Cumulative incidence of vancomycin-resistant Enterococcus faecium detection by patient characteristics or possible exposures: Prioritization of patients for active screening culture.

OBJECTIVES: The target population for active surveillance culture (ASC) of vancomycin-resistant Enterococcus species (VRE) by stool or rectal swabs has not been fully determined during VRE outbreaks in healthcare settings in non-VRE endemic situation. We evaluated cumulative incidences of VRE detection during a vancomycin-resistant Enterococcus faecium outbreak to determine reasonable target populations for ASC. METHODS: Cases included inpatients whose first VRE-positive sample was obtained at Shizuoka General Hospital between February 2022 and January 2023, during which we conducted admission screening for possible high-risk patients, biweekly screening of all inpatients, admission and discharge screening in the high-care unit, and screening of contacts in each ward by using stool or rectal samples. We calculated cumulative incidences of VRE detection for those screened by patient characteristics or possible exposure. FINDINGS: Among 60 cases identified, 55 (92%) were by ASC. Cumulative incidence was higher for contacts (6.4%, 15/234) than for those identified by other screening methods (0.5%, 40/8565). Among the patients identified through admission screening, those previously hospitalized in areas of reported VRE outbreaks had the highest cumulative incidence (6.6%, 5/78) followed by patients requiring toilet assistance (3.7%, 6/161). A bundle approach including ASC and prompt contact precautions by the hospital infection control team, local public health centre, and local and national infection control experts helped terminate the outbreak in seven months. CONCLUSION: Patients with contacts, prior hospitalization in areas with known VRE outbreaks, and who need toilet assistance appear to be high-risk populations for VRE detection and are candidates for ASC.

A case of adrenal lymphangioma successfully treated with laparoscopic partial adrenalectomy.

Introduction: Adrenal lymphangioma is a rare benign tumor of lymphatic origin, usually incidentally detected from various imaging studies taken for an unrelated purpose. We present a case of a right adrenal lymphangioma treated successfully with surgical intervention. Case presentation: A 36-year-old previously healthy woman was referred to our urology department for a right adrenal mass, discovered during a routine health checkup. The tumor had no endocrinological activity, and the patient opted for surgical resection following a concern for malignancy. A laparoscopic right partial adrenalectomy was performed, and on histological examination, the tumor was diagnosed as right adrenal lymphangioma. Conclusion: Adrenal lymphangiomas lack disease specific radiological characteristics that allow for a definitive diagnosis from imaging alone. To rule out tumors of potentially malignant nature, surgical intervention should be considered.

A case of prostatic metastasis from non-seminomatous testicular cancer.

Introduction: Prostatic metastasis from testicular cancer is extremely rare, with only 10 reported cases, all of which were diagnosed as relapse. Herein, we report the case of a patient with concurrent testicular cancer and prostatic metastasis. Case presentation: A 57-year-old man presented at our emergency department with urinary retention. A painless mass was found in the right scrotum, and computed tomography showed lung, mediastinal, and liver metastases, and an enlarged prostate. Tumor markers were measured in 2057 U/L lactate dehydrogenase, 2460 mIU/mL human chorionic gonadotrophin, 1303 ng/mL alpha-fetoprotein, and 1.51 ng/mL prostate specific antigen. An orchiectomy and biopsy were performed; the pathological results showed immature teratomas, embryonal carcinomas, choriocarcinomas, and seminomas in the testis, and embryonal carcinomas in the prostate, liver, and mediastinum. The patient refused chemotherapy and died 3 months following diagnosis. Conclusion: Prostatic metastasis should be considered in cases of dysuria or prostate enlargement in testicular cancers.

[LONG TERM ADMINISTRATION OF RELATIVE DOSE INTENSITY-ADJUSTED CABAZITAXEL FOR METASTATIC CASTRATION-RESISTANT PROSTATE CANCER: A CASE REPORT].

We report the case of a 74-year-old man with metastatic castration-resistant prostatic cancer (CRPC), who underwent treatment with cabazitaxel. Initially, he underwent docetaxel treatment for 2 years and exhibited severe neuropathy in his hands caused by its toxicity. As a result, we replaced docetaxel with cabazitaxel. On receiving 100% of the dose of cabazitaxel in the first course, febrile neutropenia (FN) was observed on the seventh day. However, he soon recovered from the FN and we began relative dose intensity (RDI) treatment with an adequate dose-volume and interval of treatments. He was successfully administered 51 cabazitaxel treatment courses without severe adverse effects. Cabazitaxel is a highly effective drug used as second-line chemotherapy following docetaxel, and it causes fewer adverse effects compared with docetaxel. Cabazitaxel may be a suitable alternative for outpatient treatment. Given that the patient in this case had a long overall survival of more than 3.5 years and received over 50 courses of cabazitaxel, it is crucial for RDI to be taken very seriously.

[COMPLETE REMISSION OF METASTATIC RENAL CELL CARCINOMA AFTER PARTIAL NEPHRECTOMY FOLLOWING PEMBROLIZUMAB PLUS AXITINIB THERAPY: A CASE REPORT].

This case is a 62-year-old man diagnosed with metastatic renal cell carcinoma. He was referred to our department due to the left renal mass pointed with ultra sound examination. Radiographical examination showed left-side 42 mm renal tumor with multiple lung tumors, suggesting renal cell carcinoma, cT1bN0M1 (pul). As an induction therapy, we selected Pembrolizumab plus Axitinib combination therapy. After 4 course of the therapy, the left kidney tumor shrank to 27 mm, and the lung metastasis disappeared with computed tomography imaging. For the next step, we performed laparoscopic partial nephrectomy. The pathological diagnosis was clear cell carcinoma, grade 2 with central necrosis. Since then, complete remission has been maintained without any treatment for 21 months.

Influence of Genetic Polymorphisms and Concomitant Anxiolytic Doses on Antidepressant Maintenance Doses in Japanese Patients with Depression.

To prevent recurrent depression, patients should ideally continue treatment for >6 months with the antidepressant dose that effectively suppressed acute depressive symptoms. However, there are inter-individual differences in the antidepressant doses required to achieve response and maintenance. Therefore, this study was conducted to examine the role of clinical features, including genetic polymorphisms, on the antidepressant dose required for maintenance therapy in 82 Japanese patients with depression. We calculated the antidepressant dose using the imipramine equivalent scale and the dose of concomitant anxiolytics and hypnotics using the diazepam equivalent scale. The 82 participants were classified into two groups based on the median imipramine equivalent dose, and we examined the influence of patient characteristics and the presence of genetic polymorphisms of brain-derived neurotropic factor (BDNF; rs6265) and cyclic adenosine monophosphate responsive element-binding protein 1 (CREB1; rs2253306, rs4675690, rs769963) on the antidepressant maintenance dose. Using a multivariate logistic regression analysis, we found that the concomitant diazepam equivalent dose and presence of the CREB1 rs4675690 polymorphism were significantly associated with the antidepressant maintenance dose. We concluded that these factors influenced the antidepressant dose in maintenance therapy among Japanese patients with depression. However, further research is required in large cohorts.

A CASE REPORT OF PANCREATIC METASTASIS FROM PROSTATE CANCER.

We report a case of pancreatic metastasis from prostate cancer. A 65 year-old man developed gross hematuria, and was found to have a markedly elevated PSA and abnormal CT findings indicating mass lesions in bilateral lungs, and pancreatic head, and osteoblastic lesions in pelvic bone. He was referred to the department of Urology and Gastroenterology at Seirei Hamamatsu General Hospital. Digital rectal examination revealed a hen's egg-sized, stony-hard prostate. A systematic needle biopsy of the prostate demonstrated adenocarcinoma (Gleason score 4+4=8). We diagnosed multiple lung and bone metastases from prostate cancer, and suspected that a primary pancreatic ductal carcinoma. The patient was started on an androgen deprivation therapy (ADT) with bicalutamide and degarelix. After 4 months from the initiation of ADT, an MRI of the pancreas showed decreased size of the pancreatic head mass from 18 mm to 7 mm in diameter. We concluded that the pancreatic head mass was metastasis from prostate cancer, and currently continue ADT. Pancreatic metastasis from prostate cancer is very rare, and further accumulation of cases will be required.

[Prevalence and clinical characterization of Coxiella burnetii infection in patients with protracted low-grade fever].

We report here a persistent form of Coxiella burnetii infection. There have been no prospective surveys of chronic C. burnetii infection reported in Japan. Until recently, it was not possible to distinguish between previous and current infection with serological tests for antibody to C. burnetii. The nested PCR method, however, allows us to appreciate the current infection by detecting C. burnetii DNA with high sensitivity. Inoculation method using an A/J mouse was performed to confirm the viability of C. burnetii. To obtain an approximation of the prevalence of C. burnetii infection in the general population, we evaluated a random sample of patients with symptoms of continuous low-grade fever for one month or more. Analysis of 54 subjects with protracted debility and fatigue symptoms identified 13 subjects as carriers of C. burnetii (24.1%). There were no significant differences in age, C-reactive protein levels (0.69 +/- 1.19 mg/dl), white blood cell counts (6,089 +/- 2,189/microliter), eosinophil (3.4 +/- 3.6%) between the patients with C. burnetii infection and infection-free subjects. All thirteen patients had experienced protracted low-grade fever (up to 37.5 degrees C) for four months to seven years (30.5 +/- 27.7 months). Transthoracic echocardiography showed no evidence of endocarditis, or echosonography revealed no abnormal findings in the liver or kidneys. Although domestic animals constitute an important reservoir of C. burnetii, only two of the positive subjects had direct contact with them and none of the positive subjects were occupationally exposed to farm animals or common sources of infection. None had a history of hospitalizations for pneumonia or hepatic disease. Interestingly, five of the thirteen patients had a history of consulting a psychiatrist, and furthermore, one had a history of several admissions in a psychiatric hospital due to chronic fatigue symptoms. Ten of the patients had a high IgE titer (> 295 IU/ml), which shows a higher prevalence than in patients without C. burnetii (76.9%: 22.0%, P = 0.001). Four of them had markedly elevated IgE levels, in excess of 2,000 IU/ml. The mean value of IgE was higher in the patients with C. burnetii infection than in infection-free subjects (1,388 +/- 1,706: 533 +/- 913 IU/ml, p < 0.045). Two subjects were rheumatoid factor positive and another three had autoimmune thyroiditis. Twelve of the 13 subjects provided written informed consent for treatment with minocycline (200 mg/day). One month later, all subject became asymptomatic and apyretic (37.1 +/- 0.43 degrees C to 36.7 +/- 0.56 degrees C; p < 0.025), and nested PCR did not identify C. burnetii DNA in serum samples. It should be noted that persistent symptoms including low-grade fever were observed for two weeks after the start of medication. Furthermore, three patients had persistent symptoms, and DNA detection by the nested PCR method became positive in all three patients within a few months.