Chubu Hospital Research Articles

How do mandatory emergency medicine rotations contribute to the junior residents’ professional identity formation: a qualitative study

BackgroundThis study aims to investigate the impact of short-term mandatory emergency medicine rotations on professional identity formation of Japanese junior residents. Using situated learning theory as a theoretical framework, we explore how this rotation, which is part of a two-year Junior residency in the transition period from students to qualified physicians.MethodsWe conducted a qualitative study conducting semi-structured face-to-face interviews with Year 1 postgraduate residents in the 2020–2021 classes of the junior residency program in Okinawa Chubu Hospital, Japan (n = 10). The data obtained from the interviews were analysed using inductive thematic analysis to identify the themes regarding professional identity formation.ResultsFour main themes regarding professional identity formation emerged from the data analysis: patient care, teamwork, role models, and peers. Junior residents said they had the opportunity to participate in the emergency department community and experience training in authentic clinical contexts. Clinical exposure influenced the professional identity formation of the junior residents. Nurses and peers played a crucial role in this. Junior residents see the training in the emergency department as the beginning of their careers.ConclusionShort-term mandatory rotations enabled junior residents to integrate into the emergency department community, demonstrating autonomy and responsibility. These experiences fostered their professional identity by helping their socialisation within the community of practice.

Predictors of relapse of polymyositis/dermatomyositis associated interstitial lung disease.

Polymyositis/dermatomyositis (PM/DM) patients often develop interstitial lung disease (ILD), which can lead to relapse despite anti-inflammatory treatments. This study aims to elucidate the clinical characteristics of relapses in PM/DM-associated ILD patients. We gathered clinical data, including laboratory results, pulmonary function tests, chest high-resolution computed tomography findings from patients treated at Okinawa Chubu Hospital between January 1, 2010 and December 31, 2018. We identified a total of 74 patients, comprising 21 men and 53 women. Among them, 38 patients remained relapse-free with maintenance therapy, while 36 experienced relapses despite immunosuppressive management. We followed these patients until June 30, 2023, and 13 patients died. The median survival period was 51.4 months (range, 0.3-214 months). When comparing clinical variables, relapsed patients tended to be younger (49.9 vs. 64.1 years), reported myalgia and rash more frequently (63.9% vs. 28.9% and 61.15% vs. 21.1%, respectively). In terms of laboratory findings, lactate dehydrogenase (LDH) levels were higher in relapsed patients (613±464 vs. 381±203 U/L). Radiological findings showed that ground glass opacity (GGO) was more prevalent in relapsed patients (58.3% vs. 16.7%). A Cox-proportional hazards model for relapse demonstrated that serum LDH [hazard ratio (HR) 1.005, 95% confidence interval (CI): 1.000-1.009, P=0.02] and GGO (HR 1.863, 95% CI: 1.103-3.147, P=0.02) were valuable predictors of relapse. Receiver operating characteristic curve analysis of serum LDH indicated that a threshold of 450 correctly classified relapse in PM/DM-associated ILD patients. Serum LDH and GGO may serve as predictors of relapse in PM/DM-associated ILD patients.

Radiological and Physiological Predictors of IPF Mortality.

Background and Objectives: Idiopathic pulmonary fibrosis (IPF) has a variable clinical course, which ranges from being asymptomatic to progressive respiratory failure. The purpose of this study was to evaluate the novel clinical parameters of IPF patients who receive an anti-fibrotic agent. Materials and Methods: From January 2011 to January 2021, we identified 39 IPF patients at Okinawa Chubu Hospital. Clinical information was obtained, such as laboratory data, pulmonary function test (PFT) results, and chest images, including of soft tissue thickness and the high-resolution computed tomography (HRCT) pattern at diagnosis. Results: The mean age was 72.9 ± 7.0 (53–85); 27 patients were men and 12 were women. The mean body mass index was 25.1 ± 3.9 (17.3–35). Twenty-four were active smokers and the median number of packs per year was 20. Regarding laboratory findings, mean white blood cell (WBC), lactate dehydrogenase (LDH), and Krebs Von den Lungen-6 (KL-6) values were 7816 ± 1859, 248 ± 47, and 1615 ± 1503, respectively. In PFT, the mean percent predicted FVC, percent predicted total lung capacity, percent predicted functional residual capacity (FRC), and percent predicted diffusion capacity of the lung for carbon monoxide (DLco) were 66.8 ± 14.9%, 71.8 ± 13.7%, 65 ± 39.6%, and 64.6 ± 27.9%, respectively. In chest radiological findings, soft tissue thickness at the right 9th rib was 26.4 ± 8.8 mm. Regarding chest HRCT patterns, 15 showed the definite usual interstitial pneumonia (UIP) pattern, 16 showed the probable UIP pattern, and eight showed the indeterminate for UIP pattern. In the treatment, 24 patients received pirfenidone and 15 patients took nintedanib. The mean observation period was 38.6 ± 30.6 months and 24 patients died. The median survival time was 32.4 months (0.9–142.5). Multivariate analysis adjusted for age showed that both soft tissue thickness [Hazard ratio (HR): 0.912, 95% confidence interval (CI): 0.859–0.979, p-value: 0.009] and percent FRC [HR: 0.980, 95% CI: 0.967–0.992, p-value: 0.002] were robust predictors of IPF mortality. Conclusions: In IPF patients treated with anti-fibrotic agents, both soft tissue thickness at the right 9th rib shown on the chest radiograph and %FRC can be novel predictors of IPF mortality.

Clinical Characteristics of Disseminated Strongyloidiasis, Japan, 1975-2017.

Clinical characteristics of disseminated strongyloidiasis, the severest form of strongyloidiasis, are not well described. We conducted a retrospective, consecutive chart review of patients with disseminated strongyloidiasis admitted to Okinawa Chubu Hospital in Okinawa, Japan, during January 1975-December 2017. The 70 patients were classified into 3 clinical phenotypes: dissemination (32 patients [45.7%]), occult dissemination with meningitis caused by enteric organisms (12 patients [17.1%]), and occult dissemination with culture-negative suppurative meningitis (26 patients [37.1%]). Associated mortality rates were 56.3%, 16.7%, and 11.5%, respectively, and sepsis occurred in 40.6%, 58.3%, and 11.5% of cases, respectively. Common symptoms included fever (52.9% of patients), headache (32.9%), and altered mental status (24.3%). Patients were treated with thiabendazole (before 2003) or ivermectin (after 2003). Our findings show that disseminated strongyloidiasis has clinical phenotypes in terms of severity and that identification of occult dissemination, a mild form with prominent neurologic manifestations, is lifesaving.

Utility of point-of-care Gram stain by physicians for urinary tract infection in children ≤36 months.

Urinary tract infection (UTI) in children requires early diagnosis and treatment to prevent repeated UTI and renal scarring. This study aimed to evaluate the usefulness of the point-of-care Gram stain by physicians for suspected UTI in children at Okinawa Chubu Hospital as a rapid diagnostic test.A single-center, retrospective study was undertaken between January 2011 and December 2015. Patients aged 36 months or younger who were reviewed had suspected UTI in the emergency room or outpatient clinic. Urine culture, urinalysis, and point-of-care Gram stain were performed on a single specimen. Patients with structural or functional urological defects requiring routine catheterization were excluded. We compared the diagnostic performance among the rapid diagnostic tests (i.e., pyuria, point-of-care Gram stain, or both). Kappa statistics were used to evaluate the agreement between the results of point-of-care Gram stain and morphotypes of urine culture with the 95% CI (bias corrected bootstrap interval). We also analyzed which antibiotics were more susceptible to the bacteria of urine culture results, selected by the results of point-of-care Gram stain or empirical treatment based on the Japanese guidelines by McNemar test.Of 1594 patients reviewed in the study, 1546 were eligible according to our inclusion criteria. Using urine culture as the gold standard for UTI, the sensitivity and specificity of pyuria were 73.2% and 95.1%, whereas those of the point-of-care Gram stain were 81.4% and 98.2%, respectively. The concordance rate between the morphotypes of bacteria detected by point-of-care Gram stain and those of urine culture was 0.784 (kappa coefficient) (95% CI 0.736–0.831). Furthermore, the proportion of “susceptible” in the minimum inhibitory concentration of pathogen-targeted treatment based on the point-of-care Gram stain was higher than that of empirical therapy (exact McNemar significance probability: .0001).Our analysis suggests that the point-of-care Gram stain is a useful rapid diagnostic tool for suspected UTI in young children. Pathogen-targeted treatment based on the point-of-care Gram stain would lead to better antibiotic selection compared with empirical therapy.

鈍的腎茎部損傷の治療法の変遷(Transition of treatment for blunt renal pedicle injury: through our 12 cases)

要旨鈍的腎茎部損傷（以下，本症）は，多発外傷を伴うことが多く，迅速な治療の選択を迫られる。しかし治療法が確立しているわけではない。自験例を検討し，本症の治療法を考える。沖縄県立中部病院の33年間と，沖縄県立北部病院の27年間に経験した12例に対して，診療録を後方視的に検討した。男女比は男9例，女3例。年齢中央値は31歳（9–58）。受傷機転は交通外傷10例，木材による圧挫傷1例，転落1例。多発外傷は5例で，他臓器損傷は全例に認めた。治療は腎摘6例，再建4例，未治療2例であった。再建腎の腎機能回復例は，1例のみであった。未治療の1例に高血圧を発症した。血液透析を要する症例はなかった。死亡例は2例で，原因は大量出血による凝固障害と敗血症であった。本症の治療では，救命が最優先であり，そのための腎摘や未治療は，許容される。再建群では不完全閉塞型腎動脈損傷の1例に術後腎機能が回復した。完全閉塞型に対する再建の成功率は非常に低いと考える。

Current State of the Consistent Treatment of Cleft Lip and/or Palate Patients in Craniomaxillofacial Center, Okinawa Chubu Hospital

Current State of the Consistent Treatment of Cleft Lip and/or Palate Patients in Craniomaxillofacial Center, Okinawa Chubu Hospital

Clinical characteristics of idiopathic pulmonary fibrosis patients with gender, age, and physiology staging at Okinawa Chubu Hospital.

Gender, age, and physiology (GAP) staging was recently advocated for idiopathic pulmonary fibrosis (IPF). However, clinical findings of GAP staging for IPF are limited. We aimed to investigate the clinical characteristics of IPF patients according to GAP staging in our hospital. We retrospectively reviewed patient medical records and chest high-resolution computed tomography (HRCT) images from June 1, 2002, to December 31, 2012. We identified 54 IPF patients with [36 men; mean age: 71 years (range, 53-85 years)]. Mean fibrosis and ground glass opacity (GGO) scores were 1.9 (0-4) and 1.6 (1-3.3), respectively. Mean percent predicted forced vital capacity (% FVC), percent predicted diffusing capacity of the lung for carbon monoxide (% DLco) were 70.6 (6.4-114.3), 49.2 (15-105.9), respectively. Cox proportional hazards model showed that gender, percent predicted diffusing capacity of the lung for carbon monoxide (% DLco), and composite physiologic index (CPI) were strong predictors of mortality. Stage III patients had more pulmonary hypertension (50% vs. 23%, 0%) and progressive modified Medical Research Council (mMRC) changes at 1 year (1.3 vs. 0.6, 1.1; P=0.07) compared with other stages. In our cohort, GAP staging was useful for evaluating IPF severity. Stage III patients might had more pulmonary hypertension and progressive dyspnea. Multicenter analyses are warranted to confirm these findings.

FRI0412 Urinalysis Findings and Renal Pathology in Japanese Patients with Lupus Nephritis

BackgroundRenal biopsy is crucial to establish the pathologic classification of lupus nephritis (LN), but urinalysis is usually evaluated first. Active urinary sediment (hematuria or cellular casts) is conventionally interpreted as...

Staging of Acute Exacerbation in Patients with Idiopathic Pulmonary Fibrosis

The purpose of this study was to evaluate the predictors of a 3-month mortality rate of acute exacerbation of idiopathic pulmonary fibrosis (IPF) and provide a new staging system. A total of 594 patients with IPF were included in this retrospective, observational study conducted from January 2001 to December 2010 at Okinawa Chubu Hospital. Among the 594 patients, 58 (9.8%) developed acute exacerbation (AE) of IPF during the 10-year observation period. The median follow-up period for AE was 10.4months. In-hospital mortality was 56.9% and the 3-month mortality rate was 63.8%. We identified the following four parameters in a multivariate analysis as: serum lactate dehydrogenase, sialylated carbohydrate antigen (KL-6), ratio of partial pressure of oxygen and fraction of inspiratory oxygen, and total extent of abnormal findings on high-resolution computed tomography of the chest. Patients were divided into two groups on the basis of the four composite parameters. Patients in the extensive disease-stage group required more mechanical ventilation and intensive therapy than those in the limited disease-stage group. The 3-month mortality rate was higher in patients in the extensive disease-stage group than in patients in the limited disease-stage group (80.6 vs. 54.5%, respectively; p=0.007). Staging of AE in patients with IPF provided useful information regarding disease severity and short-term outcome.

Management of spontaneous isolated dissection of the superior mesenteric artery: Case report and literature review

Background and methodThe aim of this study was to assess retrospectively the clinical presentation, management and outcome of three patients with isolated SMA dissection encountered at Okinawa Prefectural Chubu Hospital, Japan from 2005 to 2006, along with a review of the literature. We follow up the patient's clinical symptoms and the image by using enhanced dynamic CT at 1 week, 1 or 2 months, 6 months, and yearly after onset.Case presentationWe present three patients with acute abdominal pain due to spontaneous dissection of the superior mesenteric artery (SMA), who were treated by surgical revascularization or conservative management. Two patients underwent surgery because of signs or symptoms of intestinal ischemia and one patient elected conservative management. The SMA was repaired by bypass graft in two cases, and in one of these, the graft was occluded because of prominent native flow from the SMA. All patients were symptom free and there was no evidence of disease recurrence after a median follow-up of 4.3 years.ConclusionAlthough the indications for surgery are still controversial, we should proceed with exploratory laparotomy if the patient has acute symptoms with suspicion of mesenteric ischemia. A non-operative approach for SMA dissection requires close follow-up abdominal CT, with a focus on the clinical signs of mesenteric ischemia and the vascular supply of the SMA, including collateral flow from the celiac artery and inferior mesenteric artery.

Population Strategies to Decrease Sodium Intake

Letters17 August 2010Population Strategies to Decrease Sodium IntakeMihaly Tapolyai, MDMihaly Tapolyai, MDFrom University of Hawaii Postgraduate Medical Program Chubu Hospital, Okinawa 904-2293, Japan.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-153-4-201008170-00021 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:Smith-Spangler and colleagues (1) strategize how to reduce dietary sodium in entire populations and countries for the benefits they assume will result. Unfortunately, their assumptions are incorrect. They state that “sodium consumption raises blood pressure, increasing the risk for heart attack and stroke.” This is true only in a small percentage of the population. Most persons (especially white persons) are not salt-sensitive, as shown in a Cochrane review (2), and salt restriction does not achieve better survival, as shown in NHANES I (First National Health and Nutrition Examination Survey) (3), although it may reduce blood pressure somewhat. ...

Management of right-sided diverticulitis: A retrospective review from a hospital in Japan

Right-sided diverticulitis is a rare clinical entity in Western countries; however, in some Asian countries diverticulitis affects the right side of the colon more often than the left side. This study aims to establish some guidelines for patients with right-sided diverticulitis because at present, there are only guidelines for those with acute left-sided diverticulitis. A review was conducted of the medical records of patients with acute right-sided diverticulitis admitted to Okinawa Prefectural Chubu Hospital, a teaching hospital in Japan, between 1994 and 2005. Right-sided diverticulitis was identified in 110 patients. The mean age of these patients was significantly lower than that of those with left-sided diverticulitis (43.4 +/- 14.8 years vs 54.8 +/- 17.4 years, respectively). Emergency laparotomy was performed for suspected acute appendicitis in 10 patients. Initial conservative therapy did not fail in any of the remaining 100 patients, although 5 underwent subsequent elective surgery, and 8 (8.4%) of the remaining 95 suffered recurrent right-sided diverticulitis, which was treated successfully with conservative therapy. Patients with acute right-sided diverticulitis seldom require emergency surgery unless acute appendicitis is misdiagnosed preoperatively. Most cases of uncomplicated right-sided diverticulitis, even if it is recurrent, can be treated conservatively.

Diagnostic Performance of Pyogenic Vertebral Osteomyelitis

Early diagnosis of pyogenic vertebral osteomyelitis (PVO) is frequently difficult. There are, however, few studies that have investigated the diagnostic performance of PVO in Japan. Our aim was to analyze the diagnostic performance and identify clinical factors associated with the diagnostic delay of PVO. We performed hospital-based retrospective case analysis. All patients with PVO were identified from the computerized medical database at Okinawa Chubu Hospital in Okinawa, Japan, from January 1985 to December 2004. We collected the following data; baseline information; laboratory tests; clinical and microbiologic outcomes; and diagnostic process. We used multivariable-adjusted linear regression to identify significant factors associated with patient and hospital delay to the diagnosis of PVO. We reviewed total of 209,428 patients hospitalized during the 20-year study period. Of those, we identified 51 patients with PVO. Eighty percent of these patients were misdiagnosed at their initial clinical encounters. Median duration from the symptom onset to the diagnosis was 19 days. Median durations of patient factor and hospital factor that contributed to the total delay were 1 and 8 days, respectively. Significant patient factor that contributed to delay was cognitive dysfunction. Cognitive dysfunction is a risk factor for patient delay for visiting physicians in patients with PVO. Diagnosis of PVO is difficult at the initial clinical encounter. High index of suspicion is needed for more rapid diagnosis of PVO.

Emergence of rifampicin resistance in methicillin-resistant Staphylococcus aureus in tuberculosis wards

To assess whether the occurrence of rifampicin (RFP) resistance in methicillin-resistant Staphylococcus aureus (MRSA) is related to treatment of tuberculosis, we determined the RFP susceptibility of MRSA isolates obtained from tuberculosis patients and screened for mutation(s) in the rpoB gene of these isolates. The MICs of RFP for 84 MRSA isolates obtained from two hospitals in Japan were determined. DNA was sequenced in the region 1318-1602 nucleotides (nt) of the rpoB gene, which includes RFP resistance-determining clusters I (1384-1464 nt, 462-488 amino acids). The majority of MRSA isolates from tuberculosis wards, i.e., 48 of 51 (94%) [33 of 34 in a Tokyo hospital (97%) and 15 of 17 in a Chubu hospital (88%)], were resistant to RFP. Meanwhile, no isolates of 33 from the other wards were resistant to RFP. All RFP-resistant MRSA isolates had a mutation(s), including novel mutation(s) such as Val453-->AEPhe, Asp471-->AEAsn, and Ile527-->AELeu, in rpoB. An emergence of RFP-resistant MRSAs in tuberculosis wards in Japan was strongly suggested.

Postgraduate Medical Training System at Okinawa Chubu Hospital

Postgraduate Medical Training System at Okinawa Chubu Hospital

沖縄県における高脂血症用剤の処方せん発行実態調査

We investigated the characteristics of hypolipidemic drug use at hospitals in Okinawa. We constructed a drug information database for prescriptions issued by 5 hospitals with over 300 beds in Okinawa (Okinawa Hokubu Hospital, Okinawa Chubu Hospital, Urasoe General Hospital, University of the Ryukyus Hospital and Okinawa Kyodo Hospital). A total of 16, 250 prescriptions was issued by the 5 hospitals from June 1 to 7, 1999 and among them 999 (6.1%) were for hypolipidemic drugs.Hypolipidemic drugs comprised the highest proportion of prescriptions in the 65-74 years age group and in the 45-84 years age group they accounted for 92.9% of the total. By chemical structure, HMG-CoA reductase inhibitors were prescribed the most among hypolipidemic drugs and nicotinic acid derivatives came second, followed by fibrates and probucol. In terms of individual drugs, pravastatin sodium was most prescribed and then came simvastatin, tocopherol, nicotinate, bezafibrate and probucol in that order. These five drugs accounted for more than 95% of all prescriptions. As for prescriptions for combinations of hypolipidemic drugs, the combination of HMG-CoA reductase inhibitors and fibrates accounted for about 25%. Since such combinations are contraindicated in principle, particular attention should be paid to adverse effects. Looking at combinations of hypolipidemic drugs and other drugs, the most frequently prescribed other drug type was vasodilators, followed by antipyretic analgesics, antihypertensive agents, peptic ulcer drugs, and antidiabetic drugs.

Risk Factors For Mortality From Infectious Diseases Among Elderly From Long-Term Care Facilities

Background: The purpose of this study was to analyze risk factors for mortality in elderly residents who had acquired infections in long-term care facilities (LTCF) and were transferred to an acute care hospital. Methods: A retrospective medical record review was conducted in Okinawa Chubu Hospital, a 550-bed community teaching hospital in Okinawa, Japan. Study population included elderly LTCF residents in central Okinawa with signs or symptoms suggestive of infectious diseases or referred with probable infections that were transferred to an acute care hospital from 1995 to 1999. The medical records were reviewed and data were analyzed by stepwise logistic regression. Results: Two hundred patients (median age, 83 years) with diagnosis of infections were evaluated during the 5-year study period. Overall, 23 patients (11.5%) died. Independent predictors of mortality were lower respiratory tract infection, history of hip fracture, systolic blood pressure less than 100 mmHg, and serum creatinine greater than 1.5mg/dl.

An epidemiological study regarding the hearing acuity of residents in the area with high level of aircraft noise: results of hearing tests conducted in the vicinity of Kadena Air Base

Hearing tests, primary and secondary, were conducted in two communities vicinal to Kadena US Air Base in Okinawa from May 1996 to July 1998. The noise exposure expressed in WECPNL as designated by the Defense Facilities Administration Agency ranged from 85 to 95 and above. A total of 2035 subjects aged between 25 and 69 years inclusive were considered eligible for inclusion in this study and among them 137 males and 206 females underwent the primary test. Before the test, subjects were asked about hearing difficulty, tinnitus, otological anamnesis and past experience of noise exposure at work and/or hobbies. The primary test was a pure tone audiometry using the ascending method of limits with 5 dB step at 7 test frequencies of 0.5 to 8 kHz. Forty individuals who were judged to have possible noise induced hearing loss were sent to Okinawa Chubu Hospital as subjects for the secondary test. The secondary test consisted of pure tone audiometry with 1 dB step at 9 test frequencies with the addition of 3 kHz and 6 kHz to the primary test frequencies, a Short Increment Sensitivity Index (SISI), test, tympanometry and audioscan audiometry. Based on test findings 12 subjects were considered to have noise induced hearing loss. The examiners interviewed the 12 subjects again to confirm that they had not experienced habitual or repeated intense noise exposure other than aircraft noise exposure around their homes. The geographical distribution of the subject's residences showed their proximity to the airfield, which strongly suggests that the cause of hearing loss may be exposure to aircraft noise from Kadena Air Base.

市中総合病院における感染性心内膜炎症例の検討

There have been few reports on the clinical features of infective endocarditis (IE) in Japan. We clinically investigates 45 episodes (36 cases) of definite IE that were experienced from January 1985 to March 1997 at a community hospital, Okinawa Chubu Hospital, Okinawa, Japan. Regarding age, prior dental procedure, causative organisms and sites of infection, analyses and comparison were performed on a total of 94 episodes, by adding another 49 episodes of IE that were experienced between 1977 and 1984 at our hospital. The mean age was 47 years and majority of patients in the recent 12 years were older than 50 years of age. Mortality of all 94 episodes was 20%, while that of recent 45 cases was 13%. Eight % of all episodes had history of recent dental treatment but significance of the finding remains unclear. Alpha streptococci were most common (33%) and Staphylococcus aureus was the second most common organism (17%). Eleven % of all episodes were culture-negative and there was a statistically significant difference in the histories of prior antibiotic therapy between culture-negative and culture-positive episodes. Regarding sites of infection, 27% of all episodes involved mitral valves, while 24% involved aortic valves. Prosthetic valves were involved in 12%. Ninety-eight % of the recent episodes had fever, 98% had cardiac murmurs and 27% had characteristic mucocutaneous lesions. Heart failure was the most common complication (27%) and half of the cases with prosthetic valve infection had heart failure. Cerebral embolism was most frequently seen among the major arterial embolic complications. Our results were similar to those which were previously reported from other countries. We should have a high index of suspicion for endocarditis whenever we see patients who present various clinical manifestations and fever of which origin remains unclear. Willingness to obtain blood culture before starting antibiotics is most important.