Implementation of multifaceted diagnostic stewardship for Clostridioides difficile infection during the COVID-19 pandemic at a small Japanese hospital.

Objective: Clostridioides difficile infection (CDI) is a common, healthcare-associated infection. However, in Japan, testing for CDI is infrequent, suggesting that its incidence may be underestimated. This study aimed to examine the implementation of a multifaceted, diagnostic stewardship (DS) for CDI in a small Japanese hospital during the coronavirus 2019 pandemic. Design: Before-after study. Setting: A small Japanese community hospital. Participants: Healthcare workers including physicians, nurses, and pharmacists. Interventions: A multifaceted intervention including (1) the addition of CD testing criteria to the hospital guidelines; (2) provision of a tutorial on CD testing to physicians, nurses, and pharmacists; (3) assessment by clinical pharmacists and nurses of the need for CD testing in patients with nosocomial diarrhea and issuance of recommendations for CD testing to physicians; (4) reporting of data on the CD testing rate and CDI incidence in the study center. Results: The CD testing rate increased before the pandemic (+0.16/10,000 patient-days (PD); P = .28), decreased significantly during the pandemic (-0.79/10,000 PD; P = .02), and then increased significantly immediately after the implementation of the intervention (+29.6/10,000 PD; P < .01). Similarly, the CDI incidence increased significantly before the pandemic (+0.26/10,000 PD; P = .02) and decreased significantly during the pandemic (-0.49/10,000 PD; P = .01). Implementation of the intervention resulted in an immediate and significant increase in the CDI incidence (+6.2/10,000 PD; P < .01). Conclusion: Multifaceted DS involving multidisciplinary specialists was effective in improving CD testing, suggesting that appropriate testing can contribute to diagnosing CDI accurately.

Impact of coronavirus disease 2019 (COVID-19) pandemic on antimicrobial consumption and antimicrobial resistance at a small, local hospital in Japan.

The coronavirus disease 2019 (COVID-19) pandemic negatively affected antimicrobial stewardship programs at hospitals throughout Japan by diverting resources toward managing the pandemic. However, antimicrobial stewardship needs to continue regardless of hospital size or supervening crises. Herein, we discuss the impact of COVID-19 on antimicrobial stewardship at a small, local hospital in Japan.

Prognostic Accuracy of the qSOFA Score for In-Hospital Mortality in Elderly Patients with Obstructive Acute Pyelonephritis: A Multi-Institutional Study.

Prognostic accuracy of the quick sequential organ failure assessment (qSOFA) score for mortality may be limited in elderly patients. Using our multi-institutional database, we classified obstructive acute pyelonephritis (OAPN) patients into young and elderly groups, and evaluated predictive performance of the qSOFA score for in-hospital mortality. qSOFA score ≥ 2 was an independent predictor for in-hospital mortality, as was higher age, and Charlson comorbidity index (CCI) ≥ 2. In young patients, the area under the curve (AUC) of the qSOFA score for in-hospital mortality was 0.85, whereas it was 0.61 in elderly patients. The sensitivity and specificity of qSOFA score ≥ 2 for in-hospital mortality was 80% and 80% in young patients, and 50% and 68% in elderly patients, respectively. For elderly patients, we developed the CCI-incorporated qSOFA score, which showed higher prognostic accuracy compared with the qSOFA score (AUC, 0.66 vs. 0.61, p < 0.001). Therefore, the prognostic accuracy of the qSOFA score for in-hospital mortality was high in young OAPN patients, but modest in elderly patients. Although it can work as a screening tool to determine therapeutic management in young patients, for elderly patients, the presence of comorbidities should be considered at the initial assessment.

Selective adaptation in sentence comprehension: Evidence from event-related brain potentials.

In this study, two event-related potential experiments were conducted to investigate whether readers adapt their expectations to morphosyntactically (Experiment 1) or semantically (Experiment 2) anomalous sentences when they are repeatedly exposed to them. To address this issue, we experimentally manipulated the probability of occurrence of grammatical sentences and syntactically and semantically anomalous sentences through experiments. For the low probability block, anomalous sentences were presented less frequently than grammatical sentences (with a ratio of 1 to 4), while they were presented as frequently as grammatical sentences in the equal probability block. Experiment 1 revealed a smaller P600 effect for morphosyntactic violations in the equal probability block than in the low probability block. Linear mixed-effects models were used to examine how the size of the P600 effect changed as the experiment went along. The results showed that the smaller P600 effect of the equal probability block resulted from an amplitude's decline in morphosyntactically violated sentences over the course of the experiment, suggesting an adaptation to morphosyntactic violations. In Experiment 2, semantically anomalous sentences elicited a larger N400 effect than their semantically natural counterparts regardless of probability manipulation. Little evidence was found in favour of adaptation to semantic violations in that the processing cost associated with the N400 did not decrease over the course of the experiment. Therefore, a dynamic aspect of language-processing system was demonstrated in this study. We will discuss why the language-processing system shows a selective adaptation to morphosyntactic violations.

[IMPACT OF MEMBRANOUS URETHRAL LENGTH IN DE NOVO STRESS URINARY INCONTINENCE FOLLOWING HOLMIUM LASER ENUCLEATION OF THE PROSTATE].

(Purpose) Holmium laser enucleation of the prostate (HoLEP) is widely performed in recent years; however, difficulties of surgical techniques and high frequency of postoperative stress urinary incontinence (SUI) remain as significant problems. We determined the predictive factors for de novo SUI after HoLEP. (Patients and methods) A total of 303 patients with benign prostatic hyperplasia who underwent HoLEP were retrospectively evaluated between July 2013 and April 2019. Of these, 109 patients underwent MRI preoperatively. Patients who were unable to answer the questionnaire regarding their SUI because of dementia, those who presented with SUI preoperatively, and those with placed Foley catheter at the time of MRI were excluded. Hence, a total of 83 patients were eligible for the present study. We recorded the MRI findings and clinical variables, including membranous urethral length (MUL), transitional zone (TZ) volume, serum prostate-specific antigen levels, operative time, and presence or absence of SUI. The predictive factors for de novo SUI were determined using multivariable logistic regression analysis. (Results)De novo SUI occurred in 19 (22.9%) patients but disappeared in 16 (84.2%) patients at a mean duration of 14 weeks. The mean MUL was 17.2 mm. Univariate analysis showed that MRI TZ volume >40 mL, MUL ≤17 mm, operative time >100 min, and enucleation time >50 min were associated with de novo SUI. In multivariable logistic regression analysis, MUL ≤17 mm (odds ratio [OR], 23.81; 95% confidence interval [CI], 4.34-447.19; P < 0.0001) and operative time >100 min (OR, 3.91; 95% CI, 1.20-14.01; P = 0.023) were significantly associated with de novo SUI. (Conclusions) Although de novo SUI occurred occasionally after HoLEP, most of them improved in about 3 months. The MRI measurement of MUL was shown to be a practical tool for predicting de novo SUI after HoLEP.

Inter-participant variabilities and sample sizes in P300 and P600.

Reliably and efficiently detecting physiological differences between conditions of interest is of importance in psychophysiology. In particular, when it comes to the observation of relatively small differences, such as a P600 effect, a language-related brain potential elicited by ungrammatical sentences compared to grammatical sentences, inter-participant variability is a critical factor since a larger inter-participant variability decreases statistical significance, and therefore increases the necessary sample size. The present study investigated how stable individual P600s are, at which sample sizes the P600 becomes stable, and how many participants are necessary to observe a P600 effect. P600s were recorded from 48 participants, as well as P300 (P3b) from 40 participants for comparison. Unlike the P3b effect, which had an approximately 10 µV difference between the target and standard stimuli, P600 increased in amplitude by only 1.4-1.7 µV at Pz during the processing of ungrammatical sentences relative to the grammatical counterparts. The sample size analysis suggests that 20 to 30 participants are needed to detect a P600 effect at Pz, and the distribution of variances does not change significantly with a larger sample size.

The Effect of Emotional State on the Processing of Morphosyntactic and Semantic Reversal Anomalies in Japanese: Evidence from Event-Related Brain Potentials.

The present study examined the locus responsible for the effect of emotional state on sentence processing in healthy native speakers of Japanese, using event-related brain potentials. The participants were induced into a happy, neutral, or sad mood and then subjected to electroencephalogram recording during which emotionally neutral sentences, including grammatical sentences (e.g. window-NOM close vi, 'The window closes.'), morphosyntactically-violated sentences (e.g. window-ACC close vi, Lit. 'Close the window.'), and semantically-reversed sentences (e.g. window-NOM close vt, 'The window closes pro.') were presented. The results of the ERP experiment demonstrated that while the P600 effect elicited by morphosyntactic violation was not modulated by mood, the P600 effect elicited by semantic reversal anomaly was observed only in participants previously induced into a happy mood. The LAN and N400 were not sensitive to the participants' transient emotional state. These results suggest intact memory access and impaired integration of syntactic and semantic information in individuals in a sad mood.

A case of bacterial meningitis caused by methicillin-resistant Staphylococcus lugdunensis after surgery.

An 51-year-old man had undergone surgery for Rathke's cleft cyst by transsphenoidal approach on October 2015. After the surgery, cerebrospinal fluid (CSF) rhinorrhea arose. Surgical treatment of CSF rhinorrhea was performed by the same approach. Ten days after reoperation, he suffered from severe headache, high fever, and nuchal rigidity. CSF findings indicated bacterial meningitis. CSF culture showed methicillin-resistant Staphylococcus lugdunensis. He received vancomycin intravenously for 19 days and recovered from the bacterial meningitis with no serious complication.

Predictive risk factors of postoperative urinary incontinence following holmium laser enucleation of the prostate during the initial learning period.

PURPOSE: To determine the predictive factors for postoperative urinary incontinence (UI) following holmium laser enucleation of the prostate (HoLEP) during the initial learning period. PATIENTS AND METHODS: We evaluated 127 patients with benign prostatic hyperplasia who underwent HoLEP between January 2011 and December 2013. We recorded clinical variables, including blood loss, serum prostate-specific antigen levels, and the presence or absence of UI. Blood loss was estimated as a decline in postoperative hemoglobina levels. The predictive factors for postoperative UI were determined using a multivariable logistic regression analysis. RESULTS: Postoperative UI occurred in 31 patients (24.4%), but it cured in 29 patients (93.5%) after a mean duration of 12 weeks. Enucleation time >100 min (p=0.043) and blood loss >2.5g/dL (p=0.032) were identified as significant and independent risk factors for postoperative UI. CONCLUSIONS: Longer enucleation time and increased blood loss were independent predictors of postoperative UI in patients who underwent HoLEP during the initial learning period. Surgeons in training should take care to perform speedy enucleation maneuver with hemostasis.

Predictive risk factors of postoperative urinary incontinence following holmium laser enucleation of the prostate during the initial learning period

ABSTRACT Purpose: To determine the predictive factors for postoperative urinary incontinence (UI) following holmium laser enucleation of the prostate (HoLEP) during the initial learning period. Patients and Methods: We evaluated 127 patients with benign prostatic hyperplasia who underwent HoLEP between January 2011 and December 2013. We recorded clinical variables, including blood loss, serum prostate-specific antigen levels, and the presence or absence of UI. Blood loss was estimated as a decline in postoperative hemoglobin levels. The predictive factors for postoperative UI were determined using a multivariable logistic regression analysis. Results: Postoperative UI occurred in 31 patients (24.4%), but it cured in 29 patients (93.5%) after a mean duration of 12 weeks. Enucleation time >100 min (p=0.043) and blood loss >2.5g/dL (p=0.032) were identified as significant and independent risk factors for postoperative UI. Conclusions: Longer enucleation time and increased blood loss were independent predictors of postoperative UI in patients who underwent HoLEP during the initial learning period. Surgeons in training should take care to perform speedy enucleation maneuver with hemostasis.

An ERP Study of Causative Cleft Construction in Japanese: Evidence for the Preference of Shorter Linear Distance in Sentence Comprehension.

This study examined the processing of two types of Japanese causative cleft constructions (subject-gap vs. object-gap) by conducting an event-related brain potential experiment to clarify the processing mechanism of long-distance dependencies. The results demonstrated that the subject-gap constructions elicited larger P600 effects than the object-gap constructions. Based on these findings, we argue that the linear distance rather than the structural distance between the extracted argument (filler) and its original gap position is a crucial factor for determining processing costs of gap-filler dependency in Japanese causative cleft constructions. This argument indicates that (at least) some types of long-distance dependencies are sensitive to linear distance.

Continued administration of antithrombotic agents during transperineal prostate biopsy.

PURPOSE: To determine the safety of continued administration of antithrombotic agents during transperineal (TP) prostate biopsy. PATIENTS AND METHODS: A total of 811 men who underwent transrectal ultrasound (TRUS)-guided TP biopsy from January 2008 to June 2012 at our two institutions were retrospectively analyzed. Among these 811 men, 672 received no antithrombotic agents (group I), 103 received and continued administration of antithrombotic agents (group II), and 36 interrupted administration of antithrombotic agents (group III). Overall complications were graded and hemorrhagic complications were compared (group I with group II) using propensity score matching (PSM) analysis. RESULTS: An overall complication rate of 4.6% was recorded. Hemorrhagic complications occurred in 1.8% and they were virtually identical in all the three groups, and no severe hemorrhagic complications occurred. One patient in group III required intensive care unit admission for cerebral infarction. PSM analysis revealed no statistical difference between groups I and II with regard to the incidence of gross hematuria, perineal hematoma, and rectal bleeding. Multiple regression analysis revealed that hemorrhagic complications were associated with lower body mass index (<21 kg/m2, P=0.0058), but not with administration of antithrombotic agents. CONCLUSIONS: Continued administration of antithrombotic agents does not increase the risk of hemorrhagic complications; these agents are well tolerated during TP biopsy.

Continued administration of antithrombotic agents during transperineal prostate biopsy

Purpose To determine the safety of continued administration of antithrombotic agents during transperineal (TP) prostate biopsy. Patients and Methods A total of 811 men who underwent transrectal ultrasound (TRUS)-guided TP biopsy from January 2008 to June 2012 at our two institutions were retrospectively analyzed. Among these 811 men, 672 received no antithrombotic agents (group I), 103 received and continued administration of antithrombotic agents (group II), and 36 interrupted administration of antithrombotic agents (group III). Overall complications were graded and hemorrhagic complications were compared (group I with group II) using propensity score matching (PSM) analysis. Results An overall complication rate of 4.6% was recorded. Hemorrhagic complications occurred in 1.8% and they were virtually identical in all the three groups, and no severe hemorrhagic complications occurred. One patient in group III required intensive care unit admission for cerebral infarction. PSM analysis revealed no statistical difference between groups I and II with regard to the incidence of gross hematuria, perineal hematoma, and rectal bleeding. Multiple regression analysis revealed that hemorrhagic complications were associated with lower body mass index (<21 kg/m2, P=0.0058), but not with administration of antithrombotic agents. Conclusions Continued administration of antithrombotic agents does not increase the risk of hemorrhagic complications; these agents are well tolerated during TP biopsy. .

Processing of Japanese cleft constructions in context: evidence from event-related brain potentials.

Numerous studies have found "subject gap preference" in relative clauses and cleft constructions in English, French, and other languages. In contrast, previous studies have reported "object gap preference" in cleft constructions in Japanese. However, the effect of integrating a filler and its gap may be influenced by the effect of transitional probabilities, so previous studies confounded these two factors. This study explores processing asymmetries in Japanese cleft constructions by conducting an event-related brain potential experiment by controlling transitional probabilities. The results demonstrate that the subject gap preference in Japanese is well aligned with that observed in other languages, suggesting that subject gap preference is a universal aspect of language comprehension.

Altered nitric oxide synthase, arginase and ornithine decarboxylase activities, and polyamine synthesis in response to ischemia of the rabbit detrusor.

PURPOSE: Little is known about L-arginine catabolism following ischemia in the bladder. We examined the changes in nitric oxide synthase, arginase and ornithine decarboxylase activity, polyamine biosynthesis and the ability to produce nitric oxide following ischemia of the rabbit bladder. MATERIALS AND METHODS: Bladder ischemia was created by ligation of a unilateral bladder artery. At various time points, that is 1, 4, 8, 24, 48 and 72 hours following ligation, the bladders were excised and harvested for determinations. RESULTS: Constitutive nitric oxide synthase, inducible nitric oxide synthase arginase and ornithine decarboxylase activities increased with time, peaking at 48 hours without significant differences between the ligated and nonligated sides in the whole layer. Arginase and ornithine decarboxylase increased mainly in the muscularis following ischemia. Also, putrescine in the muscularis was significantly higher than in the mucosa 48 hours following ischemia. Baseline nitrite/nitrate production in the whole detrusor on the ligated side at 24 hours was significantly lower than that in the normal detrusor. However, nor-hydroxyarginine as an arginase inhibitor and L-arginine increased nitrite/nitrate production in the ischemic detrusor without changing in the normal detrusor. This increasing effect of nor-hydroxyarginine was abolished by nitroarginine methylester as a nitric oxide synthase inhibitor. CONCLUSIONS: Enzymes related to L-arginine catabolism were involved in the early events of ischemic bladder. Arginase may have 2 independent roles, that is 1) activation of arginase/ornithine decarboxylase/polyamines pathways in the muscle injury and remodeling following ischemia, and 2) endogenous negative regulation of nitric oxide production by limiting the L-arginine substrate for nitric oxide synthase.

Three-dimensional combination of transrectal and transperineal biopsies for efficient detection of stage T1c prostate cancer.

BACKGROUND: Although an increasing number of men present with stage T1c prostate cancer, the optimal biopsy strategy for detecting stage T1c disease still remains to be defined. The aim of this study was to explore an efficient first-time biopsy scheme for detecting stage T1c and T2 prostate cancer. METHODS: A transrectal ultrasound-guided systematic three-dimensional 26-core (3D26) biopsy comprising 12 transrectal and 14 transperineal sampling sites was performed in 321 men with median prostate-specific antigen (PSA) level of 6.0 ng/ml in the first-time biopsy setting. By analyzing site-specific cancer detection rates, we determined the best combination of transperineal and transrectal sampling sites. RESULTS: Prostate cancer was detected in 109 of the 321 men (34%) with a major complication rate of 0.6%. 3D26 biopsy significantly improved cancer detectability by 60% relative to the conventional transrectal sextant (TR6) biopsy. Improvement was significant in 263 men with normal digital rectal examination (DRE) (85%, P = 0.0004) but not in 58 men with abnormal DRE (22%, P = 0.18). The mean Gleason score of the 41 cancers without a positive core within the TR6 sites was marginally lower than that of 68 cancers with a positive core within the TR6 sites (P = 0.04). Recursive partitioning revealed that a three-dimensional 14-core (transrectal 8-core plus transperineal 6-core) and a three-dimensional 8-core (transrectal 4-core plus transperineal 4-core) biopsies could detect more than 95% of stage T1c and T2 cancers with a minimum number of cores, respectively. CONCLUSION: We propose a three-dimensional 14-core and a three-dimensional 8-core biopsy as efficient first-time biopsy schemes to detect stage T1c and T2 prostate cancer, respectively.

[A case of asymptomatic adrenal hematoma which progressively enlarged during follow-up].

We report a case of asymptomatic adrenal hematoma that enlarged during a 3-year follow-up. A 66-year-old woman exhibited a 4 cm right adrenal mass, incidentally discovered by computed tomography of abdomen, which progressively enlarged to 6 cm in diameter during the 3 years. The patient underwent right adrenalectomy with a diagnosis of a suspected non-functional adrenal tumor. Histopathological examination indicated adrenal hematoma without tumor cells. The patient had received aspirin medication for 4 years, and it is possible that the enlargement of the mass might have been due to aspirin medication.

Portless endoscopic adrenalectomy via a single minimal incision using a retroperitoneal approach: experience with initial 30 cases.

AIM: To assess the feasibility of portless endoscopic adrenalectomy via a single minimum incision that narrowly permits extraction of the specimen. METHODS: For 30 cases of adrenal tumor, portless endoscopic surgery through a single flank incision (3-9 cm; mean, 5.6 cm) was performed without gas inflation or trocar port placement. All of the instruments used during surgery were reusable. The cases included primary aldosteronism (12), Cushing's syndrome (6), preclinical Cushing's syndrome (3), pheochromocytoma (1), non-functioning cortical adenoma (6), adrenocortical carcinoma (1) and adrenocortical hemorrhage (1). RESULTS: Resection of the tumor was successfully completed, without complications, in all of the cases. Operative time was between 83 and 240 min (mean, 147 min). Estimated blood loss was 5-470 mL (mean, 139 mL). None of the patients required blood transfusion. Postoperative course was uneventful. Wound pain was mild and walking and full oral feeding were resumed on the first and second postoperative day, respectively, in the majority of cases. CONCLUSIONS: Adrenal tumors are good candidates for portless endoscopic surgery, which is safe, cost-effective, minimally invasive and matches favorably with laparoscopic surgery.

Portless endoscopic radical nephrectomy via a single minimum incision in 80 patients.

AIM: To assess the feasibility of our portless endoscopic radical nephrectomy via a single minimum incision, which narrowly permitted extraction of the specimen in the initial 80 patients. METHODS: Radical nephrectomy was carried out extraperitoneally in patients with T1-3aN0M0 renal tumors using an endoscope through a single minimum incision without trocar ports and gas. All the instruments used were reusable. RESULTS: The average length of incision, operative time and estimated blood loss were 6.6 cm (range, 4-9 cm), 3. 1 h (range, 1.7-5.6 h) and 324 mL (range, 10-2288 mL), respectively. The complication rate was 2.5% (2/80); complications included injury of the pleura and hemorrhage from the vena cava, both of which were repaired by suture during operation. Transfusion was performed in three patients (3.8%). Average times to oral feeding and walking were both 1.4 days. Wound pain was minimal and analgesics were generally not required by the second postoperative day. In patients with larger incisions (7 cm or more), estimated blood loss increased (approximately 100 mL on average) and oral feeding resumed later (0.3 days on average), relative to patients with smaller incisions (6 cm or less). However, overall results were similar between the two patient groups. In patients with a large tumor (7 cm or greater), operative time did not increase and complications and transfusions were both avoided. CONCLUSION: Portless endoscopic radical nephrectomy via a single minimum incision is a safe, reproducible, cost-effective and minimally invasive treatment option for patients with T1-3aN0M0 renal tumors.

A pilot study evaluating a new questionnaire for prostatic symptom scoring, the SPSS, and its sensitivity as constructed to objective measures of outflow obstruction.

AIM: To evaluate the extent to which our newly developed questionnaire, the Saitama Prostate Symptom Score (SPSS), for prostatic symptom scoring reflects objective findings in benign prostatic hyperplasia (clinical BPH) and to compare it with the International Prostate Symptom Score (IPSS) with regard to diagnostic sensitivity in clinical BPH. METHODS: In this study, both the SPSS and the IPSS were self-administered by patients. Free uroflowmetry, a pressure-flow study and the measurement of prostatic volume were carried out. RESULTS: There was no significant correlation between the results of the IPSS questionnaire and the urethral obstruction grade estimated by Schaefer or Abrams-Griffiths nomograms. The total score of the SPSS was correlated with these nomograms (P = 0.0487 and P = 0.0413, respectively). There was no significant correlation between the results of the IPSS questionnaire and the total volume or transition zone volume of the prostate, whereas the total score of the SPSS correlated with the total volume of the gland and transition zone volume (P = 0.0044 and P= 0.0051, respectively). CONCLUSION: This study revealed the SPSS to correlate with objective findings satisfactorily. However, there are still several aspects of the SPSS which need to be improved upon, and the questionnaire should be studied in larger numbers of patients suffering from lower urinary tract symptoms.