Impact of long-term macrolide therapy on the evaluation indicator of outpatient oral antimicrobial use according to the AWaRe classification.

The WHO recently proposed a new indicator for judging the appropriateness of antimicrobial selection according to the AWaRe classification. Although macrolides are often administered for long-term macrolide therapy, the impact of this therapy on the indicator remains unclear. This study examined the impact of this therapy on the indicator for outpatient oral antimicrobial use. Using the JMDC claims database, outpatients who were prescribed an oral antimicrobial at least once between January and December 2022 (n = 2.66 million) were included in the study. The ratio of patient numbers and antimicrobial usage (AMU) were calculated based on age group (<15, 15-64, and ≥65 years) and prescription days (1-15, 16-30, 31-60, 61-90, and ≥91 days), and AMU of each drug was corrected for defined daily doses and classified according to the AWaRe. Patients with chronic airway disease for whom macrolides were prescribed for 91 days and more were defined as long-term macrolide therapy. Macrolides accounted for more than 30 % of total oral AMU in all age groups. In the elderly, 11.2 % of patients were prescribed macrolides for 91 days or more, accounting for 66.4 % of macrolide use. With regard to diseases that were associated with macrolide prescriptions, the percentage of patients prescribed for chronic airway diseases increased as the number of days of prescription increased. These results suggest that the impact of long-term macrolide therapy should be considered when assessing the appropriateness of outpatient oral AMU according to the AWaRe classification.

Roles of programmed death-1 and muscle innate lymphoid cell-derived interleukin 13 in sepsis-induced intensive care unit-acquired weakness.

BACKGROUND: Intensive care unit-acquired weakness (ICU-AW) is a syndrome characterized by a long-term muscle weakness often observed in sepsis-surviving patients during the chronic phase. Although ICU-AW is independently associated with increased mortality, effective therapies have yet to be established. Programmed death-1 (PD-1) inhibitors have attracted attention as potential treatments for reversing immune exhaustion in sepsis; however, its impact on ICU-AW remains to be elucidated. Here, we study how PD-1 deficiency affects sepsis-induced skeletal muscle dysfunction in a preclinical sepsis model. METHODS: Chronic sepsis model was developed by treating wild-type (WT) and PD-1 knockout (KO) mice with caecal slurry, followed by resuscitation with antibiotics and saline. Mice were euthanized on days 15-17. Body weights, muscle weights, and limb muscle strengths were measured. Interleukin 13 (IL-13) and PD-1 expressions were examined by flow cytometry. Messenger RNA (mRNA) expressions of slow-twitch muscles were measured by reverse transcription and quantitative polymerase chain reaction (RT-qPCR). In an in vitro study, C2C12 myotubes were treated with lipopolysaccharide (LPS) and recombinant IL-13 followed by gene expression measurements. RESULTS: WT septic mice exhibited decreased muscle weight (quadriceps, P < 0.01; gastrocnemius, P < 0.05; and tibialis anterior, P < 0.01) and long-term muscle weakness (P < 0.0001), whereas PD-1 KO septic mice did not exhibit any reduction in muscle weights and strengths. Slow-twitch specific mRNAs, including myoglobin (Mb), troponin I type 1 (Tnni1), and myosin heavy chain 7 (Myh7) were decreased in WT skeletal muscle (Mb, P < 0.0001; Tnni1, P < 0.05; and Myh7, P < 0.05) after sepsis induction, but mRNA expressions of Tnni1 and Myh7 were increased in PD-1 KO septic mice (Mb, not significant; Tnni1, P < 0.0001; and Myh7, P < 0.05). Treatment of C2C12 myotube cells with LPS decreased the expression of slow-twitch mRNAs, which was restored by IL-13 (Mb, P < 0.0001; Tnni1, P < 0.001; and Myh7, P < 0.05). IL-13 production was significantly higher in ILC2s compared to T cells in skeletal muscle (P < 0.05). IL-13-producing ILC2s in skeletal muscle were examined and found to increase in PD-1 KO septic mice, compared with WT septic mice (P < 0.05). ILC2-derived IL-13 was increased by PD-1 KO septic mice and thought to protect the muscles from experimental ICU-AW. CONCLUSIONS: Long-term muscle weakness in experimental ICU-AW was ameliorated in PD-1 KO mice. ILC2-derived IL-13 production in skeletal muscles was increased in PD-1 KO mice, thereby suggesting that IL-13 alleviates muscle weakness during sepsis. This study demonstrates the effects of PD-1 blockade in preserving muscle strength during sepsis through an increase in ILC2-derived IL-13 and may be an attractive therapeutic target for sepsis-induced ICU-AW.

A computed tomography-based score indicative of lung cancer aggression (SILA) predicts lung adenocarcinomas with low malignant potential or vascular invasion.

BACKGROUND: Histologic grading of lung adenocarcinoma (LUAD) is predictive of outcome but is only possible after surgical resection. A radiomic biomarker predictive of grade has the potential to improve preoperative management of early-stage LUAD. OBJECTIVE: Validate a prognostic radiomic score indicative of lung cancer aggression (SILA) in surgically resected stage I LUAD (n= 161) histologically graded as indolent low malignant potential (LMP), intermediate, or aggressive vascular invasive (VI) subtypes. METHODS: The SILA scores were generated from preoperative CT-scans using the previously validated Computer-Aided Nodule Assessment and Risk Yield (CANARY) software. RESULTS: Cox proportional regression showed significant association between the SILA and 7-year recurrence-free survival (RFS) in a univariate (p< 0.05) and multivariate (p< 0.05) model incorporating age, gender, smoking status, pack years, and extent of resection. The SILA was positively correlated with invasive size (spearman r= 0.54, p= 8.0 × 10 - 14) and negatively correlated with percentage of lepidic histology (spearman r=-0.46, p= 7.1 × 10 - 10). The SILA predicted indolent LMP with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.74 and aggressive VI with an AUC of 0.71, the latter remaining significant when invasive size was included as a covariate in a logistic regression model (p< 0.01). CONCLUSIONS: The SILA scoring of preoperative CT scans was prognostic and predictive of resected pathologic grade.

Evaluating Factor VIII Concentrates Using Clot Waveform Analysis.

Background/Objectives: FVIII reagent activity varies across different assays, as well as activated partial thromboplastin time (APTT) reagents. The hemostatic ability of various FVIII reagents was examined via clot waveform analysis (CWA). Methods: APTT was measured using 12 APTT reagents, a small amount of tissue factor-induced FIX activation (sTF/FIXa) and a small amount of thrombin time (sTT) in order to examine 10 FVIII reagents and reference plasma (RP) using CWA. FVIII activity was measured using CWA-APTT, a chromogenic assay, or CWA-sTT. Results: Although the peak time (PT) and peak height (PH) of the CWA-APTT were markedly different in different FVIII reagents using several APTT reagents, the PTs of CWA-APTT were generally normal or shortened and the PHs of CWA-APTT were generally lower than those of RP. The FVIII activity varied, as evaluated using APTT, and was higher when using the CWA-sTT method than the APTT or chromogenic methods. CWA-sTT showed an elevated second peak of first DPH in all FVIII reagents, and both CWA-sTF/FIXa and CWA-sTT were enhanced using APTT reagents. Conclusions: Our evaluation of the hemostatic ability of FVIII reagents varied among APTT reagents. CWA-sTT can be used to further evaluate the hemostatic ability of an FVIII concentrate based on thrombin burst.

Veno-venous extracorporeal membrane oxygenation in managing acute respiratory distress syndrome associated with hemolytic uremic syndrome and septic shock: a case report.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a rescue therapy for severe respiratory failure in which conventional mechanical ventilation therapy is unsuccessful. Hemolysis during VV-ECMO support arises from multiple factors associated with organ damage and poor outcomes. Therefore, close and prompt monitoring is needed. Hemolytic uremic syndrome (HUS) is characterized by hemolysis, acute renal failure, and thrombocytopenia. Hemolytic features of the disease may complicate VV-ECMO management. A 26-year-old man with a history of cerebral palsy underwent VV-ECMO for acute respiratory distress syndrome (ARDS) due to septic shock caused by bacterial translocation during treatment for HUS. He showed features of hemolysis, with elevated lactate dehydrogenase (LDH), fragmented red blood cells, and low haptoglobin levels. Plasma free hemoglobin was measured daily throughout the whole course of ECMO with levels higher than 10 mg/dL but not exceeding 50 mg/dL. The extracorporeal membrane oxygenation (ECMO) circuit pressures were carefully monitored to ensure the pump generated no excessive negative pressure. The patient was weaned off ECMO on the eleventh day. There have been several cases of VA-ECMO in patients with HUS; however, there is limited literature on VV-ECMO. As the days on VV-ECMO tend to be longer than those on VA-ECMO, features of hemolysis may complicate management. Although HUS did not directly influence the clinical course in the present case, features of hemolysis were continuously observed. This case highlighted the importance of standard ECMO monitoring, especially daily measurement of plasma free hemoglobin.

Safety net hospital risk model demonstrates stronger, population-specific applicability in characterizing lung cancer risk.

Background: Determining lung cancer (LC) risk using personalized risk stratification may improve screening effectiveness. While the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) is a well-established stratification model for LC screening, it was derived from a predominantly Caucasian population and its effectiveness in a safety net hospital (SNH) population is unknown. We have developed a model more tailored to the SNH population and compared its performance to the PLCO model in a SNH setting. Methods: Retrospective dataset was compiled from patients screened for LC at SNH from 2015 to 2019. Descriptive statistics were calculated using the following variables: age, sex, race, education, body mass index (BMI), smoking history, personal cancer history, family LC history, chronic obstructive pulmonary disease (COPD), and emphysema. Variables distribution was compared using t- and chi-square tests. LC risk scores were calculated using SNH and PLCO models and categorized as low (scores <0.65%), moderate (0.65-1.49%), and high (>1.5%). Linear regression was applied to evaluate the relationship between models and covariates. Results: Of 896 individuals, 38 were diagnosed with LC. Data reflected the SNH patient demographics, which predominantly were African American (53.5%), current smokers (69.9%), and with emphysema (70.1%). Among the non-LC cohort, SNH model most frequently categorized patients as low risk, while PLCO model most frequently classified patients as moderate risk. Among the LC cohort, there was no significant difference between mean scores or risk stratification. SNH model showed 92.1% sensitivity and 96.8% specificity while PLCO model showed 89.4% sensitivity and 26.1% specificity. Emphysema demonstrated a strong association in SNH model (P<0.001) while race showed no relation. Conclusions: SNH model demonstrated greater specificity for characterizing LC risk in a SNH population. The results demonstrated the importance of study sample representation when identifying risk factors in a stratification model.

Developing technologies and areas of interest in lung cancer screening adjuncts.

Lung cancer remains the leading cause of cancer mortality. Screening guidelines have been implemented in the past decade to aid in earlier detection of at-risk groups. Nevertheless, computed tomography (CT) scans, the principal screening modality in use today, are still low yield, with 3.6% of lung cancer confirmed amongst 39.1% of lesions detected over a 3-year period. They also carry relatively high false positive rates, between 9% and 27%, which can bear unnecessary financial and emotional costs to patients. As such, research efforts have been dedicated to the development of lung cancer screening adjuncts to improve detection reliability. We herein review several emerging technologies in this specific arena and their efficacy. These include plasma markers (microDNA, DNA methylation, and tumor-associated antibodies), breath/sputum biomarkers [volatile organic compounds (VOCs) and exhaled breath condensate (EBC)], proteomics, metabolomics, and machine learning, such as radiomics technology. We find that, across the board, they offer promising results in terms of non-invasive diagnostics, genetic sequencing for higher-risk individuals, and accessibility for a diverse cohort of patients. While these screening adjuncts are unlikely to completely replace the current standard of care at the moment, continued research into these technologies is crucial to improve and personalize the identification, treatment, and outcome of lung cancer patients in the near future.

Safety of Home Discharge With a Chest Tube After Bronchoscopic Lung Volume Reduction Complicated by Persistent Airleak.

BACKGROUND: The incidence of pneumothorax after bronchoscopic lung volume reduction (BLVR) using Zephyr (Pulmonx Corporation) endobronchial valves is ~26%. Many patients who develop a postprocedural pneumothorax require chest tube placement. If a persistent airleak is present, patients tolerating waterseal can be discharged home with a mini-atrium with a low risk of empyema. METHODS: Data were collected on patients from the Epic (Epic System Corporation) electronic medical record between July 2019 and November 2022. Our retrospective study reviewed a total of 102 BLVR procedures. Twenty-six of these procedures were complicated by a pneumothorax post-BLVR (25%). After 24 procedures, patients were discharged home with a chest tube after a persistent airleak. The primary endpoint of the study was the incidence of intrapleural infection in this population. The secondary endpoint was the average length of time the chest tube was in place until outpatient removal. RESULTS: Out of the 24 discharge events, 2 events (8.3%) were complicated by an intrapleural infection before chest tube removal. The average number of days requiring a chest tube until outpatient removal was 16.9 days, which is similar to the duration observed in patients discharged home with a chest tube after lung volume reduction surgery. CONCLUSION: Discharging patients home with a chest tube after BLVR therapy is safe and may reduce hospital length of stay. Our study shows the incidence of intrapleural infection after home discharge with a chest tube after BLVR is low.

Disparities in Lung Cancer Clinical Trial Discussion and Enrollment at a Safety Net Hospital.

BACKGROUND: In the United States, less than 5% of all adult cancer patients enroll in clinical trials. Few studies explore participation in cancer clinical trials at safety net hospitals, which disproportionately care for minoritized, low-income, uninsured, and underinsured populations. Our study aims to investigate disparities in clinical trial discussions and enrollment among lung cancer patients at Boston Medical Center, the largest safety net hospital in New England. METHODS: We included 1121 patients diagnosed with lung cancer between January 2015 and December 2020. Electronic Medical Records (EMR) were queried, and patients were categorized into three groups: (1) clinical trial discussed and the patient enrolled, (2) clinical trial discussed but the patient not enrolled, and (3) clinical trial not discussed. Sociodemographic variables such as age, gender, race, ethnicity, city, primary language, median household income, medical insurance type, and education level were also collected. Chi-squared,t test, and multivariate regression analysis was done using SPSS version 26.0. RESULTS: Of the 1121 patients, clinical trials were discussed in 141 patients (12.6%), of which 22 (15.6%) were enrolled. Clinical trial discussions were conducted more with younger patients (68.19 vs 71.37, p = .001), but on multivariate analysis there was no significant difference (OR = 1.023; 95% CI 0.998-1.048; p = .068). There was no significant difference in clinical trial discussion or enrollment between the other sociodemographic factors. CONCLUSION: Additional study of barriers to cancer clinical trial discussion and enrollment at safety net institutions can serve as a prerequisite to ameliorating racial disparities observed on a national scale.

The Evaluation of Clot Waveform Analyses for Assessing Hypercoagulability in Patients Treated with Factor VIII Concentrate.

BACKGROUND: Regular prophylactic therapy has become an increasingly common treatment for severe hemophilia. Therefore, hypercoagulability-a potential risk factor of thrombosis-is a cause for concern in hemophilic patients treated with a high dose of FVIII concentrate. In clot waveform analysis (CWA)-thrombin time (TT), a small amount of thrombin activates clotting factor VIII (FVIII) instead of fibrinogen, resulting in FVIII measurements using CWA-TT with a small amount of thrombin. METHODS: The coagulation ability of patients treated with FVIII concentrate or emicizumab was evaluated using activated partial thromboplastin time (APTT), TT and a small amount of tissue factor-induced FIX activation assay (sTF/FIXa) using CWA. RESULTS: The FVIII activity based on CWA-TT was significantly greater than that based on the CWA-APTT or chromogenic assay. FVIII or FVIII-like activities based on the three assays in plasma without emicizumab were closely correlated; those in plasma with emicizumab based on CWA-TT and chromogenic assays were also closely correlated. CWA-APTT and CWA-TT showed different patterns in patients treated with FVIII concentrates compared to those treated with emicizumab. In particular, CWA-TT in patients treated with FVIII concentrate showed markedly higher peaks in platelet-rich plasma than in platelet-poor plasma. CWA-APTT showed lower coagulability in hemophilic patients treated with FVIII concentrate than in healthy volunteers, whereas CWA-sTF/FIXa did not. In contrast, CWA-TT showed hypercoagulability in hemophilic patients treated with FVIII concentrate. CONCLUSIONS: CWA-TT can be used to evaluate the thrombin bursts that cause hypercoagulability in patients treated with emicizumab. Although routine APTT evaluations demonstrated low coagulation ability in patients treated with FVIII concentrate, CWA-TT showed hypercoagulability in these patients, suggesting that the evaluation of coagulation ability may be useful when using multiple assays.

Black race and lower age at surgery are associated with smoking relapse in a safety-net setting after surgery for stage I non-small cell lung cancer.

Background: Smoking relapse after surgical resection for lung cancer (LC) remains a health concern. This study aims to determine various factors associated with postoperative smoking relapse in patients undergoing surgical resection for stage I non-small cell lung cancer (NSCLC) at an urban safety net hospital. Methods: We analyzed the demographic and clinical variables of all patients who underwent surgical resection for stage I NSCLC from 2002 to 2016 at our institution. Based on the post-operative smoking history, we segregated the cohort into two groups: relapse and abstinent. Chi-squared and analysis of variance tests were used to identify the variables that registered a significant difference between the two groups. Further, we used univariable and multivariable logistic regression to determine association between variables and smoking relapse. Results: We analyzed data from 168 patients, excluding those with inadequate smoking history and never smokers. In total, 64 (38.1%) patients experienced smoking relapse, and 104 (61.9%) remained abstinent. The age, annual income, and race showed significant differences between the two groups. Multivariable logistic regression reflected that black patients had higher odds of relapse than white patients [odds ratio (OR) =3.26, confidence interval (CI): 1.54-6.89, P=0.002] and the chances of relapse decreased as the age increased (5-year age gap, OR =0.70, CI: 0.58-0.85, P<0.001). Conclusions: Black race and younger age at the time of surgery are associated with smoking relapse after surgery for stage I NSCLC. Targeted smoking cessation programs catered towards these patient groups may help reduce the prevalence of post-operative smoking.

Severe hypocalcemia after denosumab treatment leading to refractory ventricular tachycardia and veno-arterial extracorporeal membrane oxygenation support: a case report.

BACKGROUND: Severe hypocalcemia may lead to life-threatening arrhythmias. Denosumab is an effective treatment for osteoporosis that allows long intervals between doses. However, there is a risk of hypocalcemia in some patients. Due to the long half-life of denosumab, emergency physicians caring for patients presenting with symptoms of hypocalcemia may not be aware of the medication, and adverse effects may last longer. CASE PRESENTATION: A 55-year-old woman with a history of systemic lupus erythematosus (SLE) and anxiety disorder called for an ambulance for symptoms of hyperventilation and muscle cramps. After evaluation at the local hospital, she developed pulseless ventricular tachycardia and was resuscitated by defibrillation by the hospital staff. After conversion to sinus rhythm, she was transported to a tertiary center. Upon arrival, pulseless ventricular tachycardia occurred again, and veno-arterial extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pumping (IABP) were implemented. Laboratory results showed severe hypocalcemia (corrected calcium level of 5.3 mg/dL) whereupon intravenous calcium supplementation was started. She had received the first dose of denosumab (60 mg) by subcutaneous injection 24 days prior to hospitalization. She was eventually weaned from ECMO and IABP support. CONCLUSION: Cardiac arrest due to hypocalcemia is relatively rare but can be fatal. In the present case, hyperventilation may have acutely exacerbated pre-existing hypocalcemia, leading to ventricular tachycardia. The patient had a slightly decreased serum calcium level prior to denosumab. Close monitoring may be preferable after the primary dose of denosumab in selected patients. Emergency physicians caring for patients who may be suffering from symptoms/signs of hypocalcemia must be mindful of medications that have long half-lives and affect electrolyte balance when treating fatal arrhythmia due to hypocalcemia.

Impact of body composition on patient prognosis after SARS-Cov-2 infection.

BACKGROUND: Since the first outbreak of coronavirus disease 2019 (COVID-19), it has been reported that several factors, including hypertension, type 2 diabetes mellitus, and obesity, have close relationships with a severe clinical course. However, the relationship between body composition and the prognosis of COVID-19 has not yet been fully studied. METHODS: The present study enrolled 76 consecutive COVID-19 patients with computed tomography (CT) scans from the chest to the pelvis at admission. The patients who needed intubation and mechanical ventilation were defined as severe cases. Patients were categorized into four groups according to their body mass index (BMI). The degree of hepatic steatosis was estimated by the liver/spleen (L/S) ratio of the CT values. Visceral fat area (VFA), psoas muscle area (PMA), psoas muscle mass index (PMI), and intra-muscular adipose tissue content (IMAC) were measured by CT scan tracing. These parameters were compared between non-severe and severe cases. RESULTS: Severe patients had significantly higher body weight, higher BMI, and greater VFA than non-severe patients. However, these parameters did not have an effect on disease mortality. Furthermore, severe cases had higher IMAC than non-severe cases in the non-obese group. CONCLUSIONS: Our data suggest high IMAC can be a useful predictor for severe disease courses of COVID-19 in non-obese Japanese patients, however, it does not predict either disease severity in obese patients or mortality in any obesity grade.

Novel Screening Tools for Lung Cancer.

Screening with low-dose computed tomography has been shown to decrease lung cancer mortality. However, the issues of low detection rates and false positive results remain, highlighting the need for adjunctive tools in lung cancer screening. To this end, researchers have investigated easily applicable, minimally invasive tests with high validity. We herein review some of the more promising novel markers utilizing plasma, sputum, and airway samples.

Change in stage after neoadjuvant chemoradiation is associated with survival in patients with esophageal cancer.

BACKGROUND: The aim of this study was to determine if change in stage after neoadjuvant chemoradiation (CRT) was associated with improved survival in esophageal cancer using a national database. METHODS: Using the National Cancer Database, patients with non-metastatic, resectable esophageal cancer who received neoadjuvant CRT and surgery were identified. Comparing clinical to the pathologic stage, change in stage was classified as pathologic complete response (pCR), downstaged, same-staged, or upstaged. Univariable and multivariable Cox regression models were used to identify factors associated with survival. RESULTS: A total of 7745 patients were identified. The median overall survival (OS) was 34.9 months. Median OS was 60.3 months if pCR, 39.1 months if downstaged, 28.3 months if same-staged, and 23.4 months if upstaged (p < 0.0001). On multivariable analysis, pCR was associated with improved OS compared to the other groups (downstaged: hazard ratio [HR]: 1.32 [95% confidence interval [CI]: 1.18-1.46]; same-staged: HR: 1.89 [95% CI: 1.68-2.13]; upstaged: HR: 2.54 [95% CI: 2.25-2.86]; all p < 0.0001). CONCLUSIONS: In this large database study, change in stage after neoadjuvant CRT was strongly associated with survival for patients with non-metastatic, resectable esophageal cancer. There was a significant stepwise decline in survival, in descending order of pCR, downstaged tumor, same-staged tumor, and upstaged tumor.

Magnonic Casimir Effect in Ferrimagnets.

Quantum fluctuations are the key concepts of quantum mechanics. Quantum fluctuations of quantum fields induce a zero-point energy shift under spatial boundary conditions. This quantum phenomenon, called the Casimir effect, has been attracting much attention beyond the hierarchy of energy scales, ranging from elementary particle physics to condensed matter physics together with photonics. However, the application of the Casimir effect to spintronics has not yet been investigated enough, particularly to ferrimagnetic thin films, although yttrium iron garnet (YIG) is one of the best platforms for spintronics. Here we fill this gap. Using the lattice field theory, we investigate the Casimir effect induced by quantum fields for magnons in insulating magnets and find that the magnonic Casimir effect can arise not only in antiferromagnets but also in ferrimagnets including YIG thin films. Our result suggests that YIG, the key ingredient of magnon-based spintronics, can serve also as a promising platform for manipulating and utilizing Casimir effects, called Casimir engineering. Microfabrication technology can control the thickness of thin films and realize the manipulation of the magnonic Casimir effect. Thus, we pave the way for magnonic Casimir engineering.

A Pediatric Case of Septic Pulmonary Embolism Caused by Tsukamurella paurometabola.

We herein report a three-year-old boy with septic pulmonary embolism caused by Tsukamurella paurometabola bacteremia during chemotherapy for rhabdomyosarcoma. During the interval of chemotherapy, the patient was temporarily discharged with a peripherally inserted central venous catheter but was re-admitted to the hospital with a fever on the same day. A blood culture taken at the time of re-admission showed T. paurometabola. The patient had a persistent fever, and computed tomography performed on the ninth day showed septic pulmonary embolism. We stress the importance of being aware of the possibility of septic pulmonary embolism in patients with Tsukamurella bacteremia.

Continuous High Positive-End Expiratory Pressure May Worsen Renal Function in Patients With Acute Respiratory Distress Syndrome: Retrospective Analyses of a Nationwide, Multicenter Observational Study in Japan.

BACKGROUND: Positive end-expiratory pressure (PEEP), especially continuous high PEEP, is thought to be a risk factor for worsening renal function (WRF) due to impaired venous return and the development of renal interstitial edema. In this study, we investigated whether PEEP is a risk factor for WRF in patients with acute respiratory distress syndrome (ARDS), a representative pathology that requires continuous high PEEP for respiratory management. METHODS: We performed retrospective sub-analyses of the Japanese Association for Acute Medicine, a nationwide prospective observational registry of ARDS (FORECAST ARDS registry) prospective multicenter cohort study. WRF was defined on the basis of a worsening renal Sequential Organ Failure Assessment (SOFA) score. We performed univariate and multivariable analyses to identify possible risk factors for WRF, and propensity score analyses to compare the frequency of WRF according to cutoff values for the difference in PEEP between day 1 and day 4. RESULTS: We analyzed 151 cases. Multivariable analysis showed that the difference in PEEP (odds ratio (OR) 1.123 (95% confidence interval (CI) 1.017-1.240), P = 0.022) and male sex (OR 3.287 (95% CI 1.029-10.502), P = 0.045) were risk factors for WRF. Propensity score analysis showed trends towards an increased risk for WRF in each cutoff value for the difference in PEEP: -5 cmH2O (OR 0.389 (95% CI 0.084-1.799), P = 0.229), 0 cmH2O (OR 2.222 (95% CI 0.755-6.540), P = 0.150), and 5 cmH2O (OR 3.277 (95% CI 0.940-11.425), P = 0.065). CONCLUSIONS: This study revealed that the difference in PEEP between days 1 and 4 was positively associated with WRF. However, a significant cutoff value for the difference in PEEP was not determined.

Do Feed Plants Provide Sufficient Sodium, Calcium and Magnesium to Sika Deer in Japan? An Analysis Using Global Plant Trait Data.

Deficient minerals in overabundant populations could act as an attractant to cull sika deer (Cervus nippon). Because selective culling of female deer is reported to be effective in reducing sika deer populations, it is particularly important to clarify the differences in mineral requirements between males and females. Here, using global plant trait data and a published list of sika deer feed plants in Japan, we estimated whether feed plants provide sika deer sufficient sodium (Na), calcium (Ca) and magnesium (Mg), and compared the results between males and females. An analysis of 191 feed plant species suggested that feed plants can provide sufficient Mg, whereas sufficient Na and Ca is not always provided, especially when the intake is small or the deer large. Na deficiency was more intense for lactating females than males, suggesting that Na can be an effective attractant for selectively culling female deer. In summary, this study demonstrated that sika deer in Japan might require extra Na and Ca sources in addition to feed plants, and therefore these minerals could be useful for developing effective culling methods.