Impact of initial empirical antimicrobial choice and cause of in-hospital death in patients with nursing and healthcare-associated pneumonia (NHCAP): A retrospective study.

Objectives: To examine the differences in antimicrobial selection outcomes in nursing and healthcare-associated pneumonia (NHCAP) patients with and without risk factors for drug-resistant pathogen (RDRP) infection, and to identify the cause of in-hospital death after improvement of NHCAP. Methods: We conducted a retrospective analysis of the medical records of hospitalized adult patients with NHCAP. NHCAP patients were divided into the RDRP and non-RDRP groups. The RDRP group was further classified into the narrow and broad subgroups according to the type of empirical antimicrobial agent selected. The difference in mortality between these subgroups was then examined. The cause of all in-hospital deaths was also evaluated. Results: e evaluated 220 patients with NHCAP. There was no difference in mortality between the narrow and broad subgroups (11.8% vs. 15.4%, p=0.655). Among the group with improved NHCAP, 11.3% (n=23/203) died in hospital before discharge. Although the causes of death in patients who improved after NHCAP were diverse, the most common was recurrence of pneumonia. Conclusions: Empirical antimicrobial therapy for NHCAP may not always require selection of broad-spectrum antimicrobial agents, as has been previously reported. Patients with NHCAP may die from other causes, even after NHCAP has improved.

Seasonal variation in the prevalence of Gram-negative bacilli in sputum and urine specimens from outpatients and inpatients.

Objectives: To determine whether the prevalence of gram-negative bacilli (GNB; Pseudomonas aeruginosa, Klebsiella pneumoniae, and Escherichia coli) in sputum and urine specimens from outpatients and inpatients differed by season and according to temperature and humidity changes. Methods: In this retrospective study, microbiologic data for adult patients from 2008 to 2019 were retrieved from the electronic database of a hospital in Japan. Data were categorized by specimen type (sputum and urine) and specimen collection (outpatient and inpatient). Associations between variables were assessed using Spearman's rank correlation coefficients. Differences between groups were assessed using Pearson's chi-square test and analysis of discrete variance. Results: Among inpatients, the frequencies of P. aeruginosa and K. pneumoniae isolation from sputum specimens were higher in summer and autumn. The frequency of P. aeruginosa isolation from urine specimens was higher in autumn. These seasonal trends were observed in specimens from both outpatients and inpatients. No seasonal trend was observed in the frequency of E. coli isolation. Mean monthly temperature was positively correlated with the frequency of isolating P. aeruginosa (r=0.2198, p=0.0081) and K. pneumoniae (r=0.3443, p=0.00002) from sputum as well as with the frequency of isolating K. pneumoniae (r=0.1905, p=0.0222) from urine. Mean monthly humidity was positively correlated with the frequency of isolating K. pneumoniae (r=0.2602, p=0.0016) from sputum. Conclusions: GNB were isolated more frequently in summer and autumn than in other seasons. These seasonal trends were observed for both outpatient and inpatient specimens. Seasonality should be considered for optimal infection control of GNB in hospitals.

A prospective study exploring the predictors of response to benralizumab in patients with refractory bronchial asthma.

OBJECTIVE: This study aimed to evaluate the predictors of response to benralizumab therapy in patients with refractory bronchial asthma. METHODS: After 16 weeks of benralizumab therapy, 32 patients with refractory bronchial asthma were assigned to two groups based on the response to treatment as indicated by changes in the asthma control test score (responders and non-responders) and evaluated for clinical characteristics. RESULTS: Overall, 25 responders and 7 non-responders were identified at week 16. Logistic regression analysis identified a peripheral eosinophil count of >300/µL during benralizumab treatment and a maximal peripheral eosinophil count of >300/µL in the past year as predictors of response. CONCLUSIONS: The predictors of response to benralizumab included a peripheral eosinophil count of >300/µL during treatment and a maximal peripheral eosinophil count of >300/µL in the past year. These findings could improve patient selection and reduce medical costs in the future.

Use of Assist Devices to Actuate Pressurized Metered-Dose Inhalers in Elderly Patients with Asthma.

INTRODUCTION: Some elderly patients experience difficulty when attempting to use pressurized metered-dose inhalers (pMDIs) due to reduced finger muscle strength. However, no studies have investigated the finger muscle strength required for pMDI actuation. Therefore, we created a modified pMDI pinch gauge and examined the finger muscle strength in elderly asthmatic patients with and without the use of a pMDI assist device to push the canister. METHODS: We measured the finger muscle strength (N) required to spray pMDI formulations (Adoair®, Alvesco®, Flutiform®, and Breztri®) using one hand in healthy individuals. We then similarly measured the finger muscle strength when using the modified pinch gauge in older adults aged 65 years or older with bronchial asthma who used pMDI formulations. RESULTS: The finger muscle strength required to actuate these devices was 29.4 N or more in healthy individuals. In the older patients with asthma, the finger muscle strength was 38.45 ± 5.80 N in men and 31.34 ± 9.94 N in women. The finger muscle strength was ≤ 29.4 N in 6.6% of men and 40.0% of women. CONCLUSIONS: Finger muscle strength should be considered when selecting a device for older patients with asthma, and the use of a pMDI assist device to push the canister is recommended in patients with weaker finger muscles.

Evaluation of the pneumococcal urinary antigen test (PUT): a retrospective study.

OBJECTIVES: To determine the usefulness of the pneumococcal urinary antigen test (PUT) and to describe the characteristics of pneumococcal pneumonia. METHODS: In this retrospective study, we examined the effects of prior antibiotic treatment, pneumonia onset period, and sputum quality on the results of PUT. Clinical information was collected via medical records from all adult patients who were hospitalized at the Fujita Health University Bantane Hospital with "pneumonia" as a new diagnosis from April 2015 to March 2018. RESULTS: A total of 482 patients with pneumonia were included, of whom 103 had pneumococcal pneumonia. The frequency of PUT positivity did not differ significantly in patients with a pneumonia onset period of ≥3 days compared with those with a period of ≤2 days (P=0.514). Patients with a history of prior antimicrobial therapy had a significantly lower rate of positive sputum culture vs those with no such history (P=0.005); however, PUT positivity in the two groups did not differ significantly (P=0.367). CONCLUSIONS: Our results showed that urinary antigen testing for pneumococcal pneumonia is useful for diagnosis regardless of prior antibiotic treatment and time since symptom onset.

Patient Safety Activity Under the Social Insurance Medical Fee Schedule in Japan: An Overview of the 2010 Nationwide Survey.

OBJECTIVES: Little is known about patient safety performance under the social insurance medical fee schedule in Japan. The Health Ministry in Japan introduced the preferential patient safety countermeasure fee (PPSCF) to promote patient safety in 2006 and revised the PPSCF system in 2010. This study aims to address the patient safety performance status at hospitals implementing the PPSCF. METHODS: A nationwide questionnaire survey targeting 2674 hospitals with the PPSCF was performed in 2010 to 2011. The 627 participant hospitals were divided into the following three groups: 178 hospitals implementing PPSCF 1 with 400 beds or more (group A), 286 hospitals implementing PPSCF 1 with 399 beds or fewer (group B), and 163 hospitals implementing PPSCF 2 (group C). RESULTS: The mean numbers (standard errors) of patient safety managers were 1.45 (0.07) in group A, 1.12 (0.04) in group B, and 0.37 (0.12) in group C (P < 0.001). The participation number and rates of all staff for the patient safety seminar were 1721 (167) and 1.64 (0.10) in group A, 580 (26) and 1.94 (0.09) in group B, and 349 (31) and 1.98 (0.17) in group C (P < 0.001, P = 0.105).These results can be explained because hospitals with PPSCF 1 (groups A and B) must assign at least one full-time patient safety manager, whereas hospitals with PPSCF 2 (group C) are not required to do so. Patient safety performance at hospitals with PPSCF 1 was more active than that at hospitals with PPSCF 2. However, when the values were converted to per capita or per 100 beds, there were no differences across the three groups. CONCLUSIONS: The PPSCF encourages hospitals to perform actions for patient safety by providing incentives under the social insurance medical fee schedule in Japan.

A Prospective, Randomized, Open-Label Trial of Early versus Late Favipiravir Therapy in Hospitalized Patients with COVID-19.

Favipiravir is an oral broad-spectrum inhibitor of viral RNA-dependent RNA polymerase that is approved for treatment of influenza in Japan. We conducted a prospective, randomized, open-label, multicenter trial of favipiravir for the treatment of COVID-19 at 25 hospitals across Japan. Eligible patients were adolescents and adults admitted with COVID-19 who were asymptomatic or mildly ill and had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. Patients were randomly assigned at a 1:1 ratio to early or late favipiravir therapy (in the latter case, the same regimen starting on day 6 instead of day 1). The primary endpoint was viral clearance by day 6. The secondary endpoint was change in viral load by day 6. Exploratory endpoints included time to defervescence and resolution of symptoms. Eighty-nine patients were enrolled, of whom 69 were virologically evaluable. Viral clearance occurred within 6 days in 66.7% and 56.1% of the early and late treatment groups (adjusted hazard ratio [aHR], 1.42; 95% confidence interval [95% CI], 0.76 to 2.62). Of 30 patients who had a fever (≥37.5°C) on day 1, times to defervescence were 2.1 days and 3.2 days in the early and late treatment groups (aHR, 1.88; 95% CI, 0.81 to 4.35). During therapy, 84.1% developed transient hyperuricemia. Favipiravir did not significantly improve viral clearance as measured by reverse transcription-PCR (RT-PCR) by day 6 but was associated with numerical reduction in time to defervescence. Neither disease progression nor death occurred in any of the patients in either treatment group during the 28-day participation. (This study has been registered with the Japan Registry of Clinical Trials under number jRCTs041190120.).

Detecting Severe Incidents from Electronic Medical Records Using Machine Learning Methods.

The goal of this research was to design a solution to detect non-reported incidents, especially severe incidents. To achieve this goal, we proposed a method to process electronic medical records and automatically extract clinical notes describing severe incidents. To evaluate the proposed method, we implemented a system and used the system. The system successfully detected a non-reported incident to the safety management department.

Serological analysis of sensitization in allergic bronchopulmonary aspergillosis: a study on allergen components and interspecies relationships.

Background: Serological testing for immunoglobulin (Ig) E or IgG is useful for diagnosing allergic bronchopulmonary aspergillosis (ABPA), as it detects type I and III allergic reactions to Aspergillus species. However, few reports have investigated the allergen component and cross-reactivity among Aspergillus species. We aimed to measure and analyze the levels of IgGs specific to each Aspergillus species and investigate the prevalence of IgEs specific to each allergen component of A. fumigatus (Af) in ABPA patients.Methods: Serum samples were collected from 12 ABPA patients who visited our hospital between February and December 2017, and 16 with Af-sensitized asthma and 41 with Af-unsensitized asthma were controls. Immuno-CAP was performed to analyze the IgEs and IgGs specific to Af, A. niger, A flavus and A. terreus, and IgEs specific to allergen components Asp f 1, 2, 3, 4 and 6.Results: The ABPA group was significantly more frequently sensitized to Asp f 1 and 2 than the control groups. Af-specific IgEs were significantly positively correlated to the IgEs specific to A. flavus, A. niger and A. terreus. Af-specific IgGs were positively correlated to the IgGs specific to all the other species.Conclusions: Tests using allergen components were useful for ABPA diagnosis. Both IgE and IgG were highly cross-reactive among the Aspergillus species. There were many patients apart from asthmatic patients with ABPA, who displayed high Aspergillus IgG values.

Primary care doctor fostering and clinical research training in Sweden: Implications for Japan.

In 2018, a new training program for primary care physicians was launched in Japan. As physicians responsible for the training of new primary care physicians, we have faced many problems, particularly in rural areas. The influence of this new program on primary care physicians in rural areas of Japan has not been sufficiently investigated. The aim of this research was to improve training for primary care physicians in Japan by examining training programs in Sweden, where the population challenges are similar to those seen in Japan. In this paper, we will express our opinions and describe the differences in the primary care fostering systems and clinical research training for generalist in Japan and Sweden.

How asymptomatic are early cancer patients of five organs based on registry data in Japan.

BACKGROUND: One reason for the low cancer screening rate in Japan is that people are not concerned about cancer if they do not have symptoms. METHODS: The authors retrospectively analyzed 18,405 cancer patients using hospital-based cancer registry data collected between 2007 and 2013 at the 13 hospitals of Shimane Prefecture, Japan. The symptomatic rates of five cancers (stomach, colorectal, lung, breast, and cervix) at each stage and the time of early diagnosis were investigated. The early detection rates of symptomatic and asymptomatic individuals were investigated. RESULTS: The percentages of symptomatic cases tended to increase with progressive stages. The odds ratio (OR) of stage IV compared with that of stage I was 12.23 for stomach, 7.21 for colorectal, 16.91 for lung, 10.30 for breast, and 51.62 for cervical cancer. The proportions of early symptomatic cases at the time of diagnosis were low. Compared with the percentage of early symptomatic cases of stomach cancer of 25.5%, the percentage of lung cancer was the lowest, at 8.2% (OR 0.26), and the percentage of breast cancer was the highest, at 30.2% (OR 1.26). The percentages of early symptomatic cases of colorectal and cervical cancer were 18.9% (OR 0.68) and 19.9% (OR 0.73), respectively. The early detection rates of the asymptomatic and symptomatic groups were 77.6 and 36.1%, respectively. CONCLUSION: Cancer registry data indicate that early cancers are asymptomatic, and once symptoms appear, treatment may not be effective. Policy makers should inform people of the necessity of cancer screening before they have symptoms.

Additional Medical Costs Due to Hospital-Acquired Falls.

OBJECTIVES: To explore the additional medical costs (AMCs) due to hospital-acquired falls (falls), as well as their impact on clinical services within hospitals under the nationally uniform universal health insurance system in Japan. METHODS: With the use of administrative profiling data based on accounting systems linked with the Japanese social insurance medical fee schedule, we analyzed data from 2 teaching hospitals: Shimane University Hospital (SUH) and St. Mary's Hospital (SMH). We extracted 588 fall cases from 4669 incident reports in SUH and 1168 fall cases from 7717 incident reports in SMH that potentially incurred AMCs. RESULTS: Additional medical costs were 364 ± 2129 USD for minor injuries and 4336 ± 3645 USD for major injuries at SUH (P < 0.001) and 114 ± 124 USD for minor injuries and 2267 ± 2811 USD for major injuries at SMH (P < 0.001). Among the clinical services provided, imaging services were the most frequently used, with 89.9% (n = 205) of 228 minor injuries at SUH and 86.7% (n = 339) of 391 minor injuries at SMH; imaging services were used in all major injury cases at both hospitals. Although the number of cases using additional procedure/surgery services was lower than those using imaging services at both hospitals, AMCs for procedure/surgery services accounted for the highest proportions of total AMCs in both hospitals. CONCLUSIONS: Although falls with minor injuries outnumbered falls with major injuries, fall-related AMCs for the latter were higher at both teaching hospitals because procedure/surgery services were required for cases with major injuries such as femoral neck and trochanteric fractures. The findings suggest that hospital administrators and policy makers have to take appropriate measures to prevent major injuries inpatients due to hospital-acquired falls.

Asthma phenotypes.

Currently, categorization based on cluster analysis by objectively grasping the diversity of pathology is being conducted and the diversity of asthma is being categorized as phenotypes. Clinically, there is categorization based on aging and on allergic diathesis which is clinically useful; however, it has not, up to now, come to the point of selection based on phenotype. Subsequently, what is desired is the establishment of phenotype categorization for the purpose of materialization of treatment strategy which corresponds to individual cases. This study elaborates on order-made medicine while considering phenotype.

Sex differences in use of inhalants by elderly patients with asthma.

BACKGROUND: The number of elderly patients with asthma has been increasing in Japan. Treatment for these patients should be provided based on the condition of individual patients. This study was performed to clarify the relationship between inhalation procedure and sex difference in elderly patients with asthma. METHODS: The inhalation procedure was examined in 155 elderly patients with asthma (male: n=66, average age ± standard deviation: 75.5±5.65 years old; female: n=89, average age ± standard deviation: 78.7±6.87 years old) during a medical examination. RESULTS: For the three items that were common to all devices, the percentages of the 155 patients who could/could not perform the actions were examined by separate Fisher's exact tests for males and females. A statistically significant difference (P=0.007) was observed for "breath holding", and more females than males were not able to hold their breath. Although no significant difference was seen in the "accurate number of times of inhalation", females tended to not be able to inhale accurately compared to males (P=0.072). CONCLUSION: Our results suggest that elderly female patients with asthma have less understanding of inhaled steroid therapy, compared to elderly male patients. Therefore, it is particularly important to confirm that the correct inhalation procedure is used by elderly female patients with asthma.

Visualizing variations in organizational safety culture across an inter-hospital multifaceted workforce.

RATIONALE, AIMS AND OBJECTIVES: To develop a reliable and valid questionnaire that can distinguish features of organizational culture for patient safety across subgroups such as hospitals, professions, management/non-management positions and units/wards. METHODS: We developed a Hospital Organizational Culture Questionnaire based on a conceptual framework incorporating items from a review of existing literature. The questionnaire was administered to hospital staff including doctors, nurses, allied health personnel, and administrative staff at six public hospitals in Japan. Reliability and validity were assessed through exploratory factor analysis, multitrait scaling analysis, Cronbach's alpha coefficient and multiple regression analysis using staff-perceived achievement of safety as the response variable. Discriminative power across subgroups was assessed with radar chart profiling. RESULTS: Of the 3304 hospital staff surveyed, 2924 (88.5%) responded. After exploratory factor analysis and multitrait analysis, the finalized questionnaire was composed of 24 items in the following eight dimensions: improvement orientation, passion for mission, professional growth, resource allocation prioritization, inter-sectional collaboration, responsibility and authority, teamwork, and information sharing. Construct validity and internal consistency of dimensions were confirmed with multitrait analysis and Cronbach's alpha coefficients, respectively. Multiple regression analysis showed that improvement orientation, passion for mission, resource allocation prioritization and information sharing were significantly associated with higher achievement in safety practices. Our questionnaire tool was able to distinguish features of safety culture among different subgroups. CONCLUSIONS: Our questionnaire demonstrated excellent validity and reliability, and revealed distinct cultural patterns among different subgroups. Quantitative assessment of organizational safety culture with this tool may further the understanding of associated characteristics of each subgroup and provide insight into organizational readiness for patient safety improvement.

Self-reported histories of disease and vaccination against measles, mumps, rubella and varicella in health care personnel in Japan.

Health care personnel are required to be immune against vaccine-preventable diseases, such as measles, mumps, rubella, and varicella. The aim of this study is to evaluate the accuracy of self-reported histories of disease and vaccination against measles, mumps, rubella, and varicella in order to determine the immune status of health care personnel. A self-reported questionnaire of history of previous disease and vaccination against these diseases was administered to a total of 910 health care personnel in Shimane university hospital in Japan, whose results were compared with serological evidences. There were numerous subjects who did not remember a history of disease (greater than 33% each) and of vaccination (greater than 58% each). Self-reported history of disease and vaccination had high positive predictive value against either disease for testing positive for antiviral antibodies. However, a considerable number of false-negative subjects could be found; 88.9% of subjects for measles, 89.3% for mumps, 62.2% for rubella and 96.3% for varicella in the population who had neither a self-reported history of disease nor a vaccination against each disease. In addition, regardless of the disease in question, a negative predictive value in self-reported history of disease and vaccination was remarkably low. These results suggest that self-reported history of disease and vaccination was not predictive to determine the accurate immune status of health care personnel against measles, mumps, rubella, and varicella. A seroprevalence survey, followed by an adequate immunization program for susceptible subjects, is crucial to prevent and control infection in hospital settings.

Comparison of hemagglutination inhibition assay and enzyme immunoassay for determination of mumps and rubella immune status in health care personnel.

BACKGROUND: Screening tests are available to determine immunity to vaccine-preventable diseases, such as mumps and rubella. We aimed to define better assay for detecting immune status of health care personnel to vaccine-preventable diseases. METHODS: Mumps and rubella antibodies of health care personnel at Shimane University Hospital were examined by hemagglutination inhibition assay (HI), comparing with those by enzyme immunoassay (EIA). RESULTS: A total of 910 sera from health care personnel were tested. There was poor correlation between HI and EIA in detecting mumps antibodies with correlation coefficient values (r) = 0.190 (P < 0.001), but in rubella antibodies HI and EIA were relatively well correlated (r = 0.930, P < 0.001). Seropositivity rate of HI versus EIA was found to be 65.7 versus 93.2, and 89.5 versus 86.5% for mumps and rubella, respectively. As compared with EIA, HI identified sixfold larger seronegative subjects in mumps. Moreover, in mumps, 88.8% of seronegative subjects detected by HI were seropositive by EIA, while 3.7% of seropositive subjects detected by HI were seronegative by EIA. In rubella, 2.1% of seronegative subjects detected by HI were seropositive by EIA, and 1.7% of seropositive by HI was seronegative by EIA. CONCLUSION: Considerable difference between HI and EIA in determining immune status of health care personnel to mumps and rubella suggests beneficial use of EIA for the identification of accurate susceptible personnel who subsequently undergo an effective vaccination programs. Seroprevalence survey of health care personnel by using appropriate assay is essential for prevention and infection control strategies in health care settings.

The development of a multiplayer game for education of hospital management.

This paper designed and prototyped a networked hospital management serious game for education, and evaluated the prototype. A player, the president of each hospital, makes management decisions under various clinical indicators, and the decision affects condition of the other hospitals as well as of his/her own. The interaction makes the players compete, and, at the same time, exchange their findings each other.

Comparative analysis of a complement fixation assay and enzyme immunoassay to determine the seroprevalence of measles and varicella in a survey of healthcare workers.

OBJECTIVE: Seroprevalence surveys of healthcare workers for vaccine-preventable diseases, including measles and varicella, are essential for disease prevention and infection control programmes. The purpose of this study was to compare the complement fixation (CF) assay and an enzyme immunoassay (EIA) to determine the prevalence of immunoglobulin G antibodies directed against measles and varicella viruses in healthcare workers. METHODS: Antimeasles and antivaricella antibody titres were measured simultaneously in serum samples from healthcare workers employed at a Japanese university hospital, using the CF assay and an EIA. RESULTS: Serum samples were obtained from 898 healthcare workers. Seropositivity rates determined using the CF assay and EIA were 67.8% versus 94.0%, respectively, for measles, and 83.2% versus 97.6% for varicella. Compared with EIA, a nine- and 22-fold higher number of seronegative subjects was identified by the CF assay for measles and varicella, respectively. CONCLUSION: Differences between the CF assay and EIA in detecting seronegative or seropositive healthcare workers for measles and varicella suggest that undertaking a seroprevalence survey using an EIA, rather than a CF assay, would more accurately determine susceptibility to vaccine-preventable diseases, in healthcare settings.