Multiple Prostatic Abscesses Caused by Staphylococcus aureus Without Physical Findings in an Immunosuppressed Older Patient.

Staphylococcus aureus is endemic to human and animal skin and the gastrointestinal tract and is highly tissue-destructive. Staphylococcus aureus bacteremia has a high mortality rate of 20%-30%. A prostatic abscess is a rare complication of acute bacterial prostatitis. The focus of S. aureus infection is elsewhere in the body, and bacteremia causes the abscess, hence difficult to diagnose. Here, we report a case of prostatic abscesses, followed by a diagnosis of S. aureus bacteremia without specific physical findings. The patient was a 72-year-old male with independent activities of daily living who developed prostate and perifemoral abscesses with multiple vague symptoms due to diabetes-related methicillin-susceptible S. aureus bacteremia. It is important to comprehensively evaluate multiple vague symptoms considering the immunological conditions of patients and investigate any suspicion of bacteremia and abscess in deep parts of the body. General physicians should be system-specific specialists to deal with multiple symptoms among older immunocompromised patients.

Perspectives on Collaboration between Physicians and Nurse Practitioners in Japan: A Cross-Sectional Study.

BACKGROUND: Nurse practitioners (NPs) are known as effective healthcare providers worldwide. In Japan, nurse practitioner adoption is considered to be in a shaky period. Although nurse practitioners were introduced approximately 10 years ago at the initiative of educational institutions in Japan, the full extent of this trend is not known. Therefore, we have clarified the whole picture of nurse practitioners from two directions: the perception of nurse practitioners in Japan and the perception of physicians who work with nurse practitioners. This will inform discussions regarding the recruitment of nurse practitioners at the national level in Japan. METHODS: From 18 June to 24 July 2021, we administered a nationwide cross-sectional survey of NPs and physicians working in the same clinical settings as NPs in Japan. The domains of the survey included "scope and content of work", "perceptions of NPs' clinical practice", and "individual clinical practice characteristics". The survey was distributed and collected digitally. RESULTS: The total number of respondents to the survey was 281, including 169 NPs and 112 physicians; the percentage of NPs who responded was 50.5%. The number of valid responses was 164 NPs and 111 physicians, for a total of 275 respondents. Approximately 60% of NPs are concentrated in Tokyo, the capital of Japan, and the three prefectures adjacent to Tokyo. They also worked fewer hours per week, cared for fewer patients per day, and earned less money than physicians. More physicians than NPs indicated that "more NPs would improve the quality of care". A total of 90.1% of physicians and 82.3% of NPs agreed that "Nurse practitioners should practice to the full extent of their education and training," and 73.9% of physicians and 81.7% of NPs agreed that "Nurse practitioners' scope of practice should be uniformly defined at a national level". CONCLUSIONS: This study clarified the present working conditions of NPs from NPs' and physicians' perspectives in Japanese contexts. Japanese NPs may be able to work effectively in collaboration with physicians. Therefore, the implementation of NPs in Japanese medical conditions should be discussed further for better healthcare.

Coexistence of Pancytopenia and Myositis After Developing COVID-19.

COVID-19 causes not only acute but also subacute medical conditions during the clinical course. COVID-19 causes severe inflammatory conditions; therefore, patients may develop long-term complications. Among patients with acute COVID-19, some patients can experience persistent symptoms, such as fatigue, joint pain, and smell and taste abnormalities, known as the long COVID-19 syndrome. The symptoms can be severe and require continuous medical care. Patients with severe clinical courses of COVID-19 may have critical symptoms again after the cure of the acute infections, especially among older patients. We encountered a case of neutropenia and myositis one month after contracting COVID-19. An 89-year-old man presented to our hospital with acute-onset systemic muscle pain and difficulty in movement and speaking. The patient had neutropenia and myositis with an extremely high level of immunoglobulin G caused by COVID-19. A granulocyte colony-stimulating factor could be effective for treating neutropenia. Besides, prednisolone was effective for treating myositis. In community hospitals, after developing COVID-19, appropriate history taking and physical examination should be performed in older patients with ambiguous symptoms, as they might have critical medical conditions such as neutropenia and myositis. The appropriate diagnosis and treatments of older patients with the complications of COVID-19 should be performed.

Pseudogout as a Cause of Fever of Unknown Origin Following Staphylococcal Bacteremia in an Older Patient.

The causes of fevers in older adults are numerous and diverse, resulting in fevers of unknown origin that complicate the diagnosis process. Compared to young adults, older adults are characterized by comorbidities, aging-induced physiological changes, decreased homeostasis, reduced activities of daily living, and a diminished quality of life due to disease and aging. Thus, diverse perspectives are required to facilitate the accurate diagnosis of fever in older adults. In this study, we experienced a case of epidermal staphylococcal bacteremia of unknown cause with a persistent fever that eventually led to the diagnosis of cervical pseudogout. A 94-year-old bedridden woman visited our hospital with a chief complaint of persistent fever. She was diagnosed with cervical pseudogout after closely examining the prolonged fever following Staphylococcus epidermidis bacteremia. Noninfectious diseases are frequent causes of unexplained fever in older adults, and systemic inflammatory diseases, such as cervical pseudogout, should be considered during examination.

Exploring the Competencies of Japanese Expert Nurse Practitioners: A Thematic Analysis.

Nurse practitioners (NPs) provide medical care equivalent to that of physicians and facilitate access to healthcare. Although Japan's first NP graduated in 2010, how Japanese expert NPs work effectively in clinical contexts is yet to be investigated. We aimed to identify the competencies that make expert NPs in Japan effective. Twelve Japanese expert NPs were purposely selected. The average age of the participants was 44.8 years, average NP experience was 7.5 years, and eight participants were women. Semi-structured interviews were conducted online from March to May 2021. Interviews were recorded, transcribed verbatim, and analyzed using thematic analysis. Thematic analysis revealed five themes: working in physicians' contexts, interprofessional collaboration, involvement in nurses' work, contribution to healthcare, and personal qualities for effective working. Japanese expert NPs can function effectively in clinical settings by flexibly and humbly collaborating with other medical professionals who have autonomous positions. They can improve the quality of healthcare by proposing practical solutions to problems faced by patients and medical organizations. These explored competencies can be applied to other aging and more complex societal contexts, and in updating the required competencies of Japanese NPs.

Sex-Dependent Phenotypic Variability of an SCN5A Mutation: Brugada Syndrome and Sick Sinus Syndrome.

Background Brugada syndrome ( BS ) is known to be 9 times more prevalent in males than females. However, little is known about the development of sick sinus syndrome in female members with familial BS . Methods and Results Familial BS patients and family members, both from our institutions and collaborating sites that specialize in clinical care of BS , participated in this study. We collected information on their clinical and genetic background, along with the inheritance patterns of BS . Detailed information on each case with familial BS is described. A total of 7 families, including 25 BS patients (12 females and 13 males), were included. Seven were probands and 18 were family members. Ten out of the 12 female patients and none of the 13 male patients developed sick sinus syndrome. Sudden death or spontaneous ventricular fibrillation occurred in 7 out of 13 male patients and 2 out of 12 female patients. Conclusions Familial BS existed in which female patients developed sick sinus syndrome but male patients did not. Some of those female patients with sick sinus syndrome had unrecognized BS . Information should be collected not only regarding a family history of sudden death or BS , but also whether a pacemaker was implanted in female members.

Vasospastic angina resulting in sudden cardiac arrest, initially misdiagnosed as a psychiatric disorder.

A 51-year-old-woman with a history of ablation therapy due to Wolff-Parkinson-White syndrome had been suffering from ambiguous chest pain, prompting investigation by several cardiologists. After being dissatisfied with a psychiatric disorder diagnosis, she was admitted to our hospital for further investigation. She lost her consciousness due to a sudden cardiac arrest shortly after admission. A provocation test indicated vasospastic angina associated with a diffuse spastic pattern of her left anterior descending artery. .

Intravascular ultrasound-guided bail-out therapy in a case of acute myocardial infarction with iatrogenic coronary artery spiral dissection.

A 54-year-old man with suspected vasospastic angina returned to the hospital 2 weeks later with symptoms of acute myocardial infarction. Emergent coronary angiography (CAG) showed an occlusive lesion just beyond the bend of the proximal right coronary artery segment. The selected 7F AL1.0 guiding catheter may have injured the vessel surface and the guide wire might have entered the pseudo-lumen. Balloon dilatation of the pseudo-lumen resulted in a spiral dissection. We were able to provide bail out with therapy under guidance of combined CAG and intravascular ultrasound, which provided structural 3D images of coronary artery anatomy. .

Specific immunoadsorption therapy using a tryptophan column in patients with refractory heart failure due to dilated cardiomyopathy.

BACKGROUND: Certain cardiac-specific autoantibodies found in patients with dilated cardiomyopathy (DCM) play a role in mediating myocardial damage and fatal ventricular arrhythmias resulting in sudden cardiac death. Immunoadsorption therapy (IA) is one of the therapeutic tools to remove such autoantibodies. Clinical studies from Germany have shown that nonspecific IA using columns loaded by sheep antihuman IgG or protein A improved hemodynamic data and affected favorably cardiac function and survival in patients with heart failure (HF) due to DCM. The goal of this study is to determine if IA therapy using the high-profile tryptophan column, which has high affinity for IgG3 subclass, affects favorably cardiac function in patients with severe HF who are refractory to conventional therapy. METHODS AND RESULTS: IA therapy was conducted in 16 patients with DCM (age 53 ± 4, male 8, New York Heart Association functional class III/IV, mean ejection fraction 18 ± 2%). Study subjects had autoantibodies directed against either ß1-adrenergic or M2-muscarinic receptors. Plasma brain natriuretic peptide levels were significantly decreased after IA (P = 0.016). Plasma inflammatory cytokines including interleukin-6 and tumor necrosis factor-α did not change after each session of IA. Six-minute walk distance was significantly increased after IA (P = 0.01). Left ventricular ejection fraction increased by 3% 3 months after IA (P = 0.039). CONCLUSIONS: Our initial experience demonstrated safety and short-term efficacy of IA using a new IgG3-specific tryptophan column for patients with advanced HF due to DCM. Long-term follow-up is needed to confirm the effects on cardiac function and morbidity/mortality in such patients.

Temporal patterns of progression and regression of electrical and mechanical remodeling of the atrium.

OBJECTIVES: We evaluated serial changes of electrical and mechanical parameters of atrial remodeling in dogs subjected to rapid atrial pacing. BACKGROUND: Prolonged rapid atrial excitation causes electrical and mechanical remodeling, which contributes to persistence of atrial fibrillation and clot formation. However, the temporal relationship between these two types of atrial remodeling remains unknown. METHODS: In 8 dogs, rapid pacing at 400 ppm was continued for 14 days. The electrophysiologic and transesophageal echocardiographic studies were performed on the day before and after 2, 7, and 14 days of rapid pacing, then 1 and 7 days after the cessation of pacing. These were compared with sham-operated dogs (instrumented but not paced, n=6). RESULTS: With rapid pacing, there was an immediate shortening of the effective refractory period (ERP) and decreases in the transmitral atrial wave velocity (MAV) and the left atrial appendage emptying velocity (LAAV). In contrast, conduction velocity (CV) decreased and the left atrial appendage area (LAAA) increased progressively over 14 days. During the recovery, ERP, MAV, and LAAV returned to the baseline in 1 day, whereas CV and LAAA did in 7 days. ERP was highly positively correlated with LAAV (r=0.78, p<0.001) and MAV (r=0.73, p<0.001), while CV was negatively correlated only with LAAA (r=-0.58, p<0.001). CONCLUSIONS: Pacing-induced electrical and mechanical remodeling of the atrium exhibits divergent patterns of progression and regression such that changes of ERP and contractile function take place more rapidly than those of CV and atrial size.

A comparison between calcium channel blocking drugs with different potencies for T- and L-type channels in preventing atrial electrical remodeling.

Calcium overload plays a key role in the development of atrial electrical remodeling. The effect of an L-type Ca channel blocker in preventing this remodeling has been reported to be short lasting, partly due to down-regulation of this channel and persisting Ca entry through the T-type Ca channel. To prove if efonidipine, a dual L- and T-type Ca channel blocker exerts a greater effect than an L-type Ca channel blocker verapamil, 21 dogs underwent rapid atrial pacing at 400 bpm for 14 days, pretreatment with efonidipine in 7 (E), verapamil in 7 (V), and none in 7 (C). We measured the atrial effective refractory period (ERP) serially during 14 days of rapid pacing. In response to rapid pacing, ERP decreased progressively in C. In contrast, in E and V, ERP remained greater than ERP in C (P < 0.01) on days 2 through 7. However, on the 14th day, ERP in V decreased to the level seen in C, whereas ERP in E remained significantly longer than ERPs in C or V (P < 0.01). The blockade L-type Ca channel alone is not sufficient, but the addition of a T-type Ca channel blockade shows a more sustained effect to prevent atrial electrical remodeling.

Oral verapamil attenuates the progression of pacing-induced electrical and mechanical remodeling of the atrium.

BACKGROUND: Calcium overload plays a major role in the development of electrical and mechanical remodeling during atrial fibrillation, but the potential of verapamil, a Ca blocker, for preventing atrial electrical remodeling remains controversial. METHODS AND RESULTS: Pacing and recording electrodes were sutured to the right atrium in 16 dogs. After a 5-day recovery period, rapid atrial pacing at 400 ppm was initiated in 8 dogs (control group). In the remaining 8 dogs, oral administration of verapamil (8 mg/kg per day) was started 1 week before the initiation of rapid pacing (verapamil group). On the day before and at 2, 7, 14 days after rapid pacing, electrophysiological (EP) and transesophageal echocardiographic (TEE) studies were performed under autonomic blockade. In response to rapid pacing, EP and TEE parameters changed progressively in the control group (p<0.05 vs day 0), whereas in the verapamil group, no significant changes in the various parameters were observed for the first 7 days. However, verapamil failed to prevent progression of both types of remodeling after 14 days of pacing. CONCLUSION: Verapamil can attenuate the progression of electrical and mechanical remodeling of the atrium for at least 7 days.

A 19-year-old man with myocardial infarction and sitosterolemia.

This is a case report of a 19-year-old man who presented with acute myocardial infarction with obstruction of one coronary artery and rapid progression to three vessels in 8 months. He was proved to have sitosterolemia, a rare hereditary disease with plant sterol storing, resulting in juvenile coronary artery disease. Atherosclerotic complications can be preventable by administration of bile acid-binding resin, after the correct diagnosis is made. We introduce this disease with a review of the literature.

Preserved effects of potassium channel blockers in the pacing-induced remodeled canine atrium: a comparison between E4031 and azimilide.

This study was designed to evaluate the electrophysiologic effects of E4031 (a pure IKr blocker) and azimilide (AZ: a combined Ikr + IKs blocker) at various stages of atrial electrical remodeling. Twelve dogs underwent continuous rapid atrial pacing (400/min) for 14 days. The electrophysiologic study was performed on the day before as well as after 2, 7, and 14 days of rapid atrial pacing both before and after the administration of either E4031 (n = 6) or AZ (n = 6). In response to rapid atrial pacing, the atrial effective refractory period (ERP), conduction velocity, and wavelength decreased significantly at pacing cycle lengths (PCLs) of 200 and 400 ms (P < 0.05). E4031 prolonged ERP in a reverse use-dependent manner throughout the study period. AZ also prolonged ERP during the 14 days of rapid pacing. ERP prolongation at a PCL of 200 ms was significantly greater with AZ than with E4031 (P < 0.05). The effects of blocking IKr by E4031 and IKr + IKs by AZ were well preserved at various stages of atrial electrical remodeling. However, the effect of prolonging ERP at a shorter PCL was more prominent by AZ than by E4031. Thus, IKs blockade may add a favorable anti-fibrillatory effect to IKr blockade even in the remodeled atrium.

Daily oral verapamil before but not after rapid atrial excitation prevents electrical remodeling.

BACKGROUND: Intravenous verapamil has been reported to prevent electrical remodeling induced by rapid atrial excitation of several minutes to several hours. However, the clinical efficacy of verapamil when taken orally and daily remains controversial. PURPOSE: We attempted to demonstrate our hypothesis that if verapamil prevents calcium (Ca) overload, its efficacy would be greater when taken before, rather than after, the onset of rapid atrial excitation. METHODS: In 24 dogs, pacing and recording electrodes were sutured onto the right atrium. After a 5-day recovery period, rapid atrial pacing at 400 ppm was started, followed 2 days later by oral verapamil (8 mg/kg per day) in eight dogs (After group; A). In another eight dogs, oral verapamil administration was begun 1 week before the initiation of rapid pacing (Before group; B). In the remaining eight dogs, only rapid atrial pacing was started, without oral verapamil (Control group; C). We measured the effective refractory period (ERP) and conduction velocity (CV), and calculated wavelength (WL) at cycle lengths 200 and 300 ms on the day before (P0), and after 2 (P2), 7 (P7), 14(P14) days of rapid pacing. RESULTS: In response to rapid atrial pacing, ERP, CV, WL decreased and progressively and comparably in A and C (P<0.05 vs. P0). In contrast, in B, these parameters did not change significantly and remained greater than those in A and C (P<0.05). Moreover, the adaptation of ERP to rate was preserved only in B. The duration of atrial fibrillation (AF) was shorter in B than in A and C (P<0.05). The inducibility of AF tended to be lower, and the fibrillation cycle length was longer in B than in A and C. CONCLUSIONS: Oral verapamil started before but not after rapid atrial excitation prevents electrical remodeling. Verapamil may exert beneficial effects when it is taken during sinus rhythm, but not after more than 2 days of atrial tachyarrhythmia.

Discordant temporal changes in electrophysiological properties during electrical remodeling and its recovery in the canine atrium.

Prolonged rapid atrial excitation gives rise to atrial electrical remodeling, which perpetuates atrial fibrillation (AF). However, there has been controversy regarding the nature of temporal changes in conduction characteristics during the development and recovery of electrical remodeling. This study was designed to clarify the nature of the development and recovery of electrical remodeling in relation to AF inducibility in dogs subjected to rapid atrial pacing. Eleven dogs underwent rapid atrial pacing (400/min) for 28 days. The electrophysiological study was performed on the day just prior to the commencement of pacing, on days 2, 7, 14, and 28 of rapid pacing, as well as 1 and 7 days after the cessation of pacing. In response to rapid atrial pacing, atrial effective refractory period (ERP), conduction velocity and wavelength decreased significantly (p < 0.05). ERP had shortened significantly and rapidly within 2 days of pacing, while conduction velocity decreased more gradually. During the recovery, ERP returned to almost baseline levels within a day, whereas conduction velocity returned to baseline by day 7. Sustained AF became inducible in 37% of the dogs from 7 days of pacing until 1 day after the cessation, when wavelength fell below 8.7 cm. In conclusion, rapid atrial excitation causes a progressive but discordant temporal pattern of a decrease in ERP and conduction velocity. The resultant shortening of the wavelength determines the inducibility and maintenance of AF. The electrophysiological changes produced by one month of rapid atrial pacing can be fully reversed within a week, although in a discordant temporal pattern.