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Abstract Background Lower gastrointestinal perforation (LGP) is an acute abdominal condition associated with a high mortality rate. Timely and accurate diagnosis is crucial. Nevertheless, a diagnostic delay has been estimated to occur in approximately one-third of the cases, and the factors contributing to this delay are yet to be clearly understood. This study aimed to evaluate the diagnostic process for appropriate clinical reasoning and availability of image interpretation in cases of delayed diagnosis of LGP. Methods A secondary data analysis of a large multicenter retrospective study was conducted. This descriptive study analyzed data from a multicenter, observational study conducted across nine hospitals in Japan from January 2015 to December 2019. Out of 439 LGP cases, we included 138 cases of delayed diagnosis, excluding patients with traumatic or iatrogenic perforations, or those secondary to mesenteric ischemia, appendicitis, or diverticulitis. Clinical history and computed tomography (CT) imaging information were collected for 138 cases. Additionally, information on the clinical course of 50 cases, which were incorrectly diagnosed as gastroenteritis, constipation, or small bowel obstruction, was also collected. Results In 42 (30.4%) cases of delayed diagnosis of LGP, CT imaging was performed before diagnosis, indicating a missed opportunity for timely diagnosis. Moreover, 33 of the 50 patients initially diagnosed with gastroenteritis, constipation, or small bowel obstruction at the time of initial examination had atypical findings that were not consistent with the initial diagnosis. Of the 138 cases with delayed diagnosis in our study, 67 cases (48.6%) showed problems with either the interpretation of CT scans or with the process of clinical reasoning. Conclusion Our retrospective study results indicate that approximately half of the cases with delayed diagnosis of LGP were due to problems in interpreting CT images or in clinical reasoning. This finding suggests that clinical reasoning and image interpretation by radiologists are important in improving the diagnostic process for LGP.

Introduction: The cognitive function score (CFS) is a public scale for assessing the activities of daily living (ADL) in older adults with dementia in Japan. In contrast, the scores of the revised Hasegawa’s dementia scale (HDS-R), an easy-to-use dementia screening tool developed in Japan, are significantly correlated with mini-mental state examination scores and are widely utilized in various countries. This novel study aimed to elucidate the previously unexplored criterion-related validity of the CFS and HDS-R and the Bedriddenness Rank (BR), Barthel index (BI), and Katz index (KI). Methods: This was a multicenter retrospective study and a secondary analysis of our previous study. The study included patients aged ≥20 years hospitalized in chronic care settings between April 1, 2018, and March 31, 2021. We collected data from medical charts on admission, including age, sex, the BR, CFS, BI, KI, and HDS-R scores. Correlations between the CFS and HDS-R score, as well as between the BR and BI or KI, were analyzed using Spearman’s rank correlation coefficients. Results: A total of 749 participants were included in the analysis of criterion-related validity between the CFS and HDS-R. In the CFS cohort analysis, 202 patients (27.0%) were categorized as having a normal CFS, and the median HDS-R score was 18 (range: 6–26). The correlation coefficient between the CFS and HDS-R scores was −0.834 (p < 0.001). The correlation coefficient between BR and BI was −0.741 (p < 0.001), BR and KI was −0.740 (p < 0.001). Conclusion: The CFS revealed significant criterion-related validity compared with the established cognitive assessment scale, the HDS-R. The BR also demonstrated significant criterion-related validity with the BI and KI.

Key Clinical Message Listeria can cause neurological symptoms in immunocompromised and older patients. Additionally, it is impossible to rule out meningitis by the absence of typical meningeal irritation signs. Therefore, patients with fever and neurological impairments should be rapidly examined for blood and cerebrospinal fluid cultures to rule out Listeria meningitis. Abstract A woman in her 90s developed fever, dysarthria, and transient disturbance of consciousness. Physical examination revealed no meningeal irritation signs. Listeria monocytogenes were detected in her blood culture the following day. Because of an increased number of cells in cerebrospinal fluid, she was diagnosed with Listeria meningitis.

Abstract Lower gastrointestinal perforation is rare and challenging to diagnose in patients presenting with an acute abdomen. However, no study has examined the frequency and associated factors of diagnostic errors related to lower gastrointestinal perforation. This large-scale multicenter retrospective study investigated the frequency of diagnostic errors and identified the associated factors. Factors at the level of the patient, symptoms, situation, and physician were included in the analysis. Data were collected from nine institutions, between January 1, 2015 and December 31, 2019. Timely diagnosis was defined as diagnosis at the first visit in computed tomography (CT)-capable facilities or referral to an appropriate medical institution immediately following the first visit to a non-CT-capable facility. Cases not meeting this definition were defined as diagnostic errors that resulted in delayed diagnosis. Of the 439 cases of lower gastrointestinal perforation identified, delayed diagnosis occurred in 138 cases (31.4%). Multivariate logistic regression analysis revealed a significant association between examination by a non-generalist and delayed diagnosis. Other factors showing a tendency with delayed diagnosis included presence of fever, absence of abdominal tenderness, and unavailability of urgent radiology reports. Initial misdiagnoses were mainly gastroenteritis, constipation, and small bowel obstruction. In conclusion, diagnostic errors occurred in about one-third of patients with a lower gastrointestinal perforation.

Abstract A 66‐year‐old man with perianal pain was found to have a tender erythematous mass on the left side of the anus. Thoracoabdominal computed tomography with contrast enhancement showed a massive anorectal abscess extending from the rectum to the perianal area. The final diagnosis was anorectal abscess caused by rectal cancer.

Abstract An 80‐year‐old man who presented with only lower anterior chest pain was diagnosed as sigmoid colon diverticulitis. His chest pain was considered to be referred pain from a disease at sigmoid colon, which should be suspected when other major causes of chest pain are excluded.

Abstract An 85‐year‐old woman presented with pain and a palpable mass in her left flank. Abdominal computed tomography revealed massive splenomegaly and para‐aortic lymphadenopathies. Bone marrow biopsy showed CD79a, CD20, and bcl‐2‐positive atypical lymphocytes, which led to the diagnosis of splenic marginal zone lymphoma.

AimBedriddenness Rank (BR) and Cognitive Function Score (CFS), issued by the Ministry of Health, Labour and Welfare, Japan, are easy-to-use and widely used in the medical and long-term care insurance systems in Japan. This study aims to clarify the criterion-related validity of the CFS with the Mini-Mental State Examination (MMSE) and ABC Dementia Scale (ABC-DS), and to re-evaluate the criterion-related validity of BR with the Barthel Index (BI) or Katz Index (KI) in more appropriate settings and a larger population compared with the previous study.MethodsA single-center prospective observational study was conducted in an acute care hospital in a suburban city in Japan. All inpatients aged 20 years or older admitted from October 1, 2018 to September 30, 2019. The relationship between BR and the BI and KI, and the relationship between CFS and the MMSE and ABC-DS were analyzed using Spearman's correlation coefficients.ResultsWe enrolled 3,003 patients. Of these, 1,664 (56%) patients exhibited normal BR. The median (interquartile range) values of the BI and KI were 100 (65-100) and 6 (2-6), respectively. Spearman's rank correlation coefficients between BR and the BI and KI were -0.891 (p < 0.001) and -0.877 (p < 0.001), respectively. Of the patients, 1,967 (65.5%) showed normal CFS. The median (interquartile range) MMSE of 951 patients with abnormal CFS and ABC-DS of all patients were 15 (2-21) and 117 (102-117), respectively. Spearman's rank correlation coefficients between CFS and MMSE and ABC-DS were -0.546 (p < 0.001) and -0.862 (p < 0.001), respectively.ConclusionsBR and CFS showed significant criterion-related validity with well-established but complicated objective scales for assessing activities of daily living and cognitive functions, respectively. These two scales, which are easy to assess, are reliable and useful in busy clinical practice or large-scale screening settings.

Abstract Physicians should be familiar with May‐Thurner syndrome, characterized by the compression of the left common iliac vein by the right common iliac artery and the vertebral body, resulting in pain and swelling of the left lower extremity and DVT. A 64‐year‐old woman presented with unexplained edema in the left lower extremity. Computed tomography with contrast enhancement revealed that the left common iliac vein was compressed and narrowed by the right common iliac artery and the vertebral body, leading to the diagnosis of May‐Thurner syndrome.

Summary: Background: Severe fall injuries in inpatients extend hospital stay, increase medical costs, and shorten patients' healthy life expectancy. The objective of this study was to clarify the predictors for severe fall injuries requiring treatments of inpatients in acute care settings. Methods: We retrospectively analysed adult inpatients who suffered falls in an acute care hospital in Kyushu, Japan from April 2012 to January 2015. Using hospital record data, we compared patients who had required treatments after falls with those who had not by univariate and multivariate analyses. Results: Among 371 patients who suffered falls, the median age was 83 years (interquartile range: 78–87 years). Fall required treatments in 46 patients (12%). In those required treatments, univariate analysis revealed higher percentages of patients with visual impairment (OR: 4.1, 95%CI: 1.3–12.8, p = 0.023) and a bedriddenness rank of A (partial dependence with housebound status) (OR: 2.4, 95%CI: 1.3–4.5, p = 0.006) as well as patients aged ≥85 years (OR: 1.9, 95%CI: 1.0–3.6, p = 0.039). There were lower percentages of patients with a cognitive function score of 4 (requiring constant assistance with symptoms interfering with daily activities) (p = 0.008). In multivariate analysis, age of ≥85 years (OR: 2.2, 95%CI: 1.1–4.2, p = 0.021), visual impairment (OR: 4.2, 95%CI: 1.3–13.9, p = 0.019), and a bedriddenness rank of A (OR: 2.4, 95%CI: 1.3–4.7, p = 0.009) were associated with falls requiring treatment. Conclusion: Visual impairment, partial dependence in activities of daily living and 85 years of age or older could be useful predictors for severe fall injuries. Keywords: bedriddenness rank, cognitive function score, severe fall injuries, severity of incidents and accidents

Background: Appropriate management of patients who have fallen is crucial for reducing damage and mortality. We report the case of a patient who fell from a seated position, which caused traumatic liver injury, with gastrointestinal symptoms as the primary patient concern. Case Report: A woman in her 80s who was living independently fell from a seated position during the daytime. She presented to our clinic the next day, reporting vomiting and loose stools. Her vital signs included blood pressure of 100/48 mmHg and a pulse rate of 76 beats/minute, with tenderness over the right chest wall. She was suspected of having a fracture in the absence of X-ray imaging and was advised to rest and treated with analgesia on demand. Subsequent laboratory results showed levels of hemoglobin, alanine transaminase, and lactate dehydrogenase of 98 g/L, 659 U/L, and 429 U/L, respectively. At the hospital, a computed tomography scan revealed severe liver injury and rib fractures. Vascular embolization or surgery was not performed, and hematogenous pleural effusion was drained once via thoracentesis. The hematoma did not enlarge, and the patient's ability to perform activities of daily living gradually improved. She was discharged after 10 days of hospitalization. Conclusions: The patient presented with gastrointestinal symptoms, leading to a delayed diagnosis of severe liver injury. Low-energy trauma can cause fatal injuries, and physicians should assess patients who fall for the risk of organ injuries, while being mindful of potential biases. Additionally, non-specific symptoms after trauma can be associated with organ injury. [ABSTRACT FROM AUTHOR]

Background: Depopulated and aging areas in Japan, the proportion of older people who die at home tends to be lower than the national average. We investigated the trend regarding their preference for dying at home and associated factors among older residents living in a village. Methods: We conducted a questionnaire-based cross-sectional study in February and June 2020, targeting residents of Mitsuse Village aged ≥ 65 years. We compared two groups for each factor, residents who preferred to die at home (Group H) and the remainder (Group O). Results: In total, 223 (62%) residents responded to the survey. Participants' median age was 77 years, and 44% were men. Group H accounted for 47% of the total. Univariate analysis showed that Group H was older (p = 0.010) and included a smaller proportion who used a private vehicle (p = 0.036), compared with Group O. Multivariate analysis showed that male sex and not having a primary care physician were associated with a preference for dying at home (p = 0.031 and p = 0.041). Availability of transportation, social isolation, family economic status, or knowledge of long-term care were not independent associations with a preference for dying at home. Conclusions: To fulfill the wishes of older people who prefer to die at home in depopulated areas of Japan, establishing better home medical, nursing, or long-term care systems with improved human and financial resources is essential. Further research on how to support individuals' preference for dying at home is needed. [ABSTRACT FROM AUTHOR]

Objective: Unusual clinical course. Background: Helicobacter cinaedi is a rare bacterium, accounting for only 0.2% of the positive isolates in blood cultures. Previous reports note that patients with H. cinaedi infection often have underlying diseases. H. cinaedi infection is diagnosed by blood culture. However, because of the slow growth of this bacterium in blood culture, the diagnosis can be missed. Case Report: A 78-year-old man gradually developed erythema and pain in his left arm, then left shoulder and both lower legs. The patient presented to our hospital on day 17. He was afebrile, but the examination was remarkable for tenderness in both gastrocnemius muscles and erythema from the distal left lower leg to the ankle. We suspected pyomyositis and cellulitis and started oral administration of amoxicillin-clavulanate. On day 22, H. cinaedi was detected in blood cultures. Based on these findings, we diagnosed pyogenic myositis and cellulitis caused by H. cinaedi bacteremia. On day 24, antibiotic therapy was changed to intravenous ampicillin, and symptoms improved. Additional examination did not reveal any underlying immunodeficiency disorder, such as malignancy or HIV infection. Conclusions: H. cinaedi infection can occur in healthy patients. Myalgia can be caused by pyogenic myositis because of bacteremia. In cases of myalgia or cellulitis of unknown etiology, blood cultures can be useful when bacteremia is suspected; blood samples should be monitored over an extended period. [ABSTRACT FROM AUTHOR]