Nurses' perception of pediatric pain and pain assessment in the Japanese PICU.

BACKGROUND: Nurses play an essential role in pain management in the pediatric intensive care unit (PICU). However, their perceptions regarding pediatric pain and current practice of pain assessment in Japanese PICUs remain unknown. METHODS: In January 2021, we conducted a multicenter, cross-sectional survey across 35 PICUs in Japan. A structured questionnaire which focused on nurses' perceptions of pediatric pain and pain assessment was developed, pilot-tested, and revised. Twenty copies of the questionnaire were sent to each institution and were distributed to the nursing staff. RESULTS: A total of 356 nurses from 22 institutions responded. Median age of the respondents was 33 years and 84.6% were female. Median length of nursing experience and PICU experience were 10 and 4 years, respectively. Use of pain scales for assessing pain in children who can self-report pain, preverbal children, and children unable to self-report pain due to cognitive impairment were 90.7%, 55.9%, and 50.0%, respectively. Nurses' satisfaction regarding pain management in their PICU was 31.9% and their confidence in pain assessment and management were 32.6% and 44.9%, respectively. Lack of knowledge (95.8%), difficulty assessing pain in children (95.2%), and delay in physician's action (91.8%) were the most perceived barriers to optimal pain management. CONCLUSIONS: The use of pain scales is insufficient and nurses' satisfaction proved to be extremely low in the Japanese PICUs. Substantial effort is required to enhance the level of current pain management and improve outcomes.

Temporal trends of medical cost and cost-effectiveness in sepsis patients: a Japanese nationwide medical claims database.

BACKGROUND: Sepsis is the leading cause of death worldwide. Although the mortality of sepsis patients has been decreasing over the past decade, the trend of medical costs and cost-effectiveness for sepsis treatment remains insufficiently determined. METHODS: We conducted a retrospective study using the nationwide medical claims database of sepsis patients in Japan between 2010 and 2017. After selecting sepsis patients with a combined diagnosis of presumed serious infection and organ failure, patients over the age of 20 were included in this study. We investigated the annual trend of medical costs during the study period. The primary outcome was the annual trend of the effective cost per survivor, calculated from the gross medical cost and number of survivors per year. Subsequently, we performed subgroup and multiple regression analyses to evaluate the association between the annual trend and medical costs. RESULTS: Among 50,490,128 adult patients with claims, a total of 1,276,678 patients with sepsis were selected from the database. Yearly gross medical costs to treat sepsis gradually increased over the decade from $3.04 billion in 2010 to $4.38 billion in 2017, whereas the total medical cost per hospitalization declined (rate = - $1075/year, p < 0.0001). While the survival rate of sepsis patients improved during the study period, the effective cost per survivor significantly decreased (rate = - $1806/year [95% CI - $2432 to - $1179], p = 0.001). In the subgroup analysis, the trend of decreasing medical cost per hospitalization remained consistent among the subpopulation of age, sex, and site of infection. After adjusting for age, sex (male), number of chronic diseases, site of infection, intensive care unit (ICU) admission, surgery, and length of hospital stay, the admission year was significantly associated with reduced medical costs. CONCLUSIONS: We demonstrated an improvement in annual cost-effectiveness in patients with sepsis between 2010 and 2017. The annual trend of reduced costs was consistent after adjustment with the confounders altering hospital expenses.

In vitro and in vivo antibacterial activity of nitrofurantoin against clinical isolates of E. coli in Japan and evaluation of biological cost of nitrofurantoin resistant strains using a mouse urinary tract infection model.

INTRODUCTION: Nitrofurantoin is a well-established antibiotic, and is an important first-line oral treatment for uncomplicated urinary tract infections. However, little information is available with respect to its antibacterial activity in Japan, in vivo efficacy, or the in vivo biological cost of resistant strains. METHODS: We compared the susceptibility of six representative antibacterial agents-nitrofurantoin, sulfamethoxazole/trimethoprim, fosfomycin, mecillinam, ciprofloxacin, and cefdinir-against E. coli clinically isolated in Japan during 2017. We evaluated the in vivo efficacy of nitrofurantoin using a model of mouse urinary tract infection caused by ciprofloxacin resistant E. coli. We obtained nitrofurantoin resistant isolates through tests generating spontaneous mutations, and assessed the in vivo fitness of nitrofurantoin resistant isolates. RESULTS: The MIC90 of nitrofurantoin was 16 µg/mL, and was the lowest among the drugs tested. It was found that, in the mouse urinary tract infection model, 30 mg/kg and 100 mg/kg of nitrofurantoin reduced the count of viable bacterial cells in the kidney, while 100 mg/kg of ciprofloxacin did not. All spontaneous bacterial mutants resistant to nitrofurantoin had deletions in the nfsA gene, and we found that the resistant strain had lower growth in the mouse urinary tract infection model than in the parent strain. CONCLUSIONS: We demonstrated promising in vitro and in vivo activity of nitrofurantoin against E. coli clinical isolates in Japan, and lower in vivo fitness of the resistant strain of nitrofurantoin.

The last strategy for re-dissemination of HPV vaccination in Japan while still under the suspension of the governmental recommendation.

In Japan, the governmental recommnendation of HPV vaccine has been suspended since June 2013, due to media reports of alleged adverse vaccination events. Although evidence of effectiveness and safety of the HPV vaccine has been universally demonstrated, and the medical and academic organizations across Japan have requested the resumption of the government's recommendation, the Japanese government has not changed their official stance towards the HPV vaccine. Under the current suspension of the national government's recommendation, one local government Isumi City started sending a leaflet containing information of cervical cancer and HPV vaccine, but not recommendation for the vaccine, to the tagted girls born in the fiscal year (FY) 2003. The cumulative vaccination rate of them reached 10.07% (14/139), which was significantly higher than that (0.00%) for girls born in FY 2002 who did not receive such a leaflet (p < 0.001). We sincerely ask the national government to change their stance towards the HPV vaccine. We also strongly suggest that, in the meantime, local governments immediately begin to provide an appropriate information of cervical cancer and HPV vaccine to the targeted girls and their parents in a way similar to what Isumi City has now shown to be effective.

Proposed Pharmacokinetic-Pharmacodynamic Breakpoint of Garenoxacin and Other Quinolones.

The pharmacokinetic-pharmacodynamic (PK-PD) breakpoints (BPs) of garenoxacin (GRNX) and other oral quinolones were calculated using Monte Carlo simulation (MCS) based on the distribution of changes in their plasma concentrations. PK-PD BPs of 400 mg once a day (QD) of GRNX for the free area under the curve/minimum inhibitory concentration (fAUC/MIC) for 30 strains of Streptococcus pneumoniae and 100 strains of gram-negative bacteria (G [－]) were 0.5 and 0.125 µg/mL, respectively. PK-PD BPs of other quinolones for S. pneumoniae/G (－) were 1/0.25 µg/mL for levofloxacin (LVFX) 500 mg QD, 0.5/0.125 µg/mL for moxifloxacin (MFLX) 400 mg QD, 0.0625/0.0156 µg/mL for sitafloxacin (STFX) 50 mg twice a day (BID) (100 mg QD), and 0.125/0.0313 µg/mL for STFX 100 mg BID. We also investigated the hypothetical probability of target attainments (PTAs) of fAUC/MIC for community-acquired pneumonia (CAP) using MCS, in consideration of the isolation frequencies of the three main causative pathogens of CAP: S. pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. For hypothetical CAP in adults, PTA of fAUC/MIC was 100% with GRNX and MFLX, 96%-97% with STFX at 100 mg BID, 45%-46% with LVFX, and 53%-58% with STFX at 100 mg QD and 50 mg BID. Based on the PK-PD BP, GRNX showed higher fAUC/MIC than the other quinolones tested against the three main pathogens of respiratory infections.

What is an intensive care unit? A report of the task force of the World Federation of Societies of Intensive and Critical Care Medicine.

Since their widespread introduction more than half a century ago, intensive care units (ICUs) have become an integral part of the health care system. Although most ICUs are found in high-income countries, they are increasingly a feature of health care systems in low- and middle-income countries. The World Federation of Societies of Intensive and Critical Care Medicine convened a task force whose objective was to answer the question "What is an ICU?" in an internationally meaningful manner and to develop a system for stratifying ICUs on the basis of the intensity of the care they provide. We undertook a scoping review of the peer-reviewed and gray literature to assemble existing models for ICU stratification. Based on these and on discussions among task force members by teleconference and 2 face-to-face meetings, we present a proposed definition and classification of ICUs. An ICU is an organized system for the provision of care to critically ill patients that provides intensive and specialized medical and nursing care, an enhanced capacity for monitoring, and multiple modalities of physiologic organ support to sustain life during a period of life-threatening organ system insufficiency. Although an ICU is based in a defined geographic area of a hospital, its activities often extend beyond the walls of the physical space to include the emergency department, hospital ward, and follow-up clinic. A level 1 ICU is capable of providing oxygen, noninvasive monitoring, and more intensive nursing care than on a ward, whereas a level 2 ICU can provide invasive monitoring and basic life support for a short period. A level 3 ICU provides a full spectrum of monitoring and life support technologies, serves as a regional resource for the care of critically ill patients, and may play an active role in developing the specialty of intensive care through research and education. A formal definition and descriptive framework for ICUs can inform health care decision-makers in planning and measuring capacity and provide clinicians and patients with a benchmark to evaluate the level of resources available for clinical care.