Daily practice and prognostic factors for pneumonia caused by methicillin-resistant Staphylococcus aureus in Japan: A multicenter prospective observational cohort study.

Pneumonia caused by methicillin-resistant Staphylococcus aureus (MRSA) is associated with poor clinical outcomes. We surveyed clinical outcomes of MRSA pneumonia in daily practice to identify risk factors for the clinical failure and mortality in patients with MRSA pneumonia. This multicenter prospective observational study was performed across 48 Japanese medical institutions. Adult patients with culture-positive MRSA pneumonia were recruited and treated with anti-MRSA antibiotics. The relationships between clinical and microbiological characteristics and clinical outcomes at test of cure (TOC) or 30-day all-cause mortality were analyzed. In total, 199 eligible patients, including nursing and healthcare-associated pneumonia (n = 95), hospital-acquired pneumonia (n = 76), and community-acquired pneumonia (n = 25), received initial treatment with anti-MRSA agents such as vancomycin (n = 135), linezolid (n = 36), or teicoplanin (n = 22). Overall clinical failure rate at TOC and the 30-day mortality rate were 51.1% (48/94 patients) and 33.7% (66/196 patients), respectively. Multivariable logistic regression analyses for vancomycin-treated populations revealed that abnormal white blood cell count (odds ratio [OR] 4.34, 95% confidence interval [CI] 1.31-14.39) was a risk factor for clinical failure and that no therapeutic drug monitoring (OR 3.10, 95% CI 1.35-7.12) and abnormally high C-reactive protein level (OR 3.54, 95% CI 1.26-9.92) were risk factors for mortality. In conclusion, this study provides evidence that majority of MRSA pneumonia patients are initially treated with vancomycin in Japan, and the absence of therapeutic drug monitoring for vancomycin is significantly associated with the mortality in patients with MRSA pneumonia.

Feasibility of using 'lung density' values estimated from EIT images for clinical diagnosis of lung abnormalities in mechanically ventilated ICU patients.

This paper reports on the results of a study which compares lung density values obtained from electrical impedance tomography (EIT), clinical diagnosis and CT values (HU) within a region of interest in the lung. The purpose was to assess the clinical use of lung density estimation using EIT data. In 11 patients supported by a mechanical ventilator, the consistency of regional lung density measurements as estimated by EIT was validated to assess the feasibility of its use in intensive care medicine. There were significant differences in regional lung densities recorded in the supine position between normal lungs and diseased lungs associated with pneumonia, atelectasis and pleural effusion (normal; 240 ± 71.7 kg m(-3), pneumonia; 306 ± 38.6 kg m(-3), atelectasis; 497 ± 130 kg m(-3), pleural effusion; 467 ± 113 kg m(-3): Steel-Dwass test, p < 0.05). In addition, in order to compare lung density with CT image pixels, the image resolution of CT images, which was originally 512 × 512 pixels, was changed to 16 × 16 pixels to match that of the EIT images. The results of CT and EIT images from five patients in an intensive care unit showed a correlation coefficient of 0.66 ± 0.13 between the CT values (HU) and the lung density values (kg m(-3)) obtained from EIT. These results indicate that it may be possible to obtain a quantitative value for regional lung density using EIT.

Impact of platelet transfusion on survival of patients with intracerebral hemorrhage after administration of anti-platelet agents at a tertiary emergency center.

This study examined the impact of platelet transfusion (PLT) on the survival of intracerebral hemorrhage (ICH) patients who had been administered anti-platelet agents (APA). This retrospective cohort analysis investigated 432 patients (259 men, 60%) who were newly diagnosed with ICH between January 2006 and June 2011 at the tertiary emergency center of Kitasato University Hospital. Median age on arrival was 67.0 years (range, 40-95 years). ICH was subcortical in 72 patients (16.7%), supratentorial in 233 (53.9%), and infratentorial in 133 (30.8%). PLT was performed in 16 patients (3.7%). Within 90 days after admission to the center, 178 patients (41.2%) had died due to ICH. Before the onset of ICH, 66 patients had been prescribed APA because of atherosclerotic diseases. Multivariate regression analysis indicated APA administration was an independent risk factor for death within 7 days (odds ratio, 5.12; P = 0.006) and within 90 days (hazard ratio, 1.87; P = 0.006) after arrival. Regarding the effect of a PLT in ICH patients with APA, no patient with PLT died. PLT had a survival benefit on patients with ICH, according to our analysis. Further prospective analysis is necessary to confirm the effects of PLT on survival in ICH with APA.

Negative-pressure wound therapy over surgically closed wounds in open fractures.

PURPOSE: To evaluate the outcome of open fracture surgery with negative-pressure wound therapy (NPWT) applied directly over surgical wounds. METHODS: Medical records of 10 men and 4 women aged 6 to 70 (mean, 43.7) years who underwent internal fixation, external fixation, or splint application for open fractures of the lower leg (n=7), foot and ankle (n=5), or knee (n=2), and NPWT were reviewed. The NPWT was applied directly over the surgical wound without a non-adherent contact layer. The foam was changed every 3 days. The standard negative pressure was 125 mm Hg. The NPWT was stopped when the wound discharge became <50 ml per day. The duration of NPWT and the level of negative pressure were recorded, as were wound condition, reasons for NPWT, and outcome. RESULTS: The mean duration of NPWT was 9.1 (range, 3-24) days. Four patients developed maceration of the skin under the foam, whereas 2 patients developed skin blisters under the drape. No necrosis of flap skin or infection occurred, and all the fractures eventually united. CONCLUSIONS: Maceration of the skin was seen in some cases but did not affect the overall outcome. NPWT directly over the skin surface had no deleterious effect on wound and fracture healing.

Therapeutic strategy using extracorporeal life support, including appropriate indication, management, limitation and timing of switch to ventricular assist device in patients with acute myocardial infarction.

The appropriate indication for, management of and limitations to extracorporeal life support (ECLS) and the timing of a switch to a ventricular assist device (VAD) remain controversial issues in patients with acute myocardial infarction (AMI) complicated with cardiogenic shock or cardiopulmonary arrest. To evaluate and discuss these issues, we studied patients with AMI treated with ECLS and compared deceased and discharged patients. Thirty-eight patients with AMI who needed ECLS [35 men (92.1 %), aged 59.9 ± 13.5 years] were enrolled in this study. Of these 38 patients, 34 subsequently underwent percutaneous coronary intervention (PCI), and four subsequently received coronary artery bypass grafting (CABG). Fourteen patients (36.8 %) were discharged from the hospital. The outcome was not favorable for those patients with deteriorating low output syndrome (LOS) and the development of leg ischemia, hemolysis and multiple organ failure during ECLS. Levels of creatine kinase, creatine kinase-MB (CK-MB), lactate dehydrogenase, serum creatinine (Cr) and amylase after the patient had been put on ECLS and fluctuation of the cardiac index, blood pressure, arterial blood gas analysis and CK-MB and Cr levels during ECLS were indicators to switch from the ECLS to VAD. In the case of patients with no complication associated with ECLS, 4.6-5.6 days after initiation of ECLS was assumed to be the threshold to decide whether to switch from ECLS to VAD. Patients with AMI who suddenly developed refractory pulseless ventricular tachycardia or ventricular fibrillation without deteriorating LOS and who underwent successful PCI or CABG, and who prevented the complications associated with ECLS, showed a high probability of recovering with ECLS.

Yokukansan improves distress of medical staff, and cognitive function and motivation in patients with destructive and aggressive behaviors after traumatic brain injury.

AIM: Yokukansan (a Japanese Kampo medicine) has been reported to be safe and useful in treating behavioral and psychological symptoms in dementia patients. This study aimed to investigate the effects of yokukansan on destructive and aggressive behaviors in patients after traumatic brain injury. METHODS: From April 2008 to July 2010, 189 patients who suffered traumatic brain injury were admitted to our tertiary emergency center. Of these, patients with destructive and aggressive behaviors were treated with neuroleptics. Seven patients (five men and two women) who could not be controlled by neuroleptics were given yokukansan (2.5 g powder) three times a day before meals. Main underlying conditions included brain contusion in three patients, acute subdural hematoma in two, and acute epidural hematoma in two. The following assessments were carried out at baseline and 1 and 2 weeks after initiation of treatment: the Glasgow Coma Scale for the assessment of disturbed consciousness after traumatic brain injury; Neuropsychiatric Inventory for the distress of medical staff; Mini-Mental State Examination for cognitive function; Barthel Index for activities of daily living; Vitality Index for motivation; presence of adverse effects and drug interactions. RESULTS: After treatment with yokukansan, patients showed significant improvements in Glasgow Coma Scale (P = 0.001), Neuropsychiatric Inventory (P = 0.016), Mini-Mental State Examination (P = 0.029), Barthel Index (P = 0.043), and Vitality Index (P = 0.013). No adverse effects or drug interactions between yokukansan and Western medicines were observed. CONCLUSION: Yokukansan improved the Glasgow Coma Scale, Neuropsychiatric Inventory, Mini-Mental State Examination, Barthel Index, and Vitality Index without any adverse effects or drug interactions with Western medicines in patients with destructive and aggressive behaviors after traumatic brain injury.

Usefulness of a simple prognostication score in prediction of the prognoses of patients with out-of-hospital cardiac arrests.

Sudden cardiac death is a serious problem in public health but the overall survival rate of out-of-hospital cardiac arrests (OHCAs) remains low. In this study, we identified clinical parameters to predict the prognosis of OHCA patients and proposed a simple prognostication score for prediction of their prognoses. The study population consisted of 750 consecutive patients with OHCAs of internal cause who were transported to our institute from July 2008 to June 2010. They were divided into survivors and nonsurvivors, and clinical parameters were compared between them to detect significant parameters for prediction of their prognoses. The population of those who survived at 1 month numbered 34. Multivariate analysis exhibited 10 independent predictive factors of survival, which included witnessed cardiac arrest and bystander-initiated CPR. When the prognostication score was calculated from these independent predictive factors, a score of ≥ 6 points indicated survival with a sensitivity of 88.6% and a specificity of 97.6%. When the patients were divided into younger and older populations with a threshold of 70 years, these values were 94.1% and 96.1% in younger but 70.0% and 98.4% in older patients, respectively. In retrospective observation, a simple prognostication score was useful to predict patient prognoses in OHCAs, but its usefulness was limited in an older population.

[Acute respiratory distress syndrome and pneumonia].

Bacterial and viral pneumonia are the most frequent causes of ARDS. The other infectious risk of developing of ARDS is infections at nonpulmonary sites, and fungal as well as parasites pneumonia. Virtually all patients with ARDS require mechanical ventilation, a major risk factor for the development of VAP.

Pulse-spray treatment of total occlusive jugular venous suppurative thrombophlebitis.

A 63-year-old man was diagnosed with jugular venous suppurative thrombophlebitis after undergoing strangulation ileus surgery. His condition was not stabilized by therapy with antibiotics, heparin or other supportive treatments. Pulse-spray treatment (PST) was administered, following which, the patient was afebrile without symptoms and the laboratory data improved. There were no complications such as sustained sepsis, septic embolisms or pulmonary embolisms. This is a unique case report of the use of a pulse-spray catheter in the treatment of total occlusive jugular venous suppurative thrombophlebitis following the failure of medical therapy.

[Clostridium tetani isolated from patients with systemic tetanus].

Clostridium tetani is widely distributed in ground or mud, especially in field and pond-shore surface layers. C. tetani is rarely isolated from specimens of patients with tetanus, and is generally diagnosed based on clinical symptoms such as trismus or general tonic spasms. This means that positive C. tetani infection is rarely diagnosed bacterially. Using gram straing, we identified C. tetani in specimens from patients suspected of C. tetani infection brought to the Kitasato University Hospital emergency center. Rapid gram staining information in the bacteriology laboratory is expected to improve recovery from C. tetani infection. It is therefore necessary to ensure clinical specimen quality control, and to keep standard strains of rare bacteria for isolation and identification.

Initial experience of mobile cloud ECG system contributing to the shortening of door to balloon time in an acute myocardial infarction patient.

It is important for myocardial infarction patients to undergo immediate reperfusion of the affected coronary artery. In order to improve the prognosis, efforts to shorten the door to balloon time to within 90 minutes have been made. However, conventional methods such as faxing electrocardiograms (ECG) have not become widespread due to their high cost and lack of sharpness of the ECG. The "Doctor Car" (rapid response car system) of Kitasato University Hospital is now equipped with a Mobile Cloud ECG system. With this system, 12-lead ECG data obtained in the field are transmitted to the cloud server via a standard mobile telephone network. Since it uses an existing phone network, the cost of this system is low and it is fairly reliable. Cardiologists at the hospital read the ECG waveforms on the cloud server and decide whether emergency cardiac catheterization is necessary. In our fi rst case using this Mobile Cloud ECG system, the door to balloon time could be shortened.

Clinical efficacy and safety of arbekacin sulfate in patients with MRSA sepsis or pneumonia: a multi-institutional study.

Arbekacin (ABK) is an aminoglycoside and widely used in Japan for treatment of patients infected with methicillin-resistant Staphylococcus aureus (MRSA). Although, ABK has concentration-dependent antibacterial activity, the peak serum concentration (C (peak)) of ABK has not yet been fully investigated as an indicator of the efficacy of ABK. The present study was conducted in patients admitted to hospitals affiliated with the ABK Dose Finding Study Group, between October 2008 and June 2011, who had pneumonia or sepsis, the cause of which was identified or suspected to be MRSA. The initial target C (peak) was set at 15-20 µg/mL and therapeutic drug monitoring was conducted. Then the relationship between serum concentration and efficacy/safety of ABK was prospectively examined to obtain sufficient clinical efficacy. In total, 89 patients from 11 clinical sites in Japan were enrolled and 29 of these patients were subjected to efficacy analysis. The mean initial dose and C (peak) were 306.9 mg/day and 16.2 µg/mL, respectively. The efficacy rate was 95 % (19/20 patients) at 5-6 mg/kg or higher, 87.5 % (7/8) for sepsis and 90.5 % (19/21) for pneumonia, and the overall efficacy rate was 89.7 % (26/29). There was no increase in the incidence of adverse events. In conclusion, we recommend the initial dose of ABK at 5-6 mg/kg or higher and the dosage regimen should be adjusted to achieve C (peak) at 10-15 µg/mL or higher in the treatment of patients with pneumonia or sepsis caused by MRSA. This strategy would surely achieve low incidence of adverse events while obtaining high clinical efficacy.

Prediction of requirement for mechanical ventilation in community-acquired pneumonia with acute respiratory failure: a multicenter prospective study.

BACKGROUND: Several severity scoring systems for predicting mortality are established in community-acquired pneumonia (CAP). OBJECTIVES: The predictability of the aggravation such as requirement for mechanical ventilation in addition to mortality was examined in CAP patients with acute respiratory failure by using the age, dehydration, respiratory failure, orientation disturbance and blood pressure (A-DROP) scoring system which was proposed by the Japanese Respiratory Society. METHODS: This study was a prospective, multicenter, observational cohort study. The severity of pneumonia was examined using A-DROP and Pneumonia Severity Index (PSI) which originated from the Infectious Disease Society of America. Requirement for mechanical ventilation and mortality were evaluated for 28 days. RESULTS: 482 CAP patients with acute respiratory failure were enrolled in the study. The 28-day mortality and mechanical ventilation rates were 12.3 and 14.4%, respectively. There were no significant differences in the areas under the receiver-operator characteristic curves for prediction of mortality between A-DROP and PSI (χ² test; p = 0.3613). In the subgroup analyses by severity, the A-DROP scoring system showed a severity-dependent increase of mortality (moderate 5.6%, severe 16.1%, extremely severe 27.1%, Cochran-Armitage trend test; p < 0.0001). Similar results were obtained for mechanical ventilation rate (moderate 9.8%, severe 16.7%, extremely severe 25.4%, Cochran-Armitage trend test; p = 0.0006). The compliance with scoring the A-DROP was higher than that with scoring the PSI (96.9 vs. 71.6%). CONCLUSIONS: The results of this study suggest that the A-DROP scoring system could be a simple CAP risk scoring system which could predict not only mortality, but also the requirement for mechanical ventilation.

A case of HELLP syndrome with multiple complications.

Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is a rare complication of pregnancy. The mortality rate associated with HELLP syndrome increases when life-threatening complications occur. A 37-year-old woman at 37 weeks of gestation developed severe cerebral hemorrhage at the beginning of labor induction and was transferred to our hospital, where HELLP syndrome was diagnosed. She developed disseminated intravascular coagulation (DIC), hepatic hematoma, and cerebral infarction after surgery. On day 68, she was transferred to her local hospital. Careful observation and rapid management can save patients with severe complications of HELLP syndrome.

Elevated S100B level in cerebrospinal fluid could predict poor outcome of carbon monoxide poisoning.

OBJECTIVE: S100B is a calcium-binding protein produced by astroglia in the brain and has been used as a marker of neuronal damage after brain trauma. We investigated the utility of S100B in cerebrospinal fluid (CSF) measured during the early phase of carbon monoxide (CO) poisoning in predicting the subsequent clinical course. METHODS: The study included 31 patients who were admitted to the hospital with loss of consciousness following CO poisoning. S100B levels were measured by enzyme-linked immunosorbent assay in CSF, and serum samples collected simultaneously within 24 hours and on the fourth day after CO exposure. All patients were followed for at least 3 months and divided into 3 groups based on the clinical course: persistent vegetative state (PVS), delayed encephalopathy (DE), and complete recovery with no complications (NC). RESULTS: During the 3-month period, 3 patients developed PVS, 5 developed DE, and 23 were classified as NC. The mean S100B levels in the CSF within 24 hours after CO exposure were higher in the PVS group (9.25 ng/mL) than in the DE (2.03 ng/mL) and NC groups (1.86 ng/mL). However, the mean serum S100B levels were not elevated in the 3 groups (0.21, 0.59, and 0.16 ng/mL, respectively). CONCLUSION: Early elevation of S100B in CSF after CO poisoning could be a suitable predictor of subsequent development of PVS.

Usefulness of linezolid in the treatment of hospital-acquired pneumonia caused by MRSA: a prospective observational study.

Clinical results for linezolid (LZD) treatment of hospital-acquired pneumonia (HAP) caused by methicillin-resistant Staphylococcus aureus (MRSA), particularly microbiologically evaluable or severe cases, are limited in Japan. A prospective observational study was conducted in order to assess the usefulness of LZD in Japanese patients with MRSA pneumonia. The study tracked fifteen participants treated with LZD for pneumonia who met the criteria of the HAP guidelines and were confirmed to have pneumonia caused by MRSA. Of these, six were severe and 13 had received antibiotic treatment before treatment with LZD. Of the 13 participants assessed for their clinical responses, seven were rated as cures, three were rated as failures, and three were indeterminate. The overall cure rate (cure/cure + failure) was 70.0% (7/10), and the cure rate by severity was 33.3% (1/3) for severe cases and 85.5% (6/7) for moderate cases. The one severe case with a clinical response rating of cure had failed to respond to vancomycin. Among the seven participants with a clinical response rating of cure, the microbiological response was eradication in three, presumed eradication in three, and indeterminate in one. Three serious adverse events occurred in two of the 15 participants, but none were considered to be causally related to LZD. The results suggest that LZD has high potential for severe and multidrug-resistant cases. A higher cure rate was achieved in moderate cases. In cases of pneumonia that are most likely MRSA infections with poor prognosis, it was suggested to be important for patient outcome to implement the most effective therapy before the patient's condition becomes serious.

Notable pink excreta and severe myocardial suppression in superwarfarin (difethialone) intoxication.

Patients rarely consult physicians before developing coagulopathy or bleeding in most reported cases of superwarfarin intoxication. A 57-year-old woman ingested red-dyed pellets of anticoagulant rodenticide containing difethialone and warfarin as well as tablets of nitrazepam. Although she presented to the hospital in a comatose state, notable pink-colored excreta hinted at the consumption of anticoagulant rodenticide, which led to the early diagnosis of superwarfarin intoxication. Supplementation of large doses of intravenous and oral vitamin K successfully prevented coagulopathy and bleeding. On the other hand, temporary and reversible myocardial suppression was extremely severe, and required the introduction of percutaneous cardiopulmonary support.

Linear fractures invisible on routine axial computed tomography: a pitfall at radiological screening for minor head injury.

Computed tomography (CT) is now widely used as the only screening method for fractures in patients with head injury. However, clear depiction of a fracture requires a discontinuity in the skull, so linear fractures parallel to the CT slice may not be visualized. We retrospectively evaluated 302 patients with minor head injuries aged from 0 to 91 years, who had undergone routine skull radiography (anteroposterior and lateral views) and head CT to study these types of fracture and discuss the risk of nondetection. Three patients had linear fractures (0.99%) that were invisible on bone window axial CT but detected on skull radiography, which all ran parallel to the scan slice. Two patients developed acute epidural hematoma or traumatic subarachnoid hemorrhage. Evaluation of head injury by only axial CT may miss such fractures and result in sequelae, so diagnosticians should be alert to the possible presence of this type of fracture.