impacted by the hospitalist system. Although not statistically significant, hospital costs tended to be lower with the hospitalist system than with the conventional system. The mortality rate and 30-day readmission were also not significantly different between the groups. Conclusion The hospitalist system had a favorable impact on the quality of care and length of stay without increasing readmission in patients with urinary tract infection. This study is further evidence of the strong potential for the positive impact of an implemented hospitalist system in Japan.

Objective Quantification of patient encounters during internal medicine residency training is challenging. At present, there are no established strategies for evaluating the whole inpatient experience in Japan. We hypothesized that the Diagnosis Procedure Combination (DPC) database, which is widely used in Japan, might be a useful tool for such an evaluation. Methods We analyzed DPC-based patient encounters of five senior residents with different types of training. One of the diseases on receipt computation data, including the four main diseases and at most eight comorbidities, was matched with each category in the Online system for Standardized Log of Evaluation and Registration of specialty training system (J-OSLER), and the match ratios were assessed. The accumulation of each disease classified into J-OSLER categories was also assessed. Monthly extra working hours and total patient-days per resident were evaluated using a Pearson correlation analysis. Results Two residents with two-year rotations in the general internal medicine department showed high numbers of patient encounters and the highest matching ratio with J-OSLER (approximately 60% with 4 major diseases, 91% with all diseases). There was a moderately positive correlation between the total patient-days and extra working hours in these residents, but no such correlation was noted in the rate of monthly patient encounters and extra working hours among residents as a whole. Conclusion The DPC-based quantification of patient encounters during residency training appears effective in evaluating the coverage of the current J-OSLER list. Owing to its wide availability and generalization, this matching method may be useful as a universal tool for assessing internal medicine programs.

ObjectiveThe aim of this study was to compare postoperative mortality and morbidities in patients with hip fractures undergoing surgery by Child-Pugh classes.Summary Background DataAdvanced cirrhosis is associated with increased mortality in several types of surgery, but the impact of severity of cirrhosis on postoperative outcomes in patients with hip fractures remain unclear.MethodsWe analyzed data of patients with hip fracture within a large inpatient database. We performed three sets of 1:1 propensity-score matching for four groups: cases without cirrhosis, and Child-Pugh classes A, B and C. We compared in-hospital mortality, length of stay, hospitalization fee, rate of 30-day readmission and complications in the following three pairs: cases without cirrhosis vs Child-Pugh class A, Child-Pugh class A vs B, and Child-Pugh class B vs C.ResultsAmong 833,648 eligible cases, propensity-score matching created 1,065 pairs between cases without cirrhosis vs Child-Pugh class A, 1,012 pairs between Child-Pugh class A vs B, and 489 pairs between Child-Pugh class B vs C. In-hospital mortality did not differ between cases with cirrhosis and those with Child-Pugh A classification (1.69% vs 1.41%; RD -0.28%; 95% CI: -1.34%–0.78%). In-hospital mortality was significantly higher in patients with Child-Pugh B classification than in those with A classification (1.48% vs 5.93%; RD 4.45%; 95% CI: 2.79%–6.10%), and in those with Child-Pugh C classification compared with those with B classification (6.34% vs 28.43%; RD 22.09%; 95% CI: 17.54%–26.63%). Among cases with cirrhosis, those in more severe Child-Pugh classes had longer length of stay, higher hospitalization fees and higher ratio of complications, such as acute liver failure, upper gastrointestinal bleeding and sepsis.ConclusionsOur results could help to identify patients at high-risk of postoperative mortality and morbidity among those with both hip fracture and cirrhosis. Patients with Child-Pugh C classification may benefit from discussions about nonsurgical management, goals of care, and overall prognosis.Mini-abstractWe conducted propensity-score matched analysis to examine mortality of groups of patients with hip fractures in a national patient database according to degree of severity of cirrhosis. Patients with higher Child-Pugh class of cirrhosis was shown to be associated with higher mortality.

The quality of comprehensive geriatric assessment and medication reconciliation by a nurse practitioner (NP) based in Japan was evaluated by a prospective observational study. Within the 64 inpatients seen by the NP at a postacute care clinic, the achievement rate of 8 comprehensive geriatric assessment items was 93.8%, compared with just 33.8% in the nearby hospital (P

Vertebral compression fractures are common in elderly people and most are due to osteoporosis. Osteoporosis treatment is effective for secondary prophylaxis, so initiation is recommended. Despite the clear benefits, the rate of initiation of osteoporosis treatment is very low. It is reported to be due to several factors including insufficient systems-based approaches for hospitals and post-acute care. Hospitalists, who are physicians dedicated to the treatment of patients in hospital and whose activity is generalist rather than specialized, are reported to be associated with higher-quality inpatient care because of, among other things, closer adherence to guidelines. Co-management by hospitalists for patients with vertebral compression fractures has potential benefits towards improving the outcomes. We compared the rate of initiation of osteoporosis treatment for patients with vertebral compression fractures between conventional orthopedic surgeon-led care (conventional group) and hospitalist co-management care (co-management group).This is a single-center retrospective cohort study to evaluate the rate of initiation of osteoporosis treatment and reasons for non-initiation of osteoporosis treatment. Other clinical indicators were also evaluated, including length of hospital stay, preventable complications during hospitalization, and rate of 30-day readmission.We identified 55 patients in the conventional group and 93 patients in the co-management group. The rate of initiation of osteoporosis treatment was higher in the co-management group (45.2% vs. 3.6%, OR 21.5; 95%CI 5.12-192.0; P 0.01). Most of the patients with non-initiation in the co-management group had reasons for it described in the medical records, but in the conventional group the reasons were unknown. There was no significant difference in length of hospital stay, preventable complications during hospitalization, or 30-day readmission between the groups.Hospitalist co-management of patients with vertebral compression fractures showed significantly higher rate of initiation of osteoporosis treatment than conventional orthopedic surgeon-led care.

Early surgery is recommended for patients with hip fractures. Average time to surgery in Japan is 3.8 days. Such delay could be caused by the burden of preoperative assessment and management of geriatric comorbidities upon orthopedic surgeons. Hospitalist co-management has potential benefits in comprehensive perioperative care that could positively affect time to surgery in patients with hip fractures. We compare clinical outcomes of patients with hip fractures managed by orthopedic surgeon-led care (conventional group) vs. those of patients with hip fractures managed by hospitalist co-management.In this single-center retrospective cohort study, time to surgery was assessed with interrupted time series analyses. Whole length of hospital stay, length of hospital stay after surgery, complications during hospitalization, 30-day readmission, initiation of osteoporosis treatment and adherence to guidelines for deep vein thrombosis prophylaxis were also evaluated with Chi-square or Fisher's exact tests.The conventional group comprised 332 patients and the co-management group 418 patients. Interrupted time series analyses revealed an immediate reduction of time to surgery by 1.2 days (95%CI, -1.9 to -0.4, P = 0.003) with the start of co-management. Whole length of hospital stay and length of hospital stay after surgery tended to be shorter, but without statistical significance. Intermediate to severe complications and 30-day readmission were not significantly different between the groups. In the co-management group, the rate of initiation of osteoporosis treatment (46.4% vs. 6.3%, P 0.001) and adherence rate to guidelines for deep vein thrombosis prophylaxis (99.3% vs. 88%, P 0.001) were significantly higher than those in the conventional group.Hospitalist co-management for elderly patients with hip fractures led to significantly shorter time to surgery than conventional orthopedic surgeon-led care, and had advantages in other clinical indicators.

Acute appendicitis is an important differential diagnosis in patients with right lower quadrant pain during pregnancy. Endometriosis, a hormone-related pathology, is another possibility. Patients with endometriosis are typically symptomatic before pregnancy. Stromal endometriosis is a variant of endometriosis that presents no symptoms before pregnancy but which occasionally presents with the new onset of symptoms during pregnancy. We report the case of a 35-year-old woman in her 8th month of pregnancy who presented with impending appendiceal rupture due to deciduosis of the appendix, a progesterone-related condition, during pregnancy. This case suggests that deciduosis/stromal endometriosis should be considered as a differential diagnosis of acute abdomen during pregnancy, even if the patient is asymptomatic before pregnancy.

Objective: The hospitalist system is considered successful with respect to the quality of care and cost effectiveness in the United States. Studies have consistently demonstrated an improved clinical efficiency with this system. In Japan, however, the efficacy of the hospitalist system has not yet been examined. As a "super-aged society", Japan has a high number of elderly patients with multiple comorbidities who may theoretically receive better care by the hospitalist system than by the conventional system. This study investigates the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population. Methods: We analyzed 274 patients ≥65 years of age in whom the most resource-consuming diagnosis at admission was aspiration pneumonia over a 1-year period. We categorized patients as those managed by hospitalists and those managed by various departments (control group) and compared the groups. Propensity score matching was used to minimize selection bias. Results: For matched pairs, the length of hospital stay in the hospitalist group was shorter than that in the control group. Care by the hospitalist system was associated with significantly lower hospital costs. The quality of care (rate of switching from intravenous to oral antibiotics, duration of antibiotics therapy, number of chest X-rays and blood tests during hospitalization) was also considered to be favorably impacted by the hospitalist system. There was no statistically significant difference in the mortality rate or readmission rate between the groups. Conclusion: This study showed that the hospitalist system had a favorable impact on the quality of care and cost effectiveness, suggesting the potential utility of its implementation in the Japanese medical system.

Hyperbaric oxygen therapy (HBOT) for carbon monoxide (CO) poisoning is widely performed to prevent delayed neuropsychiatric syndrome. Although HBOT can generally be performed with safety, the appropriate management of HBOT still remains unestablished. A 31-year-old man was transferred to our facility to undergo HBOT in a multiplace chamber with a diagnosis of CO poisoning. The first HBOT session ended uneventfully. During the second HBOT session, the patient suddenly experienced convulsive seizures. The accompanying doctor administered intravenous propofol to stop the convulsion and terminated the HBOT. Soon after the convulsion, the patient developed frothy secretions through the endotracheal-tube with impaired oxygenation. Head computed tomography scan showed no abnormalities, suggesting the seizure was associated with complications of HBOT. A chest X-ray revealed bilateral pulmonary edema, and echocardiography revealed normal cardiac function, indicating that the pulmonary edema resulted from HBOT or neurogenic mechanism secondary to the seizure. The patient's respiratory status improved without recurrence of the seizure and no delayed neurological sequelae was seen afterwards. Here we report unexpected rare adverse events during HBOT. Hyperbaric oxygen therapy for acute indications should be performed in multiplace chambers, with appropriate preparation and medical equipment. J. Med. Invest. 65:286-288, August, 2018.

INTRODUCTION: Acute kidney injury (AKI) is strongly associated with poor prognosis of Coronavirus disease 2019 (COVID-19) patients The great pandemic made it challenging to allocate renal replacement therapy (RRT) such as hemodialysis or continuous hemodiafiltration to anuria patients in terms of infection control and medical resources Herein, using an actual case, we argue that peritoneal dialysis (PD) could become a more practical and safer RRT, particularly during this pandemic crisis METHODS: Our case was a 62-year-old male with a PCR test positive for severe acute respiratory syndrome coronavirus (SARS-CoV-2) He had a medical history of lung cancer and some commodities of hypertension, hyperuricemia, and hyperlipidemia The next day after the admission, his oxygenation and hemodynamics rapidly deteriorated We started mechanical ventilation, and administered vasopressors, favipiravir, and ciclesonide Additionally, serum creatinine also became gradually elevated (creatinine: day1 0 77 mg/dL → day5 7 mg/dL) We diagnosed with COVID-19-associated AKI, because urine tests and sonography did not indicate any other cause It progressed to anuria and made it difficult to control the serum potassium and the hemodynamics due to acidemia On day 6, using a portable X-ray machine, we inserted the peritoneal dialysis (PD) catheter to the recto-vesical pouch at the bedside and infused the peritoneal dialysate Although the anuria persisted for a while, the increased amount of peritoneal dialysate easily normalized the acidemia and serum potassium level After the normalization, the vasopressors could be tapered off, and the inflammation status was also improved On day 14, the patient was discharged from our ICU with the PD catheter SARS-CoV-2 was detectable in sputum, but not in the peritoneum and PD waste The whole procedure of PD catheter insertion and dialysate exchange did not influence the respiratory status and hemodynamics at any time RESULTS: Taken together, PD could be a useful option for the AKI management, particularly in the COVID-19 pandemics

Citrobacter koseri is a rare cause of liver abscess with two reported cases in diabetic patients. We report a rare case of C. koseri liver abscess with C. koseri bacteremia in an elderly male with chronic kidney disease. He presented vomiting and weakness without any other signs. He was diagnosed with liver abscess by ultrasound, and blood culture showed C. koseri growth. The patient was treated effectively with a course of antibiotics and drainage. When C. koseri is isolated in patients with comorbidity, such as chronic kidney disease, we should consider the possibility of abscess including liver abscess and utilize a combined treatment of drainage and course of antibiotics for mixed infection.