State-of-the-Art Review: Use of Antimicrobials at the End of Life.

Navigating antibiotics at the end of life is a challenge for infectious disease (ID) physicians who remain deeply committed to providing patient-centered care and engaging in shared decision making. ID physicians, who often see patients in both inpatient and outpatient settings and maintain continuity of care for patients with refractory or recurrent infections, are ideally situated to provide guidance that aligns with patients' goals and values. Complex communication skills, including navigating difficult emotions around end-of-life care, can be used to better direct shared decision making and assist with antibiotic stewardship.

Temporal characteristics of aspiration pneumonia in elderly inpatients: From resumption of oral intake to onset.

BACKGROUND: Elderly inpatients who develop fevers after resumption of oral intake are often considered to have aspiration pneumonia (AP) and be tentatively fasted. Fasting has been associated with prolonged hospital stays and decreased swallowing ability. The purpose of this study was to compare AP and other infections after resumption of oral intake in elderly inpatients and to identify the clinical characteristics. PATIENTS AND METHODS: The records of patients who were admitted to a public tertiary hospital and referred for evaluation of swallowing disability were retrospectively reviewed to identify those who had developed AP, non-AP, or urinary tract infection (UTI) after resumption of oral intake. Eligible patients were enrolled consecutively in the study. The patient characteristics, physical findings, laboratory data, oral intake status at the time of onset of symptoms, and rate of discontinuation of oral intake after onset of infection were compared between the three types of infection. RESULTS: A total of 193 patients developed an infectious illness after resuming oral intake. Among them, 114 patients had a diagnosis of AP (n = 45), non-AP (n = 24), or UTI (n = 45). There were no significant differences in patient characteristics, physical findings or laboratory data between the group with AP and the other two groups. AP developed at a median of 6 (range 1-16) days after resumption of oral intake. The rate of discontinuation of oral intake was 91.1% in the AP group, 58.3% in the non-AP group, and 26.7% in the UTI group, respectively. CONCLUSION: Infectious diseases other than AP should be considered in the differential diagnosis when nosocomial fever develops in elderly inpatients more than 17 days after resuming oral intake. Furthermore, nosocomial fever after resuming oral intake has many causes other than AP, and discontinuation of oral intake should be carefully considered.

Coexistence of gastric cancer and gastric GIST with intra-tumor bleeding: successful embolization with subsequent total gastrectomy.

BACKGROUND: Gastrointestinal stromal tumor (GIST) is a rare tumor, however, simultaneous development of gastric cancer and gastric GIST has been documented more frequently in recent years. Rupture of gastric GIST is even more rare and occurred in 7% of all GISTs. Although ruptured GIST might be occasionally difficult to be managed by endoscopy, transcatheter arterial embolization (TAE) was reported to control bleeding from GIST effectively. We report herein a case of coexistence of gastric cancer and gastric GIST with progressing intra-tumor bleeding managed successfully by TAE and review the clinicopathological characteristics of this rare condition reported previously in the Japanese literature. CASE PRESENTATION: A 75-year-old woman with dyspnea and systemic edema was diagnosed as simultaneous occurrence of gastric cancer (histopathologically detected tubular adenocarcinoma pT2N1M0 fStageIIA) and gastric GIST (65 × 92 mm in diameter at the anterior wall of the fornix) with intra-tumor hemorrhage. Perceiving the progress of bleeding from tumor growth and exacerbating anemia, TAE of left gastric artery was performed. Then remission of anemia has been obtained, the patient underwent an elective radical surgery. CONCLUSIONS: Simultaneous occurrence of gastric cancer and gastric GIST was speculated to be more common. TAE for ruptured GIST may be effective for hemostasis and reduction of tumor burden, which could facilitate minimal invasive surgery.

Condyloma latum of the plantar foot: Case report of an unusual manifestation of secondary syphilis.

Condyloma lata, a cutaneous manifestation of secondary syphilis, typically presents as verrucous papules or plaques in the anogenital area. Here, we present a case of secondary syphilis presenting in a 38-year-old man as condyloma latum of the plantar foot in the absence of other cutaneous findings of secondary syphilis. The plantar foot is an unusual location for condyloma lata which has not previously been reported in the medical literature. Histopathology was essential to diagnosis in this case and demonstrated verrucous epidermal hyperplasia with a plasma cell-rich infiltrate in the dermis and innumerable spirochetes in the epidermis. The patient was successfully treated with intramuscular penicillin benzathine G. Given the recent rise in the incidence of primary and secondary syphilis, it is essential for clinicians to be aware of atypical presentations of secondary syphilis to avoid delays in treatment and decrease the risk of transmission to sexual partners.

Using control charts to understand community variation in COVID-19.

Decision-makers need signals for action as the coronavirus disease 2019 (COVID-19) pandemic progresses. Our aim was to demonstrate a novel use of statistical process control to provide timely and interpretable displays of COVID-19 data that inform local mitigation and containment strategies. Healthcare and other industries use statistical process control to study variation and disaggregate data for purposes of understanding behavior of processes and systems and intervening on them. We developed control charts at the county and city/neighborhood level within one state (California) to illustrate their potential value for decision-makers. We found that COVID-19 rates vary by region and subregion, with periods of exponential and non-exponential growth and decline. Such disaggregation provides granularity that decision-makers can use to respond to the pandemic. The annotated time series presentation connects events and policies with observed data that may help mobilize and direct the actions of residents and other stakeholders. Policy-makers and communities require access to relevant, accurate data to respond to the evolving COVID-19 pandemic. Control charts could prove valuable given their potential ease of use and interpretability in real-time decision-making and for communication about the pandemic at a meaningful level for communities.

Bacterial coinfections with coronavirus disease 2019 (COVID-19).

Background: The pandemic caused by severe acute respiratory coronavirus virus 2 (SARS-CoV-2) has dramatically increased cheshospitalizations, and it is often difficult to determine whether there is a bacterial or fungal coinfection at time of presentation. In this study, we sought to determine the rates of coinfection and utilization of antibiotics in SARS-CoV-2 disease. Methods: Retrospective chart review of patients hospitalized with COVID-19 pneumonia from April 13, 2020, to July 14, 2020. Results: In total, 277 patients were hospitalized for COVID-19 pneumonia during this period. Patients that received antibiotics within 48 hours of presentation were more likely to be febrile (59.3% vs 41.2%; P = .01) and to have leukocytosis (23.9% vs 5.9%; P < .01) and were less likely to have a procalcitonin level <0.25 ng/mL (58.8% vs 74.5%; P = .04). In total, 45 patients had positive blood cultures collected during hospitalization, 16 of which were clinically significant. Of the clinically significant blood cultures, 5 were collected <48 hours of admission. Moreover, 18 sputum cultures were clinically significant, 2 of which were collected within 48 hours of admission. Conclusion: Bacterial and fungal coinfections in COVID-19 appear to be rare on presentation; thus, this factor may be a good target for enhanced antibiotic stewardship.

Evaluation of antibiotic escalation in response to nurse-driven inpatient sepsis screen.

Objective: To determine the frequency and predictors of antibiotic escalation in response to the inpatient sepsis screen at our institution. Design: Retrospective cohort study. Setting: Two affiliated academic medical centers in Los Angeles, California. Patients: Hospitalized patients aged 18 years and older who had their first positive sepsis screen between January 1, 2019, and December 31, 2019, on acute-care wards. Methods: We described the rate and etiology of antibiotic escalation, and we conducted multivariable regression analyses of predictors of antibiotic escalation. Results: Of the 576 cases with a positive sepsis screen, antibiotic escalation occurred in 131 cases (22.7%). New infection was the most documented etiology of escalation, with 76 cases (13.2%), followed by known pre-existing infection, with 26 cases (4.5%). Antibiotics were continued past 3 days in 17 cases (3.0%) in which new or existing infection was not apparent. Abnormal temperature (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.91-4.70) and abnormal lactate (aOR, 2.04; 95% CI, 1.28-3.27) were significant predictors of antibiotic escalation. The patient already being on antibiotics (aOR, 0.54; 95% CI, 0.34-0.89) and the positive screen occurred during a nursing shift change (aOR, 0.36; 95% CI, 0.22-0.57) were negative predictors. Pneumonia was the most documented new infection, but only 19 (50%) of 38 pneumonia cases met full clinical diagnostic criteria. Conclusions: Inpatient sepsis screening led to a new infectious diagnosis in 13.2% of all positive sepsis screens, and the risk of prolonged antibiotic exposure without a clear infectious source was low. Pneumonia diagnostics and lactate testing are potential targets for future stewardship efforts.

Inpatient antibiotic utilization in the Veterans' Health Administration during the coronavirus disease 2019 (COVID-19) pandemic.

Antibiotic prescribing practices across the Veterans' Health Administration (VA) experienced significant shifts during the coronavirus disease 2019 (COVID-19) pandemic. From 2015 to 2019, antibiotic use between January and May decreased from 638 to 602 days of therapy (DOT) per 1,000 days present (DP), while the corresponding months in 2020 saw antibiotic utilization rise to 628 DOT per 1,000 DP.

Changes in viscoelastic properties of articular cartilage in early stage of osteoarthritis, as determined by optical coherence tomography-based strain rate tomography.

BACKGROUND: Biomechanical changes in articular cartilage are associated with the onset of osteoarthritis. We developed an optical coherence tomography-based strain rate tomography method: stress relaxation optical coherence straingraphy (SR-OCSA). The purpose of this study was to establish an approach for measuring mechanical properties of articular cartilage using SR-OCSA, and to investigate the distribution of viscoelastic properties of articular cartilage in early osteoarthritis. METHODS: Anterior cruciate ligament transection surgery was performed on the left knees of 8-9-month-old New Zealand white rabbits. SR-OCSA was used to visualize and measure the viscoelastic properties of articular cartilage via attenuation coefficient of strain rate (ACSR). Using the same conditions as in the SR-OCSA test, an indentation test was conducted, and relaxation time was measured to evaluate the relationship between ACSR and relaxation time. RESULTS: SR-OCSA could nondestructively detect and visualize changes in the distribution of viscoelastic properties of articular cartilage in early osteoarthritis. SR-OCSA captured significant increases in ACSR in cartilage at 2 weeks after surgery, when a histologically slight osteoarthritis sign was present. As cartilage degeneration progressed, ACSR increased, whereas relaxation time decreased in a time-dependent manner. Moreover, ACSR negatively correlated with relaxation time. In particular, ACSR was elevated around the tidemark and the elevation tended to move as cartilage degeneration progressed. CONCLUSIONS: SR-OCSA could tomographically and nondestructively detect and visualize changes in the distribution of viscoelastic properties of articular cartilage in early osteoarthritis. The mechanical properties around the tidemark were degraded as cartilage degeneration progressed. Thus, SR-OCSA provides important data needed to understand the biomechanics of early osteoarthritis.

Long-Term Outcomes of Drug-Eluting Stent Implantation After Rotational Atherectomy for Left Main Coronary Artery Bifurcation Lesions.

The clinical outcomes of drug-eluting stent (DES) implantation after rotational atherectomy (RA) for complex left main coronary artery (LMCA) bifurcation lesions remain unclear. Among 1,809 patients retrospectively enrolled in the Assessing Optimal percutaneous coronary Intervention for LMCA Registry, we identified 1,199 patients with LMCA bifurcation lesions treated by crossover stenting with DES for the main vessel. The study population was divided according to the use of RA. The patients in the RA group were further subdivided into the 2 subgroups on the basis of the stenting approach. The rates of periprocedural myocardial infarction and in-hospital death in the RA group were comparable to those in the non-RA group. The cumulative 5-year incidences of all-cause death and target lesion revascularization (TLR) were significantly higher in the RA group than those in the non-RA group. However, after adjusting confounders, the excess risks of the RA group relative to the non-RA group for all-cause death and TLR were no longer significant (hazard ratio 0.95, 95% confidence intervals 0.59 to 1.52, p = 0.83, and hazard ratio 1.46, 95% confidence intervals 0.82 to 2.60, p = 0.20, respectively). In the RA group, the cumulative 5-year incidences of all-cause death and TLR were markedly higher in the 2-stent subgroup than in the 1-stent subgroup (58.1% vs 26.0%, p = 0.001, and 43.0% vs 16.3%, p = 0.001, respectively). In conclusion, DES implantation after RA was a safe and feasible strategy in treating those patients with complex LMCA bifurcation lesions. In this strategy, the 2-stent approach was associated with markedly worse 5-year clinical outcomes than the 1-stent approach.

Prognostic impact of final kissing balloon technique after crossover stenting for the left main coronary artery: from the AOI-LMCA registry.

It is still uncertain whether the final kissing balloon technique (FKBT) is mandatory after crossover stenting for the left main coronary artery (LMCA). Assessing Optimal Percutaneous Coronary Intervention for LMCA (AOI-LMCA) registry, a 6-center retrospective registry, enrolled 1809 consecutive patients for LMCA stenting in Japan. In the present analysis, 5-year clinical outcomes were compared between non-FKBT (n = 160) and FKBT (n = 578) groups in patients treated with crossover stenting with drug-eluting stents from the LMCA to the left anterior descending artery. Propensity score-matched analysis was also performed in 160 patient pairs. In the entire study population as well as in the propensity-matched population, the cumulative 5-year incidence of the primary outcome measure (target lesion revascularization: TLR) was not significantly different between the FKBT and non-FKBT groups (10.7 versus 14.3%, P = 0.49, and 11.8 versus 14.3%, P = 0.53, respectively). In the sensitivity analysis by the multivariable Cox proportional hazard model, the effect of FKBT relative to non-FKBT for TLR remained insignificant (adjusted HR 0.89, 95% CI 0.47-1.69, P = 0.72). Regarding the TLR location, there were no significant differences in the cumulative incidences of TLR for LMCA-only, for the main branch, and for the side branch between the 2 groups (2.2 versus 1.3%, P = 0.93, 11.8 versus 9.1%, P = 0.71, and 8.2 versus 7.6%, P = 0.82, respectively). FKBT after a 1-stent strategy for LMCA crossover stenting did not affect TLR and other clinical outcomes during 5-year follow-up.Clinical Trial Registration: Assessing Optimal Percutaneous Coronary Intervention for Left Main Coronary Artery Stenting Registry (AOI LMCA Stenting Registry). http://www.umin.ac.jp/ctr/index/htm/ . Unique Identifier: UMIN000014706.

Acute Coronary Syndrome With Unprotected Left Main Coronary Artery Culprit　- An Observation From the AOI-LMCA Registry.

BACKGROUND: Data on the clinical outcomes of percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) in patients with acute coronary syndrome (ACS) are limited. Therefore, this study aimed to assess the clinical outcome of patients with ACS who underwent PCI for LMCA culprit lesion.Methods and Results:Of 1,809 patients enrolled in the Assessing Optimal Percutaneous Coronary Intervention for the LMCA (AOI-LMCA) registry (a retrospective 6-center registry of consecutive patients undergoing LMCA stenting in Japan), the current study population consisited of 1,500 patients with unprotected LMCA stenting for LMCA ACS (ACS with shock: 115 patients, ACS without shock: 281 patients) and stable CAD (1,104 patients). The cumulative 180-day incidence of death was markedly higher in the ACS with shock group than in the other groups (49.5%, 8.6%, and 3.3%, respectively; P<0.0001), but mortality beyond 180-day was not significantly different among the 3 groups (30.2%, 20.4%, and 19.5%, respectively; P=0.65). In the ACS with shock group, the initial TIMI flow grade did not affect 5-year mortality (57.1% and 62.2%, P=0.99), but in the ACS without shock group, 5-year mortality was significantly higher in patients with initial TIMI flow grade ≤1 than in patients with TIMI flow grade ≥2 (44.4% and 23.7%, respectively; P=0.008). CONCLUSIONS: In patients with LMCA ACS, survival correlates with baseline hemodynamic and coronary flow status.

Conversion surgery for an initially unresectable, locally advanced pancreatic cancer after induction chemotherapy and carbon-ion radiotherapy: a case report.

BACKGROUND: Pancreatic cancer has a very high mortality rate worldwide, and about 30-40% of all patients have extensive vascular involvement at initial diagnosis that precludes surgical intervention. Here, we describe our experience in a patient with locally advanced pancreatic cancer (LAPC) who underwent R0 conversion surgery after undergoing a combination of chemotherapy and carbon-ion radiotherapy (CIRT), which led to long-term relapse-free survival (23 months). CASE PRESENTATION: A 41-year-old woman presented a month ago with epigastralgia referred to our facility and was subsequently diagnosed with pancreatic cancer cStage III (Ph, TS2 (35 mm), cT4, cCH1, cDU1, cS1, cRP1, cPL1, cVsm0, cAsm1, cN0, cM0) that was also categorized as an unresectable LAPC. She immediately underwent 3 cycles of induction chemotherapy (gemcitabine + nanoparticle albumin-bound (nab-) paclitaxel) followed by CIRT with concurrent gemcitabine. Although significant shrinkage of the primary tumor occurred, frequent cholangitis due to duodenal stenosis of unknown etiology prevented continued chemotherapy, and 9 months after the first visit, she underwent a radical, subtotal, stomach-preserving, pancreaticoduodenectomy (SSPPD). Histopathologic examination of the resected tissue revealed a R0 resection with a histological response of Evans grade IIB. She was administered an almost full dose of S-1 as adjuvant chemotherapy for 6 months and has shown no signs of recurrence in 23 months. CONCLUSIONS: We report a first case of successful conversion surgery for an initially unresectable LAPC after rapid induction GEM + nab-PTX chemotherapy followed by CIRT. Rapid induction GEM + nab-PTX chemotherapy followed by CIRT for LAPC might be a safe and effective treatment option.

Rectal Neuroendocrine Tumor with Synchronous Pancreatic Metastasis: A Case Report.

INTRODUCTION: Gastrointestinal neuroendocrine tumors (GI-NETs) often show hematogenous metastasis, with the liver being the most common metastatic site; however, metastasis to the pancreas is rare. CASE PRESENTATION: We report a rare case of rectal NETs with pancreatic metastases in a 75-year-old man who presented with a chief complaint of constipation. Imaging and endoscopic findings revealed a rectal submucosal tumor, a pancreatic hypovascular mass, and multiple liver masses. The rectal lesion and pancreatic lesions were diagnosed as neuroendocrine tumors using biopsy and endoscopic ultrasound fine-needle aspiration, respectively. Synchronous rectal NET and pancreatic NET (P-NET) with liver metastasis of either of these two were preoperatively diagnosed. A two-stage surgery was performed, comprising abdominoperineal resection and distal pancreatectomy. Pre-operative imaging findings showed a solitary mass in the pancreas, although the resected specimen contained multiple lesions. Immunohistochemical staining of the resected rectal and pancreatic lesions showed that both were synaptophysin positive and chromogranin A (CgA) negative. Generally, rectal NET cells are positive for synaptophysin and negative for CgA, while the majority of P-NETs are positive for both. The final diagnosis was rectal NETs with pancreatic and liver metastases. Till date, there have been no reports on the outcomes in patients with pancreatic metastasis of GI-NETs. CONCLUSIONS: More case reports on metastatic NETs are needed to arrive at a consensus for a standardized treatment regimen.