Effectiveness and safety of a program for appropriate urinary catheter use in stroke care: A multicenter prospective study.

OBJECTIVES: Since patients with stroke frequently develop bladder dysfunction, a careful approach is required to reduce unnecessary indwelling urinary catheter (IUC) for preventing catheter-associated urinary tract infection (CAUTI). This study aimed to assess the effectiveness and safety of a program to promote appropriate IUC use in stroke care. METHODS: We conducted a prospective interrupted time series study in three tertiary care hospitals in Japan. Adult patients with acute stroke were eligible. The study consisted of three phases: baseline, education and implementation. Our program included an assessment of IUC indications, educational meetings among healthcare professionals, reminders for removal of inappropriate IUC and a urinary retention protocol. The primary outcome was the proportion of inappropriate IUC use to assess effectiveness. The device utilization ratio and incidence of CAUTI were examined to assess effectiveness, and incidences of urinary retention and all symptomatic urinary tract infection (UTI) were examined to assess safety. RESULTS: Among 976 patients who met the inclusion criteria, 738 were analysed. Inappropriate IUC use decreased from 50.1% in the baseline phase to 22.5% in the implementation phase (absolute risk reduction in interrupted time series analysis 42.4% [95% confidence interval, 19.2%-65.6%]). The device utilization ratio decreased from 0.302 to 0.194 (p < 0.001), whereas CAUTI did not change significantly (from 8.81 to 8.28 per 1000 catheter-days; incidence rate ratio 0.95 [0.44-1.94]). All symptomatic UTI decreased from 9.5% to 4.9% (p = 0.015), with no increase in urinary retention. CONCLUSIONS: Our program improved the appropriateness of IUC use in stroke care while ensuring safety.

Lower serum phosphate levels in patients with Legionella pneumonia relative to patients with non-Legionella pneumonia.

INTRODUCTION: Few studies have evaluated serum phosphate levels in patients with Legionella pneumonia admitted to hospitals in Japan. This study aimed to assess serum phosphate levels among inpatients with Legionella pneumonia on admission and compare them to those of inpatients with non-Legionella community-acquired pneumonia. METHODS: This case-control study included patients aged ≥16 years who were treated for Legionella pneumonia from April 2011 through March 2017 and those aged ≥16 years who were treated for non-Legionella community-acquired pneumonia from August 2014 through July 2015. Legionella pneumonia was diagnosed based on a positive result on the urinary antigen test, as well as radiographic examinations. Serum phosphate levels on admission were compared between Legionella and non-Legionella patients. In addition, serum phosphate levels on admission and on hospital day 5-7 were compared in Legionella patients. RESULTS: We evaluated 8 Legionella patients and 61 non-Legionella patients. Median serum phosphate levels on admission were 1.90 and 2.80 mg/dL in Legionella and non-Legionella patients, respectively (P = 0.008). By hospital day 5-7, serum phosphate levels in Legionella patients had increased to 2.61 mg/dL (P = 0.029, relative to admission), which did not significantly differ from those of non-Legionella patients on admission (P = 0.372). CONCLUSION: Serum phosphate levels on admission were approximately 32% lower in Legionella pneumonia patients compared to non-Legionella pneumonia patients, but both were comparable by hospital day 7.

[One successful end-of-life home care handled by three physicians].

Aging population has been advancing in Ito city located in the northern part of Izu peninsula. Many elderly people are hoping to receive an end-of-life care at home, but there is no home care section in Ito municipal hospital, a flagship hospital in this region. One of the end-stage leukemia patients of our hospital hoped to die at home. We report a case that three physicians joined together to take care of this terminal patient with a cooperation from nurses, home-visit nursing care station and a care manager.

An Autopsy Case of TAFRO Syndrome with Type II Respiratory Failure.

BACKGROUND TAFRO syndrome (thrombocytopenia, anasarca, fever, myelofibrosis, renal dysfunction, and organomegaly) is a systemic inflammatory disorder. The histological features of TAFRO syndrome are not fully understood and few autopsy cases have been reported. CASE REPORT A 66-year-old man with type II respiratory failure was diagnosed with TAFRO syndrome. He was initially treated with tocilizumab. Although some improvements were observed, his condition worsened, and the medication was switched to rituximab. His condition remained steady for 1 year with intermittent artificial ventilation. However, he died due to exacerbation of respiratory failure about 20 months after diagnosis. An autopsy revealed mucous fluid retention in the spaces between the axis cylinder and the myelin sheath of peripheral nerves and among the peripheral nerves, suggesting that this retention contributed to neurodegeneration with demyelination. Skeletal muscles, including respiratory muscles, were highly atrophic, which could have led to type II respiratory failure. CONCLUSIONS Fluid accumulation other than pleural effusion and ascites could occur in intra-organs at a cellular level.

Study of image quality of superimposed projection using multiple projectors.

In this correspondence, we discuss the quality of images realized by a recently proposed method of generating a high-resolution image by superimposing multiple low-resolution images projected by different projectors. We show several fundamental properties of this method: 1) the accuracy of the image realization (e.g., resolution of the realized image) is heavily affected by the structures of the images to be realized, and 2) there is a tradeoff between the image quality and the maximum brightness of the images to be realized. These are properties peculiar to multiprojector super-resolution and are in contrast with multicamera super-resolution. The results will be helpful in evaluating the usefulness of the method.

Elderly patients with lower-jaw mobility require careful food texture modification: A cohort study.

BACKGROUND: Few studies have investigated the relationship between lower-jaw mobility and oral ingestible food texture choices in elderly patients. This study aimed to evaluate whether lower-jaw mobility affects levels of food texture modification. METHODS: This prospective cohort study targeted inpatients aged ≥65 years with pneumonia or urinary tract infection from August 2014 through July 2015. We defined "lower-jaw mobility" as movement of the lower jaw (more than about 1 cm) when gently supported from both sides of the mandibular angle with index fingers. The primary outcome was food texture at discharge, which was evaluated using "Japanese Dysphagia Diet 2013": non per os, codes 0-4 (in the order of increasing swallowing difficulty), and normal meal. RESULTS: We evaluated 38 patients in the mobility group (mean age: 86.5 years) and 251 patients in the nonmobility group (mean age: 83.2 years). Percentages of patients capable of ingesting each food texture were as follows (mobility vs nonmobility): normal meal, 5.3% vs 50.1%; code 4, 39.5% vs 31.9%; code 3, 5.3% vs 8.8%; code 2, 10.5% vs 4.4%; code 1, 2.6% vs 0.8%; code 0, 0.0% vs 0.4%; and non per os, 36.8% vs 2.8%. Food texture codes were lower in the mobility group (P < 0.001). These relationships remained significant even after adjusting for potential confounding factors in multivariate analysis (P < 0.001). CONCLUSION: Elderly patients with lower-jaw mobility were restricted to texture-modified foods. Lower-jaw mobility can be assessed easily even by nonmedical personnel, and regular assessment could help identify elderly patients requiring dietary adjustment.

Tocilizumab-resistant TAFRO Syndrome Complicated by Type II Respiratory Failure.

A 66-year-old man with a several year history of thrombocytopenia, pleural effusion and ascites, anasarca, and organomegaly presented with general fatigue, appetite loss, dyspnea with type II respiratory failure. The precise history of the patient and the re-evaluation of lymph node and bone marrow biopsies conducted by the previous physician indicated TAFRO syndrome. The patient's laboratory data improved for a year with tocilizumab, but then worsened to the point that the patient required artificial ventilation due to the deterioration of type II respiratory failure. The replacement of tocilizumab with rituximab yielded a steady improvement, but it was necessary to address the patient's persistent respiratory failure. Peripheral nerve disorder might have been involved with the patient's respiratory failure.

Effects of Establishing a Department of General Internal Medicine on the Length of Hospitalization.

OBJECTIVE: This study aimed to evaluate the effects of establishing a Department of General Internal Medicine (DGIM) on the length of hospitalization. We evaluated the length of hospitalization associated with diseases for which full-time specialists were not available and were instead treated by physicians of the DGIM after its establishment. METHODS: A retrospective cohort study was conducted with a review of the subjects' medical records. The subjects included patients ≥16 years of age who were hospitalized with pneumonia or cerebral infarction and treated by a physician with a specialty in internal medicine as the disease outside their specialty prior to DGIM establishment (October 1, 2006 to September 30, 2008) or by a physician of the DGIM after its establishment (October 1, 2009 to September 30, 2011). The primary outcome was the change in the length of hospitalization. The length of hospitalization for heart failure, which was treated by specialists (cardiologists) in both study periods, was also examined for comparison. RESULTS: We evaluated 322 and 423 cases of pneumonia treated before and after the establishment of the DGIM, as well as 223 and 229 cases of cerebral infarction and 132 and 206 cases of heart failure, respectively. The length of hospitalization before and after establishment of the DGIM was 21.6 and 16.0 days for the pneumonia patients (p<0.001) and 24.2 and 19.9 days for the cerebral infarction patients (p<0.001), respectively. On the other hand, the change in the length of hospitalization for the heart failure patients was not statistically significant (19.9 vs. 17.6 days; p=0.281). CONCLUSION: The establishment of the DGIM reduced the length of hospitalization associated with diseases for which full-time specialists were not available by over 17%.

Paraganglioma-induced alveolar hemorrhage.

A 21-year-old man twice developed sudden dyspnea during running examinations for promotion. Chest computed tomography (CT) revealed lobular ground-glass opacity and centrilobular shadows bilaterally. The bronchoscopy findings were consistent with alveolar hemorrhage, and echocardiography showed severe hypokinesia a few hours later. A mass was subsequently identified along the abdominal aorta on enhanced CT and iodine-131 metaiodobenzylguanidine scintigraphy. Catecholamine oversecretion, which was later confirmed, may have increased the pulmonary vein pressure, thus resulting in the development of an alveolar hemorrhage, and damaged the cardiac muscles as manifested by hypokinesia. Since the patient had not previously developed alveolar hemorrhage during usual exercise, emotional stress superimposed on the physical activity may have triggered the paraganglioma to secrete excessive catecholamines, thus resulting in the observed symptoms.

Early diagnosis of Lemierre's syndrome based on a medical history and physical findings.

A 37-year-old woman presented with fever and rigor after experiencing respiratory symptoms the previous week that had resolved within a few days. On presentation, her neck was swollen along the right sternocleidomastoid muscle, and chest CT showed pulmonary septic embolisms. Lemierre's syndrome was strongly suspected based on the patient's medical history and physical findings. Further examination revealed venous thrombus, and Fusobacterium necrophorum was later isolated from blood cultures. Antibiotics for anaerobes were administered before a final diagnosis was made, and the patient's symptoms thereafter improved. A rapid diagnosis is essential, since Lemierre's syndrome can be fatal with a diagnostic delay.

Practice patterns for lower respiratory tract infections in hospital patients with particular focus on bacteriological examinations and injection antibiotics use.

BACKGROUND: Various types of medical institutions perform treatments for lower respiratory tract infections. However, few studies have assessed and compared practice patterns across different medical institutions in Japan. To assess practice patterns for community-acquired lower respiratory tract infections among patients who needed hospitalization, we examined the use of injection antibiotics and the implementation of bacteriological examinations, and compared these across medical institutions. We then evaluated whether bacteriological examinations were being adequately implemented. METHODS: A cross-sectional study was conducted using a database of health insurance claims. Subjects were patients (≥16 years old) who received injection antibiotics to treat lower respiratory tract infections, and who were listed among 2004-2007 insurance claims data. For each type of antibiotic, we obtained the dose prescribed, the number of patients treated, and the frequency of bacteriological examinations. RESULTS: A total of 1649 patients were evaluated. The implementation rate of Gram stain and sputum culture was 14% at clinics (<20 beds), approximately 30% at small hospitals (20-99 beds), and 40%-45% at medium-sized (100-499 beds) and large hospitals (≥500 beds). As a whole, beta-lactams were most frequently used, accounting for 80% of all antibiotics used. Among beta-lactams, penicillins comprised 25% of the total amount of drugs used at hospitals with ≥300 beds, but approximately 13% at clinics and small hospitals. CONCLUSION: Practice patterns varied depending on the size of the medical institution. The implementation rate of bacteriological examinations was not high enough, especially at clinics and small hospitals.

A newly established neuronal rho-0 cell line highly susceptible to oxidative stress accumulates iron and other metals. Relevance to the origin of metal ion deposits in brains with neurodegenerative disorders.

From human neuroblastoma-derived SILA cells we have established a rho-0 cell line that is deficient in both respiration and mitochondrial DNA. Lactate dehydrogenase activity, lactate production, and growth in the medium without glucose indicate that these cells shift from aerobic to anaerobic metabolism. Electron microscopic observations revealed abnormal mitochondria with unique cristae structures. Staining with MitoTracker dye showed that the mitochondrial transmembrane potential was reduced by 30-40% from the parent cell levels. These cells were markedly susceptible to H(2)O(2) and died apparently by a necrotic mechanism, a process blocked by deferoxamine in the parent cells but not rho-0 cells. Analysis by inductively coupled plasma-mass spectrometry revealed an approximately 3-fold accumulation of iron in the rho-0 cells at confluence (n = 4-6, three clones, *p < 0.05). Iron and four other metals were all elevated in the cells of one of the rho-0 clones and were similar to control levels in the control cybrid cells, which were replenished with normal mitochondrial DNA. Their sensitivity to H(2)O(2) was also similar to that of the parent cells. These results indicate that a newly established neuronal related rho-0 cell line is highly susceptible to active oxygen species and that these toxicity effects appear to be related to an accumulation of transition metals, which probably occurs through the respiratory impairment.