Teaching Hospital In Japan Research Articles

Five-year analysis of hospital complaints at a Japanese tertiary teaching hospital.

Patient complaint taxonomies strongly support the use of healthcare complaints as a powerful tool to improve the quality and safety of patient care. Hospitals use complaint data at the organizational level to address quality variation across service lines and departments. We applied a validated typology method to identify where the complaints occured and gained deeper insights about how they can be more effectively utilized to drive and implement continuous quality and service improvement activities within a tertiary hospital. We included all complaints and opinions from patients and their families over a 5-year period at a large tertiary teaching hospital in Japan. Two analysts categorized the opinions into complaints and gratitude expressions, with complaints classified using Reader etal.'s taxonomy. We performed statistical tabulations and determined the number of complaints across hospital sectors using the chi-squared test, residual analysis, and Cramer's V tests to check for significant correlations between the variables. A total of 6607 complaints and comments were received. Of these, 5401 related to the Clinical, Administrative, and Human Relations domains, respectively (11.1%, 56.1%, and 32.8%). At the domain level, the most common complaints are related to the Relationships domain in both the Medical and Nursing departments. However, a detailed analysis of the category levels demonstrated that the Medicine department received the most complaints in the Communication and Patient Rights category, whereas in the Nursing department, the Humanness/Caring and Patient Rights categories were the most common sources for complaints. The Administrative department complaints were mostly related to the Management domain, with the largest number of complaints related to the Institutional Issues category. We used a validated taxonomy to identify and address trends in patient complaints and identified the key hospital departments that required remedial improvement actions. All hospital departments received direct and targeted feedback on how to effectively improve the quality, safety and services of their clinical service lines.

To teach is to learn twice, revisited: a qualitative study of how residents learn through teaching in clinical environments

BackgroundTeaching helps the teacher’s own learning as a professional—as the saying goes, ‘to teach is to learn twice’. Near-peer teaching in clinical practice has been shown to contribute to the development of both teaching skills and necessary competencies for doctors. Research on how near-peer teachers learn through their teaching roles has mainly focused on classroom learning. However, understanding how the phenomenon of ‘teaching is learning twice’ occurs in clinical settings and its influencing factors is important for the development of a quality workplace learning environment. Therefore, this study investigated how residents learn through teaching in clinical practice and the factors influencing this process.MethodsThis study’s methodology is based on the constructivist grounded theory from a social constructivist perspective. Several teaching hospitals in Japan were included, and the study participants were post-graduate year 2 residents (PGY2s) from these hospitals. The interviews were recorded, transcribed into text, and analysed by the first author.ResultsFrom January 2016 to July 2022, 13 interviews were conducted with 11 PGY2s from nine educational hospitals. The PGY2s played diverse educational roles in clinical settings and learned competencies as physicians in almost all areas through such roles. We found that knowledge transfer and serving as role models stimulated PGY2s’ intrinsic motivation, encouraged reflection on their own experiences, and promoted self-regulated learning. Further, educating about procedural skills and clinical reasoning prompted reflection on their own procedural skills and thought processes. Supporting post-graduate year 1 residents’ reflections led to the refinement of PGY2s’ knowledge and thought processes through the verbal expression of their learning experiences. Such processes required the formation of a community of practice. Thus, education promoted learning through reflection and clarified the expert images of themselves that PGY2s envisaged.ConclusionsThe study found that residents acquire various physician competencies through multiple processes by teaching as near-peer teachers in clinical settings, that a community of practice must be formed for near-peer teaching to occur in a clinical setting, and that teaching brings learning to those who teach by promoting reflection and helping them envision the professionals they aim to be.

Clinical Features of Candida Catheter-related Bloodstream Infections and Persistent Infections Associated with Early Catheter Reinsertion: A 6-year Retrospective Study.

Catheter-related persistent Candida infections (CRPCI) may develop after Candida catheter-related bloodstream infections (CRBSI) due to colonization of the newly inserted catheter. However, the optimal timing for new catheter insertion remains controversial. The aim of this study was to determine the clinical features of CRBSI due to Candida species and CRPCI. This was a retrospective study conducted in a teaching hospital in Japan. We retrospectively collected clinical information on hospitalized patients diagnosed with Candida CRBSIs by catheter tip culture from 2015 to 2020. CRPCI was defined as the growth of the same Candida species from the tip culture of a newly inserted catheter after the onset of a Candida CRBSI. The Chi-squared and Fisher's exact tests were used to compare differences between the case and control groups. Sixty-three cases of Candida CRBSI were collected. Fifty-four (85.7%) received total parenteral nutrition. CRPCI developed in 12 (48%) patients of the 25 in whom cultures of newly inserted catheters were performed. Despite antifungal therapy in these patients, persistent fungemia incidence was significantly higher (50.0% vs. 9.1%, odds ratio = 10.0, P = 0.033). The mean number of days from removal of infected catheter to reinsertion was significantly shorter for patients with CRPCI (0.27 days vs. 3.08 days, P = 0.038). Total parenteral nutrition may be a major risk factor in the development of Candida CRBSI. CRPCI often leads to persistent fungemia. Early insertion of a new catheter after removal of an infected catheter may be a risk factor for CRPCI.

Timing and prediction of secondary bacteremia in patients with COVID-19: A retrospective cohort study.

We aimed to aid the appropriate use of antimicrobial agents by determining the timing of secondary bacteremia and validating and updating clinical prediction models for bacteremia in patients with COVID-19. We performed a retrospective cohort study on all hospitalized patients diagnosed with COVID-19 who underwent blood culture tests from January 1, 2020, and September 30, 2021, at an urban teaching hospital in Japan. The primary outcome measure was secondary bacteremia in patients with COVID-19. Of the 507 patients hospitalized with COVID-19, 169 underwent blood culture tests. Eleven of them had secondary bacteremia. The majority of secondary bacteremia occurred on or later than the 9th day after symptom onset. Positive blood culture samples collected on day 9 or later after disease onset had an odds ratio of 22.4 (95% CI 2.76-181.2, p < 0.001) compared with those collected less than 9 days after onset. The area under the receiver operating characteristic curve of the modified Shapiro rule combined with blood culture collection on or after the 9th day from onset was 0.919 (95% CI, 0.843-0.995), and the net benefit was high according to the decision curve analysis. The timings of symptom onset and hospital admission may be valuable indicators for making a clinical decision to perform blood cultures in patients hospitalized with COVID-19.

Adverse Events in Pediatric Inpatients: The Japan Adverse Event Study.

Adverse events (AEs) represent an important cause of morbidity and mortality for pediatric inpatients; however, reports on their epidemiology in pediatrics, especially outside Western countries, are scarce. We investigated the incidence and nature of AEs in pediatric inpatients in Japan. Trained pediatrician and pediatric nurses reviewed all medical documents of 1126 pediatric inpatients in 2 tertiary care teaching hospitals in Japan, and potential incidents were collected with patients' characteristics. Age was categorized into 6 groups (neonates, infants, preschoolers, school-aged children, teenagers, and over-aged pediatric patients), and medical care when potential incidents occurred was classified into drug, operation, procedure/examinations, nursing, management, and judgment. Physician reviewers independently evaluated all collected incidents into AEs, potential AEs, medical errors, and exclusions and assessed their severity and preventability. A total of 1126 patients with 12,624 patient-days were enrolled, and 953 AEs, with an incidence of 76 (95% confidence interval, 71-80) per 1000 patient-days, were identified. Preventable AEs accounted for 23% (218/953) of AEs. The incidence of AEs tended to decrease with increasing age. The proportion of AEs that were preventable was highest in neonates (40%), and this proportion decreased as children aged. Both judgment and management-related AEs were considered preventable AEs, and judgment-related AEs were more severe AEs than no-judgment-related AEs; 43% were life-threatening. Adverse events were common in Japanese pediatric inpatients, and their preventability and severity varied considerably by age category and medical care. Further investigation is needed to address which strategies might most improve pediatric patient safety.

Association between Undergraduate Education for Community-Based Medicine and General Practice Majors: A Longitudinal Study in Japan.

There is a shortage of general practitioners in Japan. With the revision of educational guidelines, general practice (GP) education has improved. However, the amount of education on GP in medical schools remains inconsistent. This study examined the relationship between medical students' amount of GP-related education and their subsequent choice of GP majors. A retrospective cohort study was conducted in a teaching hospital in Japan. Participants were residents in the hospital. The exposure comprised compulsory lectures and training time for community-based medicine in medical schools. The outcome included participants choosing GP majors after their initial 2-year junior residency. Fifty-one participants were included in the final analysis. Of these, 14 majored in GP and 37 in non-GP after their initial 2-year junior residency. Of the participants who took GP lectures for 18 hours or more, 11 chose GP majors, and 18 chose non-GP majors (risk ratio, 2.78; 95% confidence interval [CI], 0.88-8.79). Of the participants who underwent training for 12 days or more, 10 chose GP majors, and 16 chose non-GP majors (risk ratio, 2.40; 95% CI, 0.87-6.68). The results do not support the association between the amount of compulsory undergraduate education for community-based medicine and the subsequent increase in the number of residents choosing GP majors in Japan. Educators would do well to explore different approaches, such as improving the quality of education to increase the number of GP residents. Further research is needed to reach more definitive conclusions.

Information presentation and gaze-following for grounding in simulated anaesthesia emergencies: A multimodal analysis

Unanticipated difficult intubation is a relatively common problem anaesthetists face in everyday practice. Algorithms to manage the problem were issued (Japanese Society of Anesthesiologists, 2014), but how anaesthetists actually perceive the problem and respond to the difficulties with other healthcare professionals present is still to be uncovered. Drawing on the concept of resilient healthcare (Hollnagel et al., 2013), which values “how things go well”, this study analysed interactions in simulated emergencies between a less experienced anaesthetist (trainee) and an experienced anaesthetist (trainer). The latter took a role as a nurse and led the scenario of difficult intubation. Five sessions with the same trainer, one of five different trainees and a manikin as a patient were recorded with a 360-degree camera in an operating room at a large teaching hospital in Japan. The data was transcribed and analysed with discourse and multimodal corpus analytic approaches. In the simulated interactions, four phases of grounding (Clark, 1996) were observed in the joint decision-making process between the trainer and the trainee: (1) the trainer’s information presentation with her gaze address at the referent, (2) the trainee’s gaze following and acknowledgement of information reception, (3) the trainer’s prompt for the trainee’s decision-making, and (4) the trainee’s (or trainer’s) giving instruction to manage the difficulty. The trainer presented the patient’s condition and visual/audio information affordable in the environment (e.g., signals on a vital monitor), using verbal and multimodal resources, i.e., gaze address and deictic gestures. The participants as individual sensory agencies were engaged in the embodied process of shared sense-making in the particular context to establish common ground for joint decision-making on immediate actions required.

A multi-center, randomized, parallel-group study to compare the efficacy of enhanced cognitive behavior therapy (CBT-E) with treatment as usual (TAU) for anorexia nervosa: study protocol

BackgroundThe superiority of Enhanced Cognitive Behavior Therapy (CBT-E) with regard to weight gain and improvement of psychopathology of eating disorders for patients with anorexia nervosa (AN) over other psychotherapies and treatment as usual (TAU) has not been demonstrated in randomized controlled trials (RCTs). However, a previous RCT showed that patients with AN whose baseline body mass index (BMI) was less than 17.5 kg/m2 gained more weight when treated with CBT-E than with other psychotherapies. The aim of the study is to compare the efficacy of CBT-E and TAU for patients with AN. It was hypothesized that CBT-E would be superior to TAU, at least in terms of weight gain, as most patients with AN are likely to have a BMI lower than 17.5 kg/m2.Methods/designA randomized parallel-group multicenter trial will be conducted in three teaching hospitals in Japan between January 2023 and March 2026. Patients with DSM-5 AN, aged 16 years and older, with a BMI equal to or above 14.0 and below 18.5 will be eligible to participate. 56 patients will be randomly and evenly assigned to two intervention groups (CBT-E and TAU). Those assigned to CBT-E will be offered 25–40 sessions in accordance with their initial BMI. Patients assigned to TAU will have at least one session every 2 weeks, with the number of sessions and treatment period not fixed in advance. The primary outcome is BMI at 40 weeks after treatment initiation. The secondary outcomes are the results from the Japanese version of the Eating Disorder Examination Questionnaire and Clinical Impairment Assessment questionnaire to measure eating disorder psychopathology and psychological impairment. The follow-up assessment will be performed 6 months after the 40-week assessment.DiscussionThis multi-center randomized controlled study will probably evaluate the efficacy of CBT-E compared with TAU for patients with more severe AN than in previous studies since Japanese patients are likely to have a lower BMI than those in Western countries. While it may be difficult to generalize the results of a study conducted in Japan, it would be valuable to clarify the efficacy of CBT-E as a treatment package.Trial registrationUMIN, UMIN000048847. Registered 12 Sep 2022.

Prevalence and factors associated with polypharmacy among patients with rheumatoid arthritis: a single-centre, cross-sectional study.

This study aimed to identify factors associated with polypharmacy, including social aspects, among patients with rheumatoid arthritis. We conducted this single-centre, cross-sectional study at a 715-bed regional tertiary care teaching hospital in Japan from 1 September to 30 November 2020. Polypharmacy was defined as having five or more medications administered orally regularly, and excessive polypharmacy was defined as having 10 or more medications administered orally regularly. The prevalence of polypharmacy and excessive polypharmacy, distribution of medication types, and factors associated with polypharmacy and excessive polypharmacy were investigated among patients with rheumatoid arthritis. The proportions of polypharmacy and excessive polypharmacy were 61% and 15%, respectively, in 991 patients. Polypharmacy and excessive polypharmacy were associated with older age (odds ratio, 1.03 and 1.03, respectively), high Health Assessment Questionnaire Disability Index (odds ratio, 1.45 and 2.03, respectively), medication with glucocorticoids (odds ratio, 5.57 and 2.42, respectively), high Charlson comorbidity index (odds ratio, 1.28 and 1.36, respectively), and a history of hospitalisation in internal medicine (odds ratio, 1.92 and 1.87, respectively) and visits to other internal medicine clinics (odds ratio, 2.93 and 2.03, respectively). Moreover, excessive polypharmacy was associated with the presence of public assistance (odds ratio, 3.80). Considering that polypharmacy and excessive polypharmacy are associated with a history of hospitalisation and glucocorticoid medication in patients with rheumatoid arthritis, medications during hospitalisation should be monitored, and glucocorticoids should be discontinued. Key points • The proportion of polypharmacy (five or more medications administered orally regularly) was 61%. • The proportion of excessive polypharmacy (10 or more medications administered orally regularly) was 15%. • Medications during hospitalisation should be reviewed and examined, and glucocorticoids should be discontinued.

Crowned dens syndrome: A case series of 72 patients at eight teaching hospitals in Japan.

Crowned dens syndrome (CDS) is characterized by calcification around the odontoid process, accompanied by neck pain. Although CDS is supposedly rare, we regularly diagnose and manage this condition, indicating a perception gap between previous studies and our experience. The purpose of this study was to determine the annual incidence of CDS, time to diagnosis in CDS, as well as the features of CDS. The study design was a retrospective case series study conducted at eight teaching hospitals in Japan. We identified CDS cases from April 2013-March 2015. CDS was diagnosed when patients had acute onset of neck pain and CT showed calcification around the dens and when other diagnoses were unlikely. Seventy-two CDS cases were identified. Mean annual incidence was 4.6 ± 2.3 cases at each hospital. Among those with available data, 57 of 64 had limited rotation (89.1%). The diagnosis of CDS was made in general internal medicine or the emergency medicine department in 61 cases (84.7%). A total of 62 cases (86.1%) were diagnosed within 1day of presentation, and the median time from initial presentation at the hospital to diagnosis was 0.0 days (25th-75th percentiles, 0.0-1.0). For treatment, NSAIDs were used in 56cases (77.8%) and acetaminophen in 20 cases (27.8%). CDS might be more common than has been reported to date. Time to diagnosis of CDS was within 1 day of visiting a teaching hospital. Cervical motion restriction is common in CDS and may be useful in establishing the diagnosis.

Development and evaluation of a simple predictive model for falls in acute care setting.

To develop a simple and reliable assessment tool for predicting falls in acute care settings. Falling injures patients, lengthens hospital stay and leads to the wastage of financial and medical resources. Although there are many potential predictors for falls, a simple and reliable assessment tool is practically necessary in acute care settings. A retrospective cohort study. The current study was conducted for participants who were admitted to a teaching hospital in Japan. Fall risk was assessed by the modified Japanese Nursing Association Fall Risk Assessment Tool consisting of 50 variables. To create a more convenient model, variables were first limited to 26 variables and then selected by stepwise logistic regression analysis. Models were derived and validated by dividing the whole dataset into a 7:3 ratio. Sensitivity, specificity, and area under the curve for the receiver-operating characteristic curve were evaluated. This study was conducted according to the STROBE guideline. Six variables including age > 65 years, impaired extremities, muscle weakness, requiring mobility assistance, unstable gait and psychotropics were chosen in a stepwise selection. A model using these six variables with a cut-off point of 2 with one point for each item, was developed. Sensitivity and specificity >70% and area under the curve >.78 were observed in the validation dataset. We developed a simple and reliable six-item model to predict patients at high risk of falling in acute care settings. The model has also been verified to perform well with non-random partitioning by time and future research is expected to make it useful in acute care settings and clinical practice. Patients participated in the study on an opt-out basis, contributing to the development of a simple predictive model for fall prevention during hospitalisation that can be shared with medical staff and patients in the future.

Single-centre, cross-sectional study on the factors and reasons for non-vaccination among patients with rheumatoid arthritis.

We aimed to investigate the vaccination coverage and the factors associated with non-vaccination for vaccine-preventable diseases among patients with rheumatoid arthritis. This single-centre, cross-sectional study was conducted in a 715-bed regional tertiary-care teaching hospital in Japan from 1 September to 30 November 2020. Vaccination status and the factors and reasons for not receiving the influenza vaccine, 23-valent pneumococcal polysaccharide vaccine (PPSV23), 13-valent pneumococcal conjugate vaccine (PCV13), and varicella vaccine live (VVL) were investigated. Among 991 patients, the vaccination coverage for the influenza vaccine, PPSV23, PCV13, and VVL was 62%, 46%, 14%, and 3%, respectively. The most common reasons for vaccine hesitancy were efficacy concerns for the influenza vaccine, safety concerns for the PPSV23 and PCV13, and both efficacy and safety concerns for the VVL. Younger age, no use of biologics or other hospital visits, and public assistance were factors significantly associated with non-vaccination for the influenza vaccine; younger age, short disease duration, and no visits to other hospitals for PPSV23; younger age, no hospitalisation, more experienced doctor, and no medical immunodeficiency for PCV13. We found that the factors associated with non-vaccination varied by vaccine type; therefore, vaccinations should be promoted with individualised strategies.

Polypharmacy prevalence and associated factors in patients with systemic lupus erythematosus: A single-centre, cross-sectional study.

This study aimed to clarify factors associated with polypharmacy among patients with systemic lupus erythematosus. This single-centre cross-sectional study was conducted by reviewing the medical records and questionnaire data of 261 systemic lupus erythematosus patients at a teaching hospital in Japan from 1 September to 30 November 2020. Polypharmacy was defined as the regular administration of five or more oral medications; excessive polypharmacy consisted of the regular use of 10 or more oral medications. This study investigated (1) the prevalence of polypharmacy and excessive polypharmacy, (2) the distribution of medication types, and (3) the factors associated with polypharmacy and excessive polypharmacy. The proportions of patients who exhibited polypharmacy and excessive polypharmacy were 70% and 19%, respectively. Polypharmacy was associated with older age, long duration of systemic lupus erythematosus, high disease activity, and administration of glucocorticoids or immunosuppressive agents. Excessive polypharmacy was associated with a higher updated Charlson comorbidity index, history of visits to multiple internal medicine clinics, and presence of public assistance. Polypharmacy and excessive polypharmacy in patients with systemic lupus erythematosus are related to medical aspects such as disease severity and comorbidities in addition to social aspects such as hospital visitation patterns and economic status.

Intravenous Tranexamic Acid in Percutaneous Kidney Biopsy: A Randomized Controlled Trial

Background: Tranexamic acid is frequently reported to reduce bleeding-related complications in major surgery and trauma. We aimed to investigate whether tranexamic acid reduced hematoma size after percutaneous kidney biopsy. Methods: We conducted a double-blind, parallel three-group, randomized placebo-controlled trial at a teaching hospital in Japan between January 2016 and July 2018. Adult patients with clinical indication for ultrasound-guided percutaneous biopsy of a native kidney were included. Participants were randomly assigned into three groups: high-dose tranexamic acid (1,000 mg in total), low-dose tranexamic acid (500 mg in total), or placebo (counterpart saline). Intervention drugs were intravenously administered twice, as a bolus just before the biopsy and as a continuous infusion initiated just after the biopsy. Primary outcome was post-biopsy perirenal hematoma size as measured by ultrasound on the morning after the biopsy. Results: We assessed 90 adult patients for study eligibility, of whom 56 were randomly allocated into the three groups: 20 for high-dose tranexamic acid, 19 for low-dose tranexamic acid, and 17 for placebo. The median size of perirenal hematoma was 200 mm2 (interquartile range, 21–650) in the high-dose tranexamic acid group, 52 mm2 (0–139) in the low-dose tranexamic acid group, and 0 mm2 (0–339) in the placebo group (p = 0.048 for high-dose tranexamic acid vs. placebo). Conclusion: In this trial, the median size of post-kidney biopsy hematoma was unexpectedly larger in the high-dose tranexamic acid group than in the placebo group. Although our results do not support the routine use of tranexamic acid in percutaneous kidney biopsy at present, further studies are needed to confirm the results.

The relationship between hospital ethical climate and continuing education in nursing ethics.

BackgroundIn recent years, there has been a growing interest in the importance of creating a healthy ethical climate. Although relationship with various factors and the ethical climate have been reported, understanding of the relationship between ethical education and ethical climate is limited.AimThis study aims to investigate the relationship between ethical climate, personal characteristics, and continuing education for ethics.MethodsThis study conducted a quantitative cross-sectional survey of 605 nurses in 3 teaching hospitals in Japan. Multiple-regression analysis was used to assess the relationship between ethical climate and demographic characteristics and continuing education. Further mean of ethical climate scores were compared between received continuing education and did not, using analysis of covariance adjusted for demographic variables.FindingsThe ethical climate showed significant association with hospital, gender, specialty of the unit, experience of ethics education, in-service ethical training, and workshops/ academic conferences on nursing ethics. In multiple-regression analysis, attending in-service ethical training increased the mean of ethical climate score (p = 0.031) and workshops/ academic conferences decreased the mean score (p = 0.028). Adjusted-mean of ethical climate score of nurses who had in-service training was significantly higher than those who had not (p = 0.038), whereas adjusted-mean of it of nurses who had attended workshops/ academic conferences was significant lower (p = 0.033).DiscussionIn-service training on ethics was associated with the positive ethical climate. Hospital should enhance ethical education.ConclusionEthical climate related to the nurses’ personal characteristics and continuing education. We propose that organizational support for ethical education may be effective in raising the ethical climate of the workplace.

Impact of the hospitalist system on inpatient mortality and length of hospital stay in a teaching hospital in Japan: a retrospective observational study

ObjectiveTo examine the differences in the quality of care among inpatients before and after the introduction of the hospitalist system.DesignA retrospective observational study.SettingA community teaching hospital in Japan.ParticipantsThe inpatients admitted...

Women with type 2 diabetes and coronary artery disease have a higher risk of heart failure than men, with a significant gender interaction between heart failure risk and risk factor management: a retrospective registry study

IntroductionWomen are generally perceived to have a lower risk of cardiovascular events than men, despite a lack of data, particularly among patients with diabetes. Here, we investigated gender differences in...

Risk stratification for early and late falls in acute care settings.

Falling generally injures patients, lengthens hospital stays and leads to the wastage of financial and medical resources. Although falls can occur at any stage after hospital admission, there are no studies that characterise falls with length of hospital stay in acute care settings. This study aims to clarify risk stratification of early and late falls in acute care settings. A retrospective cohort study was conducted for participants who were admitted to a teaching hospital in Japan. Patients' falls were divided into two groups based on the median of the fall date (day 10). Considering a 70/30split, the logistic regression model was used to extract independent predictors for early and late falls for nine risk variables based on exploratory analysis among 26 items selected from the modified Japanese Nursing Association Fall Risk Assessment Tool, and risk models were validated. This study was conducted according to the STROBE guideline. Of the 10,975 patients admitted, 87 and 90 with early and late falls, respectively, were identified. The five significant risk factors extracted for early falls were fall history, muscle weakness, impaired understanding, use of psychotropics and the personality trait of 'doing everything on one's own'; risk factors identified for late falls were being older than 65years, impaired extremities and unstable gait, in addition to muscle weakness. Using these variables for early and late falls in the validation cohort, the concordance indices of the risk models were both over 0.80. By separately extracting risk factors for early and late falls in an acute care hospital setting, this study shed light on the characteristics of the respective types of falls. As the risk factors of falls vary according to the length of hospitalisation, specific preventive care can be implemented to avoid fall incidents.

External validation for sensitivity of the Ottawa subarachnoid hemorrhage rule in a Japanese tertiary teaching hospital

The Ottawa subarachnoid hemorrhage (OSAH) rule is a validated clinical prediction rule for ruling out subarachnoid hemorrhage (SAH). Another SAH rule (Ottawa-like rule) was developed in Japan but was not well validated. We aimed to validate both rules by examining the sensitivity for ruling out SAH in Japanese patients diagnosed with SAH. We conducted a retrospective cohort study by reviewing the medical records of consecutive adult patients hospitalized with SAH at a tertiary-care teaching hospital in Japan who visited our emergency department between July 2009 and June 2019. Sensitivity and its 95% confidence interval (CI) were estimated for each rule for the diagnosis of SAH. In a total of 280 patients with SAH, 56 (20.0%) patients met the inclusion criteria and were analyzed for the OSAH rule, and a sensitivity of the OSAH rule was 56/56 (100%; 95% CI 93.6–100%). While, 126 (45%) patients met the inclusion criteria of the Ottawa-like rule, and the rule showed a sensitivity of 125/126 (99.2%; 95%CI 95.7–100%). The OSAH rule showed 100% sensitivity among our Japanese patients diagnosed with SAH. The implementation of the Ottawa-like rule should be cautious because the false-negative rate is up to 4%.

WBC count predicts heart failure in diabetes and coronary artery disease patients: a retrospective cohort study.

AimsWhite blood cell (WBC) count in healthy people is associated with the risk of coronary artery disease (CAD) and mortality. This study aimed to determine whether WBC count predicts heart failure (HF) requiring hospitalization as well as all‐cause death, acute myocardial infarction (AMI) and stroke in patients with Type 2 diabetes mellitus and established CAD.MethodsWe conducted this retrospective registry study that enrolled consecutive patients with Type 2 diabetes mellitus and CAD based on coronary arteriography records and medical charts at 70 teaching hospitals in Japan from 2005 to 2015. A total of 7608 participants (28.2% women, mean age 68 ± 10 years) were eligible. In the cohort, the median (interquartile range) and mean follow‐up durations were 39 (16.5–66.1 months) and 44.3 ± 32.7 months, respectively. The primary outcome was HF requiring hospitalization. The secondary outcomes were AMI, stroke, all‐cause death, 3‐point major adverse cardiovascular events (MACE) (AMI/stroke/death) and 4‐point MACE (AMI/stroke/death/HF requiring hospitalization). Outcomes were reported as cumulative incidences (proportion of patients experiencing an event) and incidence rates (events/100 person‐years). The primary and secondary outcomes were assessed using the Kaplan–Meier method and were compared using the log‐rank test stratified by the baseline WBC count. The association between the WBC count at baseline and each MACE was assessed using the Cox proportional hazard model and expressed as the hazard ratio (HR) and 95% confidence interval (CI) after adjusting for other well‐known risk factors for MACE.ResultsDuring the follow‐up, 880 patients were hospitalized owing to HF. The WBC Quartile 4 (≥7700 cells/μL) had significantly lower HF event‐free survival rate (log‐rank test, P < 0.001). The HRs for HF events requiring hospitalization with each WBC quartile compared with the lowest in the first WBC quartile were 1 for Quartile 1 (WBC < 5300 cells/μL), 1.20 (95% CI, 0.96–1.5; P = 0.1) for Quartile 2 (5300 ≤ WBC < 6400), 1.34 (95% CI, 1.08–1.67; P = 0.009) for Quartile 3 (6400 ≤ WBC < 7700) and 1.62 (95% CI, 1.31–2.00; P < 0.001) for Quartile 4 after adjusting for covariates. Similar findings were observed for the risk of AMI and death; however, no significant difference was found for stroke. WBC Quartile 4 patients had a significantly lower 3‐ or 4‐point MACE‐free survival rate (log‐rank test, P < 0.0001).ConclusionsA higher WBC count is a predictor of hospitalization for HF, all‐cause death and AMI but not for stroke in patients with concurrent Type 2 diabetes mellitus and established CAD.