Assessing sustainability of hand hygiene adherence 5 years after a contest-based intervention in 3 Japanese hospitals.

BACKGROUND: Our goal was to evaluate the 5-year sustainability of a multimodal intervention that included a prize to the hospital with the highest overall hand hygiene adherence rates among health care workers. METHODS: We conducted an observational study in 3 Japanese tertiary care hospitals using unobtrusive direct observation of physician and nurse hand hygiene adherence. Observations were performed by a trained observer on inpatient medical, surgical, intensive care, and emergency units. The primary outcome was hand hygiene adherence rates before patient contact. Secondary outcomes were health care worker survey responses to a World Health Organization (WHO) questionnaire on hand hygiene practices. RESULTS: Hand hygiene adherence rates had improved significantly after the introduction of a multimodal intervention (based on principles recommend by the WHO) in 2012 and 2013 (from 18.0% pre-intervention to 32.7% 6 months post-intervention; P < .001). No significant changes were found in hand hygiene adherence in these hospitals 5 years after the original intervention (31.9% 5 years after intervention; P = .53); however, substantial variability in hand hygiene adherence by unit and health care worker type was noted. CONCLUSIONS: A multimodal hand hygiene initiative achieved sustained improvement in hand hygiene adherence in 3 Japanese hospitals 5 years after the original intervention.

Histological Findings of Organizing Pneumonia, Based on Transbronchial Lung Biopsy, May Predict Poor Outcome in Polymyositis and Dermatomyositis: Report of Two Autopsied Cases.

Interstitial lung disease in polymyositis and dermatomyositis is a serious complication, associated with poor prognosis. In this article, we describe two cases with histological findings of organizing pneumonia, based on transbronchial lung biopsy. One is a 66-year-old female patient with clinically amyopathic dermatomyositis with anti-melanoma differentiation-associated gene 5 antibody, and another is a 61-year-old female patient with polymyositis with anti-Jo-1 antibody. Both of our cases rapidly deteriorated to death, and autopsy findings showed diffuse alveolar damage. Our experience indicates that transbronchial biopsy findings of organizing pneumonia may be a poor prognostic factor in clinically amyopathic dermatomyositis and polymyositis, in spite of the profile of myositis-specific antibodies.

Acute Carpal Tunnel Syndrome Due to Pyogenic Flexor Tenosynovitis without Any Antecedent Injury.

We herein report a case of acute carpal tunnel syndrome due to pyogenic flexor tenosynovitis in the absence of any antecedent injury whose rapid progression and course was similar to that seen with necrotizing fasciitis. This potentially disastrous clinical condition must be promptly recognized, since it needs early surgical management to prevent morbidity.

Kikuchi-Fujimoto Disease Complicated with Reactive Hemophagocytic Lymphohistiocytosis.

Kikuchi-Fujimoto disease (KFD) is a benign cause of self-limiting subacute necrotizing lymphadenitis. KFD is rarely complicated with reactive hemophagocytic lymphohistiocytosis (HLH), and the clinical features of the simultaneous occurrence of these conditions are uncertain. A 30-year-old Japanese man with a persistent fever and sore throat presented to our hospital for treatment. Laboratory analysis showed bicytopenia, and radiological studies showed systemic lymphadenopathy accompanied by splenomegaly. A bone marrow examination showed hemophagocytic macrophages, suggesting HLH. Malignant lymphoma was suspected as a possible underlying disease, but the histology of the lymph nodes led to a final diagnosis of KFD and treatment with prednisolone (1 mg/kg/day), resulting in clinical improvement. This case highlighted the importance and difficulty of differentiating KFD from malignant lymphoma as an underlying condition of HLH. The literature review showed that patients with HLH-associated KFD may have higher serum ferritin and lactate dehydrogenase levels compared to typical KFD cases. Definite diagnosis based on pathological examination is essential for a better understanding of this rare disease. The presence of systemic lymphadenopathy does not exclude the possibility of KFD. This case serves to remind physicians that KFD is a potential etiology of HLH.

Improving healthcare worker hand hygiene adherence before patient contact: A multimodal intervention of hand hygiene practice in Three Japanese tertiary care centers.

BACKGROUND: Though hand hygiene is an important method of preventing healthcare-associated infection, we found suboptimal hand hygiene adherence among healthcare workers in 4 diverse Japanese hospitals (adherence rates of 11%-25%). OBJECTIVE: Our goal was to assess multimodal hand hygiene intervention coupled with a contest to improve hand hygiene adherence. SETTING: A total of 3 to 4 inpatient wards in 3 Japanese hospitals. DESIGN: Pre-post intervention study. INTERVENTION: The intervention was a multimodal hand hygiene intervention recommended by the World Health Organization that was tailored to each facility. The hospital with the highest adherence after the intervention was given $5000 US dollars and a trophy, provided by an American coinvestigator unaffiliated with any of the Japanese hospitals. MEASUREMENT: We tracked hand hygiene adherence rates before patient contact for each unit and hospital and compared these to pre-intervention adherence rates. RESULTS: We observed 2982 postintervention provider-patient encounters in 10 units across 3 hospitals. Hand hygiene adherence rates were improved overall after the intervention (18% pre- to 33% postintervention; P < 0.001), but postintervention adherence rates varied considerably: hospital A + 29%, B + 5%, C + 8%. Hospital A won the contest with 40% adherence after the intervention. CONCLUSIONS: Using a novel contest coupled with a multimodal intervention successfully improved hand hygiene rates among Japanese healthcare workers. Given the overall low rates, however, further improvement is necessary.

Hand Hygiene Adherence Among Health Care Workers at Japanese Hospitals: A Multicenter Observational Study in Japan.

BACKGROUND: Although proper hand hygiene among health care workers is an important component of efforts to prevent health care-associated infection, there are few data available on adherence to hand hygiene practices in Japan. OBJECTIVES: The aim of this study was to examine hand hygiene adherence at teaching hospitals in Japan. METHODS: An observational study was conducted from July to November 2011 in 4 units (internal medicine, surgery, intensive care, and/or emergency department) in 4 geographically diverse hospitals (1 university hospital and 3 community teaching hospitals) in Japan. Hand hygiene practice before patient contact was assessed by an external observer. RESULTS: In a total of 3545 health care worker-patient observations, appropriate hand hygiene practice was performed in 677 (overall adherence, 19%; 95% confidence interval, 18%-20%). Subgroup rates of hand hygiene adherence were 15% among physicians and 23% among nurses. The ranges of adherence were 11% to 25% between hospitals and 11% to 31% between units. Adherence of the nurses and the physicians to hand hygiene was correlated within each hospital. There was a trend toward higher hand hygiene adherence in hospitals with infection control nurses, compared with hospitals without them (29% versus 16%). CONCLUSIONS: The hand hygiene adherence in Japanese teaching hospitals in our sample was low, even lower than reported mean values from other international studies. Greater adherence to hand hygiene should be encouraged in Japan.

Suitability of surveillance colonoscopy for patients with ulcerative colitis to detect colorectal cancer: current guidelines miss some early-stage cases.

Surveillance colonoscopy (SC) is considered important for the early detection and treatment of colorectal cancer (CRC) in patients with ulcerative colitis (UC). Here, we investigated whether current guidelines are appropriate in preventing UC patients from being diagnosed with CRC at an incurable stage. Among 1583 patients under treatment for UC, 27 patients were diagnosed with CRC. Of these, we excluded two patients who had not undergone colonoscopy before CRC diagnosis. We then divided the remaining patients into three groups based on colonoscopy interval (A, 1 year or less; B, between 1 and 2 years; and C, 2 years or longer). Fifteen patients had tubular adenocarcinomas, and 10 had other types (8 poorly differentiated adenocarcinomas, 1 mucinous adenocarcinoma, 1 endocrine cell carcinoma). Five (20%) of 25 patients developed CRC within 8 years after the onset of UC, of which one case was detected at stage IV. Six patients were classified into group A, 8 into group B, and 11 into group C. On distribution by histologic type, tubular adenocarcinomas were detected in stages 0 - II in 100% in group A, 100% in group B, and 57.1% in group C. In contrast, other types of carcinomas were detected in stage 0 - II in 100% in group A, 40% in group B, and 0% in group C. Current guideline recommendations for SC are not sufficient for the detection of early stage CRC in patients with UC. SC should be commenced earlier than recommended in the current guidelines and repeated annually.

[Retrospective evaluation of predictors and frequency of hypotension in hypertensive patients after induction of general anesthesia].

BACKGROUND: It is reported that hypotension during general anesthesia is associated with adverse outcomes in patients having both noncardiac and cardiac surgery. The present retrospective study was undertaken to evaluate the incidence and the predictors of hypotension after induction of general anesthesia (GA) until the start of operation. METHODS: After the IRB approval, 157 patients with hypertension who had undergone surgery under general anesthesia were enrolled. Data were collected using medical chart and anesthesia record. We divided the period into two intervals, from entering the operating room to tracheal intubation (first interval) and from tracheal intubation to start of operation (second period). Hypotension was defined when blood pressure decreased more than or equal to 25 percent compared to blood pressure measured at first in operating room. RESULTS: Hypotension occurred in 73.2% during the first interval and 96.8% during the second interval. The age was a significant predictor for hypotension during the second interval (P = 0.0087). CONCLUSIONS: The result in this study indicated that the age was a significant predictor for hypotension from tracheal intubation to start of operation.

[Intraoperative acute airway obstruction due to the damage of a reinforced endotracheal tube in thyroidectomy].

A 55-year-old woman was scheduled for left thyroidectomy. Anesthesia was induced without problems and maintained without nitrous oxide. Sixteen minutes after the start of the procedure, airway pressures and endtidal carbon dioxide concentration increased suddenly. An attempt to pass a suction catheter down the endotracheal tube was unsuccessful. A protuberance was found in the reinforced endotracheal tube. After reintubation with a new reinforced endotracheal tube, ventilation was improved immediately. The rest of the procedure was done uneventfully. Similar phenomenon was reported in the reuse of endotracheal tube and the use of nitrous oxide. In our case, airway obstruction was caused by the pinhole that was created in a manufacturing process. We have to keep in mind that endotracheal tube itself may be out of order if other causes have been excluded.

The efficacy of cefmetazole against pyelonephritis caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae.

OBJECTIVES: Urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae are on the increase. Although cefmetazole is stable in vitro against the hydrolyzing activity of ESBLs, no clinical study has ever evaluated its role in infections caused by these organisms. We therefore evaluated the efficacy of cefmetazole compared to carbapenems against pyelonephritis caused by ESBL-producing Enterobacteriaceae. METHODS: A retrospective chart review was conducted at a tertiary care hospital from August 2008 to July 2010. Chart reviews were done for patients with ESBL-producing organisms in urine identified in the microbiology database. Patients who were treated with cefmetazole were compared to those treated with carbapenems. The clinical and bacteriological cure rates at 4 weeks after completion of therapy were evaluated. RESULTS: Two hundred and fifty-six urine cultures growing ESBL-producing organisms were identified during the study period. Ten patients treated with cefmetazole and 12 patients treated with carbapenems were evaluated. There was no difference in clinical (9/10 vs. 12/12, p = 0.46) or bacteriological cure rate (5/7 vs. 6/7, p = 1.00) at 4 weeks after the completion of therapy. There was no difference in the incidence of adverse effects (2/10 vs. 2/12, p = 1.00). CONCLUSIONS: Cefmetazole may be a useful option for the treatment of UTIs caused by ESBL-producing organisms. Prospective and larger sized studies are needed to confirm our findings.

A fatal case of infective endocarditis caused by an unusual suspect: Serratia marcescens.

Serratia marcescens has been reported to cause infective endocarditis among intravenous drug users, but it is extremely rare in non-intravenous drug users in Japan. In this article, we report an 85-year-old woman with diabetes mellitus who presented with low-grade fever and general fatigue. She was administered intravenous prednisolone under a diagnosis of right Bell's palsy before this admission. Blood cultures revealed positive Serratia marcescens, which was complicated by multiple cerebral infarctions after admission. Transthoracic echocardiography on day 5 revealed vegetation on the mitral valve, which was diagnosed as infective endocarditis. An operation could not be performed because of the presence of multiple cerebral infarctions. She died on day 65 because of uncontrolled heart failure.

Intestinal cancers occurring in patients with Crohn's disease.

BACKGROUND AND AIMS: The number of patients with Crohn's disease (CD) and the number of cases of intestinal cancer associated with CD have both been increasing in Japan. However, the number of reported cases is lower than for ulcerative colitis-associated cancer. The aim of this study was to identify the clinical picture of CD-associated intestinal cancer in a consecutive series of patients with CD and to stress the importance of surveillance. METHODS: We enrolled 174 consecutive patients (130 men, 44 women, mean age 25 years) diagnosed with CD and investigated the development of intestinal cancer from October 1998 to July 2010. There were 104 cases of the ileocolitis type, 47 of ileitis, and 23 of colitis. RESULTS: Intestinal cancer developed in two male patients (1.5% of the total), whose respective ages at onset of CD were 41 and 19 years, and 55 and 37 years at onset of cancer. Both cases were of ileocolitis-type CD; one cancer developed in the rectum and the other in the small bowel, and both were accompanied by severe stricture. Histopathological results revealed well and moderately differentiated adenocarcinoma, respectively. CONCLUSIONS: Intestinal cancer developed in patients with ileocolitis-type CD of more than 10 years' duration. Our findings suggest that patients with chronic, widespread CD should be under cancer surveillance.

Impact of hyponatremia and the syndrome of inappropriate antidiuresis on mortality in elderly patients with aspiration pneumonia.

BACKGROUND: Hyponatremia is associated with pneumonia, and aspiration pneumonia is common in the elderly, however, there has been no study of hyponatremia in this population. OBJECTIVE: To determine the impact of hyponatremia on mortality in elderly patients with aspiration pneumonia, while focusing on the comparison between those with and without the syndrome of inappropriate antidiuresis (SIAD). DESIGN: Retrospective review of existing database and medical records. SETTING: A community teaching hospital in Japan. PATIENTS: Two hundred and twenty-one elderly patients hospitalized with aspiration pneumonia. MEASUREMENTS: Multivariate logistical regression models were used to compare 30-day and in-hospital mortality, in patients with hyponatremia of various severities and etiologies, with that in patients with normal serum sodium concentrations. RESULTS: Sixty-five (29%) of 221 patients had hyponatremia. Of these 62 (95%) had hypotonic hyponatremia, which were further assessed as having hypovolemic (39 [63%]), hypervolemic (3 [5%]), and euvolemic (20 [32%]) hyponatremia. Of the 20 euvolemic patients, 14 (70%) had SIAD. Both moderate and severe hypotonic hyponatremia were significantly associated with increased in-hospital mortality (odds ratio [OR] 6.05, 95% confidence interval [CI] 1.46-25.0, and OR 5.65, 95% CI 1.14-28.1, respectively). Hyponatremia due to SIAD was significantly associated with both increased 30-day mortality (OR 7.40, 95% CI 1.73-31.7) and increased in-hospital mortality (OR 22.3, 95% CI 4.26-117). In contrast, hypovolemic hyponatremia was not significantly associated with increased mortality. CONCLUSIONS: Hyponatremia due to SIAD was strongly associated with increased mortality in elderly patients with aspiration pneumonia, whereas hypovolemic hyponatremia was not associated with increased mortality.

Metronidazole-induced central nervous system toxicity: a systematic review.

OBJECTIVE: To assess patient and medication factors that contribute to metronidazole toxicity. DATA SOURCES: We searched PUBMED from 1965 through April 7, 2011, and performed a hand search of bibliographies. STUDY SELECTION: Case reports or case series reporting metronidazole-induced central nervous toxicity. DATA EXTRACTION: Two authors independently abstracted demographics, metronidazole indication, dose and duration, neurological manifestations, and outcomes as well as brain imaging findings. DATA SYNTHESIS: Among 64 patients, 48 (77%) had cerebellar dysfunction, 21 (33%) had altered mental status, and 8 (15%) had seizures. Patients' ages averaged 53.3 years (range, 12-87 years), and 64% were male. The median duration of metronidazole was 54 days, although 26% had taken it less than a week and 11% had taken it less than 72 hours. Among cases with outcome data, most patients either improved (n = 18 [29%]) or had complete resolution of their symptoms with discontinuation of metronidazole (n = 41 [65%]). There was no difference in resolution of symptom by age (P = 0.71) or sex (P = 0.34). The patients with cerebellar dysfunction were less likely to experience complete resolution than those with mental status changes or seizures (relative risk, 0.67; 95% confidence interval (CI), 0.49-0.92). Nearly all patients (n = 55 [86%]) underwent imaging of the brain: 44 (69%) underwent magnetic resonance imaging (MRI) and 12 (19%) underwent computed tomographic studies. All patients with cerebellar dysfunction had abnormalities on imaging: 93% (n = 39) had a cerebellar lesion, although numerous areas in the brain were affected. On follow-up MRIs, 25 patients (83%) had complete resolution of abnormalities. CONCLUSIONS: Metronidazole can rarely cause central nervous system toxicity; it does not seem to be a dose- or duration-related phenomenon. Most patients will have MRI abnormalities. Prognosis is excellent with metronidazole cessation.

Splenic abscess caused by Lactobacillus paracasei.

Splenic abscess is relatively uncommon. Infections caused by lactobacilli, which are usually one of the constituents of normal flora of human gut and vagina, are also very uncommon. Here we report a case of splenic abscess caused by Lactobacillus paracasei. We performed a literature review for this rare entity. Immunocompromised status of the patient, who had uncontrolled diabetes, could have contributed to the pathogenesis of this rare disease.

Clinical findings in parvovirus B19 infection in 30 adult patients in Kyoto.

To relate the clinical findings of parvovirus B19 infection to the phase of the disease, we performed a retrospective chart review of 30 adult patients who tested positive for IgM antibody against parvovirus B19 at our hospital from March 2003 to November 2008. Median patient age was 38 years, with 86.7% aged between 26 and 45 years. The male-to-female ratio was 4:26 (86.7% female). Symptoms in the first phase were mainly flu-like, including fever, headache, or myalgia. Symptoms in the second phase were arthralgia in 24 (85.7%) and rash in 23 (82.1%). Fever was observed in 21 (70.0%), and 22 (75.9%) were found to be lymphopenic. The onsets in 73.3% of cases were concentrated within 10.1% of the study period, an observation nearly consistent with an outbreak of erythema infectiosum. Three patients had symmetrical swelling of joints, all of whom also had rash. Most patients visited the hospital within a week of onset and prognosis was favorable. In the parvovirus B19 infection, flu-like symptoms were frequent in the first phase, while rash and arthralgia were common in the second. Female sex, age between 26 and 45, and presence of rash, arthralgia, fever, and lymphopenia were clinical findings with a high frequency (≥70%), and these factors may contribute to diagnosis. In an era when early diagnosis and therapy is required in rheumatoid arthritis, it is important to recognize the parvovirus B19 infection with a presentation of acute arthritis and a favorable prognosis.

Systematic review and metaanalysis: urinary antigen tests for Legionellosis.

BACKGROUND: Urinary antigen assays offer simplicity and rapidity in diagnosing Legionnaires' disease, though studies report a range of sensitivities. We conducted a systematic review to assess the test characteristics of Legionella urinary antigen. METHODS: We searched Medline, Excerpta Medica Database, and bibliographies of retrieved articles. English-language studies were used and included if the absolute number of true-positive, false-negative, true-negative, and false-positive observations were available, and the "gold standards" were described clearly. Two investigators independently reviewed articles and extracted data. Quality was assessed with the Quality Assessment for Diagnostic Accuracy Studies (QUADAS). Sensitivities and specificities were pooled using a random-effects model weighted with the inverse of the SE calculated through the Wald method. RESULTS: Fifty articles were retrieved for detailed evaluation, and 30 met the inclusion criteria. All but two studies focused on serotype 1 Legionella. Forty assays were reported using six different methodologies, whereas 26 assays used commercial tests, and 14 assays used in-house tests. Study quality was generally low, with average QUADAS scores of 4.4 of a total of 14 points (range, 1 to 9 points). The pooled sensitivity was 0.74 (95% CI, 0.68 to 0.81), and the specificity was 0.991 (95% CI, 0.984 to 0.997). Higher quality studies had lower sensitivity, and there was evidence of publication bias. CONCLUSIONS: Legionella urinary antigen for serotype 1 appears to have excellent specificity, though modest sensitivity. However, the poor quality of the included studies and the presence of publication bias suggest an overestimation of test performance. High-quality studies are needed.

Ethnicity and other possible risk factors for candidemia at 3 tertiary care university hospitals in Hawaii.

A total of 108 cases of candidemia detected in 3 tertiary care university hospitals in Hawaii between January 2001 and December 2002 were retrospectively reviewed. Candida albicans, Candida glabrata, and Candida tropicalis accounted for 28% of the cases. Mortality among Filipino patients was significantly higher than that among other ethnic groups (71% vs 48%; P<.05).