Diagnostic Accuracy of Point-of-Care Gram Stains in Obstructive Pyelonephritis due to Ureteral Stones.

Background: The diagnostic utility of point-of-care (POC) Gram stains for obstructive pyelonephritis with hydronephrosis is not well established. The current study aimed to assess the diagnostic accuracy of urine Gram stains in patients with obstructive pyelonephritis due to ureteral stones. Methods: A retrospective observational study was conducted on patients with obstructive pyelonephritis admitted to our hospital between January 2011 and December 2021. The diagnostic accuracy of Gram stains was evaluated based on the severity of hydronephrosis, including Gram stains performed by both trained physicians and microbiological technicians. Results: After analyzing 210 patients, POC Gram stains of bladder urine presented a sensitivity, specificity, positive predictive value, and negative predictive value of 86.8%, 81.8%, 93.7%, and 66.7%, respectively, for gram-negative rods and 65.7%, 83.4%, 48.9%, and 91.0%, respectively, for gram-positive cocci. The agreement between POC Gram stains and urine culture was good for gram-negative rods, with a kappa (κ) coefficient of 0.637 and agreement rate of 85.6%, and moderate for gram-positive cocci, with a κ coefficient of 0.435 and agreement rate of 80%. The agreement between POC Gram stains and bladder urine culture results for gram-negative rods was higher in the mild hydronephrosis group (κ coefficient = 0.677) than in the severe hydronephrosis group (κ coefficient = 0.466). Discrepancies in Gram stain results between physicians and technicians were observed in 21 of 180 cases (11.7%). Conclusions: POC Gram stains for gram-negative rods may be a useful diagnostic tool for obstructive pyelonephritis, particularly in cases of mild hydronephrosis.

Wernicke encephalopathy: limitations in a laboratory and radiological diagnosis.

Wernicke encephalopathy is an emergent neurological disorder caused by vitamin B1 (thiamine) deficiency. Here, we present a case of Wernicke encephalopathy in a male patient in his 70s with normal serum thiamine levels and MRI findings on admission. He had a history of heavy alcohol consumption and a gradual decrease in food intake. On arrival at the hospital, his consciousness was impaired which persisted even after glucose replacement. Moreover, horizontal nystagmus and cerebellar ataxia were observed. Head CT scan and MRI revealed no abnormal findings. Further, his serum thiamine level was within the normal range. The patient was clinically diagnosed with Wernicke encephalopathy, and high-dose thiamine therapy was started. Then, his symptoms improved immediately. Thus, in case of clinical suspicion, treatment for Wernicke encephalopathy must be initiated promptly even in patients with normal serum thiamine levels.

Acute Dacryoadenitis due to Primary Epstein-Barr Virus Infection.

We herein present the case of a 28-year-old male patient who presented with fever and bilateral upper eyelid edema without other upper airway symptoms and was diagnosed with acute dacryoadenitis due to Epstein-Barr virus (EBV) infection. The patient's medical history was unremarkable. Laboratory tests revealed lymphocytosis with atypical lymphocytes and abnormal liver function tests. Physical examination and computed tomography revealed swelling in the lacrimal glands, and serological tests confirmed EBV infection. Although rare, ocular symptoms of primary EBV infection are important for diagnosis. Acute dacryoadenitis should be considered as a rare manifestation and an underdiagnosed complication of primary EBV infection.

Glecaprevir/Pibrentasvir and Renal Dysfunction in Deceased Donor Renal Transplantation: A Case Report.

BACKGROUND: Glecaprevir/pibrentasvir is a novel anti-hepatitis C virus (HCV) drug, and it is currently the only drug available for patients with severe renal impairment. Here we report a case with renal dysfunction after an administration of glecaprevir/pibrentasvir. CASE REPORT: The case was 66-year-old Japanese man who turned out to be HCV-positive 14 years ago at the time of his second deceased renal transplantation. He had no prior history of HCV treatment. HCV genotype was serogroup 1, and baseline HCV-RNA was 5.3 LOG IU/mL. Since glecaprevir/pibrentasvir became available, he started to take it for treatment of HCV. His immunosuppressants were tacrolimus (trough levels 4.3∼6.5 ng/mL) and 5 mg of prednisolone. His baseline renal function was serum creatinine (Cr) 2.1 mg/dL and urine protein (-). Shortly after starting glecaprevir/pibrentasvir, the serum Cr started to increase. Serum Cr reached up to 2.92 mg/dL and urine protein was (+) at day 36. Right pleural effusion was observed while cardiac function was normal. His liver function had been consistently normal. We concluded glecaprevir/pibrentasvir was the cause of renal dysfunction as no other drugs were added. Immediately after discontinuation of glecaprevir/pibrentasvir at day 36, serum Cr decreased to 1.9 mg/dL and urine protein turned negative at day 64. Although the patient completed a half course of glecaprevir/pibrentasvir, HCV-RNA turned to be negative at day 36. CONCLUSIONS: We experienced a case with renal dysfunction after the initiation of glecaprevir/pibrentasvir in deceased donor renal transplant recipient. Renal dysfunction caused by glecaprevir/pibrentasvir has not been reported so far.

Photobacterium damselae subsp. damselae bacteraemia in a patient with liver cirrhosis.

Photobacterium damselae subsp. damselae is a family of Vibrionaceae and exists in the marine environment. The organism rarely causes soft-tissue infection in humans; moreover, most of the infected individuals have a history of fishing or exposure to brackish water. We experienced the case of a 63-year-old patient with a history of liver cirrhosis (Child-Pugh class B) who presented with a fever and swelling of the left leg with pain. His symptoms developed after fishing and eating raw fish with exposure of brackish water. He was diagnosed with cellulitis, and Photobacterium damselae spp. damselae was detected in blood culture. The patient was treated with ceftazidime and minocycline and he was discharged after recovery. We need to be aware that in immunocompromised patients with cellulitis exposed to brackish water, organisms other than Staphylococci and Streptococci may be the causative organisms.

Empyema associated with a cough-induced rib fracture.

A 44-year-old man presented to the emergency department with fever and right anterior chest pain. He reported a persistent cough and the development of sudden-onset right anterior chest pain after coughing. The inspiratory pain in the right lung was severe, and therefore deep breathing was impossible. Chest CT revealed a fracture in the right seventh rib with consolidation and pleural effusion. A pleural fluid culture test result was positive for methicillin-susceptible Staphylococcus aureus He was diagnosed with empyema associated with a cough-induced rib fracture. Thoracic drainage tube placement and intravenous antibiotic therapy successfully ameliorated his condition. He was discharged on day 13 and switched to an 8-week course of oral antibiotic therapy. There was no clinical relapse at the 6-month follow-up.

Case Report: Ninjin'yoeito May Improve Quality of Life After Hospitalization for Acute Illness in Patients With Frailty.

Introduction: Frail patients are susceptible to a large number of diseases, and frailty particularly is known to develop after acute illness. No conventional drugs are known to prevent such exacerbation after acute illness. However, traditional Japanese medicine, Kampo, is thought to confer efficacious energy and nutritional supplements and serve to improve malaise after acute illness. Ninjin'yoeito is a representative Kampo medicine for such situation. Cases: We describe three frail patients hospitalized for acute illness who started taking ninjin'yoeito at the time of discharge. Case 1: An 87-year-old man admitted with acute prostatitis complicated by hypertension and chronic obstructive pulmonary disease (COPD). His 36-Item Short Form Health Survey (SF-36) score, which is representative of total quality of life and comprises eight components, showed consistent improvements after 4 and 12 weeks of ninjin'yoeito administration, especially for body pain (BP; scores from 41 to 51 and 100, respectively), social function (SF; 50, 100, 100), and mental health (MH; 75, 75, 90). Case 2: A 65-year-old man admitted with urinary tract infection complicated by primary sclerosing cholangitis and COPD. All SF-36 component scores showed improvement 12 weeks later: physical function (PF; 70-95), role physical (RP; 75-100), BP (72-84), general health (GH; 45-52), vitality (VT; 37.5-75), SF 75-100, role emotional (RE; 75-100), and MH (70-90). Case 3: An 80-year-old man admitted for pneumonia complicated with hypertension. SF-36 score was improved 4 weeks later for RP (68.8-100), BP (52-61), GH (52-72), VT (43.8-62.5), SF (37.5-100), and RE (58.3-91.7). Conclusion: Patients with frailty often have a worsened SF-36 score after discharge following acute illness, but the score may be improved by taking ninjin'yoeito.

Long-term impact of baseline serum uric acid levels on living kidney donors: a retrospective study.

BACKGROUND: Preoperative characteristics of living kidney donors are commonly considered during donor selection and postoperative follow-up. However, the impact of preoperative uric acid (UA) levels is poorly documented. The aim of this study was to evaluate the association between preoperative serum UA levels and post-donation long-term events and renal function. METHODS: This was a single-center retrospective analysis of 183 living kidney donors. The donors were divided into high (≥5.5 mg/dl) and low (< 5.5 mg/dl) UA groups. We analyzed the relationship between preoperative UA levels and postoperative estimated glomerular filtration rate (eGFR), as well as adverse events (cardiovascular events and additional prescriptions for hypertension, gout, dyslipidemia, and diabetes mellitus), over 5 years after donation. RESULTS: In total, 44 donors experienced 52 adverse events over 5 years. The incidence of adverse events within 5 years was significantly higher in the high UA group than in the low UA group (50% vs. 24%, p = 0.003); this was true even after the exclusion of hyperuricemia-related events (p = 0.047). UA emerged as an independent risk factor for adverse events (p = 0.012). Donors with higher UA levels had lower eGFRs after donation, whereas body mass index, hemoglobin A1c, blood pressure, and low-density lipoprotein cholesterol did not have any impact on the eGFR. CONCLUSIONS: The findings suggest that preoperative UA levels should be considered during donor selection and postoperative follow-up.

Multimode-based polarization independent WDM devices using different order modes for TE and TM polarizations.

Multimode based polarization independent (PI) wavelength division multiplexing (WDM) devices are proposed and experimentally demonstrated. The key concept is to utilize two different order modes for the orthogonal polarizations, ith-order mode for TE and jth-order mode for TM (i ≠ j) polarization respectively to extend the flexibility for designing devices. PI coupler composed of a multimode directional coupler and mode converters is introduced as a basic device. Then, we apply PI coupler to Mach Zehnder interferometer (MZI) and Bragg grating bandpass filters. PI MZI is achieved by optimizing the combination of two phase shifters in the interferometer arms. PI bandpass uses 3dB-PI coupler and polarization rotate Bragg gratings that induce mode coupling between the polarizations. Each device showed good matching in the spectrum between TE and TM polarizations in term of operation wavelength. The proposed concept can be a promising approach to realize PI WDM functions without introducing polarization diversity scheme in which a polarization beam splitter, two devices designed for each polarization and a polarization beam combiner are required.

HbA1c and Aortic Calcification Index as Noninvasive Predictors of Pre-Existing Histopathological Damages in Living Donor Kidney Transplantation.

We previously reported that allografts from living donors may have pre-existing histopathological damages, defined as the combination of interstitial fibrosis (ci), tubular atrophy (ct), and arteriolar hyalinosis (ah) scores of ≧1, according to the Banff classification. We examined preoperative characteristics to identify whether the degree of these damages was related to metabolic syndrome-related factors of donors. We conducted a single-center cross-sectional analysis including 183 living kidney donors. Donors were divided into two groups: chronic change (ci + ct ≧ 1 ∩ ah ≧ 1, n = 27) and control (n = 156). Preoperative characteristics, including age, sex, blood pressure, hemoglobin A1c (HbA1c), aortic calcification index (ACI), and psoas muscle index (PMI), were analyzed. Comparing the groups, the baseline estimated glomerular filtration rate was not significantly different; however, we observed a significant difference for ACI (p = 0.009). HbA1c (p = 0.016) and ACI (p = 0.006) were independent risk factors to predict pre-existing histopathological damages, whereas PMI was not. HbA1c correlated with ct scores (p = 0.035), and ACI correlated with ci (p = 0.005), ct (p = 0.021), and ah (p = 0.017). HbA1c and ACI may serve as preoperative markers for identifying pre-existing damages on the kidneys of living donors.

Optimizing Intraoperative Blood Pressure to Improve Outcomes in Living Donor Renal Transplantation.

BACKGROUND: Adequate renal perfusion at the time of unclamping is important because it has been known to affect outcomes in renal transplantation. Nevertheless, the ideal intraoperative systolic arterial pressure (SAP) has not been well defined. METHODS: We performed a retrospective analysis of 106 living donor renal transplants performed at our center from June 2010 to May 2019. We divided the cohort into 2 groups according to our center's goal SAP of ≥150 mm Hg: 57 patients had SAP ≥150 mm Hg and 49 patients had SAP <150 mm Hg. We analyzed pretransplant characteristics, intraoperative measurements, and postoperative laboratory values to validate our center's target SAP at the time of reperfusion. This study strictly complied with the Helsinki Congress and the Istanbul Declaration regarding donor sources. RESULTS: Patients with SAP ≥150 mm Hg had been on dialysis for a significantly shorter duration before transplant compared with those who had SAP <150 mm Hg. In the SAP ≥150 mm Hg group, urinary sodium excretion normalized earlier, and they had a significantly smaller stroke volume variation, higher cardiac output and cardiac index, earlier initial urination, and higher intraoperative urine output. There were no differences in intraoperative volume repletion, central venous pressure, or postoperative estimated glomerular filtration rate. CONCLUSION: Achieving SAP ≥150 mm Hg at the time of reperfusion may be associated with early stabilization of graft function. Nevertheless, our data suggested that recipients with a prolonged dialysis history are less likely to achieve SAP ≥150 mm Hg at the time of unclamping in living donor renal transplantation.

Is the Living Donor Kidney Profile Index Valuable in Japanese Patients?

INTRODUCTION: The Living Kidney Donor Profile Index (LKDPI) was recently proposed in the United States to evaluate living donor quality. Japan has a largely different renal transplant circumstance, such as a high ABO incompatibility rate. The aim of this study was to validate the LKDPI among the Japanese population and adjust the score. METHODS: We performed a retrospective analysis of 133 living donors in renal transplant in our institution. We analyzed the clinical characteristics and outcomes, and created a modified LKDPI score considering the favorable ABO incompatible kidney transplant outcomes in Japan. RESULTS: Median (interquartile range [IQR]) donor age was 59 (51 to 65) and median (IQR) body mass index was 22.9 kg/m2 (20.9 to 25.2). ABO incompatibility rate was 28.5%. Median (IQR) donor estimated glomerular filtration rate (eGFR) (Chronic Kidney Disease Epidemiology Collaboration equation) was 108.7 mL/min/1.73 m2 (99.9 to 115.5). The 1-year graft survival rate was 98.5%, and the 3-year graft survival rate was 97%. The incidence of antibody mediated rejection was 5.2%. The median (IQR) LKDPI score was 30.2 (11.8 to 46.8). This was significantly higher than the previously reported score in the United States, which was 12.8 (-0.8 to 27.2). The modified LKDPI (mLKDPI) score was 23.2 (4.1 to 35.1). LKDPI and mLKDPI did not show a diagnostic value in graft survival; however, LKDPI and mLKDPI showed significant diagnostic value in eGFR at 1 year (area under the curve [AUC]=0.627, P = .017; and AUC=0.673, P = .01). CONCLUSION: Our outcomes had better survival even though with higher ABO incompatibility rate. According to original LKDPI, our donor pool is higher than the general US population. In this study, lower LKDPI tended to be associated with good allograft function, and mLKDPI has better diagnostic value than LKDPI. To compare internationally, an adjusted model for Japan might be necessary based on the outcomes of a large population.

Impact of Very Low-Dose Trimethoprim-Sulfamethoxazole on Serum Creatinine after Renal Transplantation: A Retrospective Study.

BACKGROUND: It is well known that high-dose trimethoprim, through its effect of inhibiting creatinine secretion, increases serum creatinine levels without changes in real glomerular filtration rate. However, there has been no report regarding the effect of very low-dose trimethoprim on serum creatinine levels after renal transplantation. METHODS: We retrospectively investigated 76 renal transplantation recipient outpatients who completed their course of initial prophylaxis at our institution. Twelve patients who experienced events that might affect their serum creatinine levels were excluded. Fifty-one patients who required readministration of trimethoprim-sulfamethoxazole to prevent a possible outbreak of pneumocystis jirovecii pneumonia and 13 patients who did not receive readministration (control) were analyzed. Dosage was 80 mg/400 mg (per tablet), administered as 3 tablets per week for 30.6 ± 13.5 days. This study strictly complied with the Helsinki Congress and the Istanbul. Declaration regarding donor source. RESULTS: All patients completed readministration without adverse events. Serum creatinine increased significantly in the readministration group (1.40 ± 0.64 mg/dL to 1.48 ± 0.70 mg/dL, P < .01) while not in the control group. The higher the initial serum creatinine level, the greater the increase of Δ serum creatinine (R = 0.59, P < .001). Sex, baseline urine protein level, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use, donor type, and time after renal transplantation did not affect Δ serum creatinine. Serum creatinine returned to baseline levels after cessation. CONCLUSIONS: Very low-dose trimethoprim-sulfamethoxazole prophylaxis significantly raised serum creatinine reversibly by 6% after renal transplantation.

Cocoa supplementation for copper deficiency associated with tube feeding nutrition.

OBJECTIVE: Because of an increasing number of case reports of copper deficiency associated with long-term tube feeding nutrition in Japan, we identified patients with copper deficiency associated with long-term tube feeding and described the prevalence, clinical data and cocoa treatment for these patients. MATERIALS AND METHODS: We conducted a retrospective study to identify patients who were referred from long-term care institutions and had copper deficiency associated with tube feeding. We reviewed all serum copper concentration data during a 6-year period. We also compared admission and post-treatment peripheral blood counts. RESULTS: Among 210 consecutive admissions with nutritional tube feeding from long-term care institutions (N=210), we identified 13 (6.2%) patients with copper deficiency (aged 46-91; 12 women). All patients had anemia, while most had neutropenia. The range of serum copper concentrations of these patients was 0.1-2.4 microg/L (normal; 6.8-12.8 microg/L). Their feeding formulas revealed a low copper content (5 to 12 microg per 100 kcal of each formula). Cocoa powder was used as the treatment. With cocoa supplements, the blood leukocyte count and hemoglobin significantly improved in all patients. Median leukocyte counts were 1,800 /mm(3)at admission and 6,300/mm(3) at follow-up (p=0.001). Median hemoglobin were 7.0 g/dl at admission and 10.3 g/dl at follow-up (p=0.001). Two patients developed transient tachycardia as a possible adverse effect of cocoa. CONCLUSION: We identified many cases with copper deficiency associated with tube feeding in Okinawa, Japan. Cocoa supplement appeared to be a safe and effective treatment. Increasing the copper content of Japanese tube feeding formulas should be considered for its prevention.

[A case of pneumonia due to coinfection by Mycoplasma pneumoniae and Chlamydia pneumoniae].

Few cases of Mycoplasma pneumoniae and Chlamydia pneumoniae coinfection in pneumonia have been reported in adults. We report a case of such a double infection in a young adult. A 16-year-old boy was admitted to our hospital with dry cough and fever. Laboratory findings revealed elevated serum GOT and GPT levels. The patient had been administered a beta-lactam antibiotic before admission to our hospital. Antibodies to M. pneumoniae were significantly elevated. Titers of IgM and IgG specific for C. pneumoniae titer were high, as measured by the enzyme-linked immunosorbent assay method. The patient was treated with clarithromycin and discharged after a satisfactory recovery. M. pneumoniae and C. pneumoniae may act as cofactors in community-acquired pneumonia. Further studies are needed to clarify the relationships of these pathogens to community-acquired pneumonia.