Naha City Hospital

A 55-year-old woman presented with vomiting and abdominal pain. Physical examination revealed abdominal tenderness, but no rebound tenderness. A computed tomography (CT) scan revealed a distended small intestine called the flower bouquet sign, as well as the fat notch sign. These findings supported the suspicion of adhesive small bowel obstruction (SBO). Emergency surgery confirmed the presence of an adhesive band formed and it was resected. The patient recovered uneventfully. Most cases of SBO are caused by adhesions, followed by internal hernias and volvulus. CT scanning is essential for diagnosing adhesive SBO, which exhibits characteristic signs such as the beak sign, fat notch sign, small bowel feces sign, and flower bouquet sign. The flower bouquet sign refers to the distended small bowel segments arranged radially within a closed loop, resembling flowers and stretched mesenteric vessels that converge toward the transition zone, resembling stems. The fat notch sign indicates extraluminal compression of the bowel by an adhesive band at the transition zone. This case underscores the importance of recognizing adhesive SBO early on through characteristic imaging signs to mitigate the risk of life-threatening complications, such as ischemia or perforation.

BackgroundAdvancing antimicrobial stewardship programs (ASP) has led to various metrics for assessing antimicrobial consumption. Since introducing the antimicrobial spectrum index (ASI) in 2017, similar metrics, such as days of antibiotic spectrum coverage (DASC), have emerged to better evaluate antimicrobial use, particularly considering de-escalation process. This study assessed antimicrobial consumption with a de-escalation process using DASC in 12 hospitals across three regions in Japan.Table 1.Characteristics of participating hospitalsFigure 1.Trend of monthly DASC/DOT and DOT per 1,000 patient-days stratified by hospital types.MethodsIntravenous antimicrobial consumption data from 12 Japanese hospitals (April 2016–March 2024) were collected. The participating hospitals were located in three regions: West (Okinawa, n=6), East (Tokyo, n=5), and Midwest (Aichi, n=1). Monthly antimicrobial consumption was expressed as days of therapy (DOT) and then converted to DASC per 1,000 patient-days (PD). Hospital-wide de-escalation was evaluated using DASC/DOT. The correlation between DASC/DOT (a new metric) and DOT per 1,000 PD (a conventional metric) was assessed using Spearman’s rank-order correlation test. Hospital characteristics, including ASP availability, and infectious disease consultation, were also collected.Figure 2.Trends of DOT per 1,000 PD, DASC per 1,000 PD and DASC/DOT stratified by hospital regionsResultsA total of 96 months of data were analyzed. Monthly median DOT, DASC, and DASC/DOT were 303.4, 2107.0, and 7.2, respectively. There was little correlation between DASC/DOT and DOT per 1,000 PD (rho=0.11; P< 0.73). University hospitals (median 7.7) and a cancer center (median 8.0) had higher DASC/DOT than the remaining 9 community hospitals (median 6.9), likely owing to the availability of transplant services and a larger number of ICU beds (Figure 1 and Table 1). A substantial decrease in DASC/DOT at one university hospital since August 2022 was observed, likely due to implementing a hospital-wide restriction of carbapenem use. Median DASC/DOTs in East and West were 6.9 and 7.2, respectively, suggesting that the de-escalation process has progressed more at hospitals in Tokyo than at hospitals in Okinawa (Figure 2).ConclusionDASC/DOT, showing little correlation with traditional DOT per 1,000 PD, is a useful metric to assess antimicrobial use and de-escalation process. A regional-level and hospital type-level comparisons can help identify facilities needing further ASP promotion.DisclosuresAll Authors: No reported disclosures

Background:EGFR L858R mutation is associated with poorer efficacy of EGFR-tyrosine kinase inhibitors (TKIs) than EGFR Ex19del in patients with non-small cell lung cancer (NSCLC). However, ramucirumab (RAM) + erlotinib (ERL) therapy exhibited comparable efficacy between patients with L858R mutation and Ex19del mutation (median progression-free survival (PFS): 19.6 vs 19.4 months) in the RELAY study, with favorable PFS for both gene mutations at 19.4 months in the Japanese subset. Meanwhile, the FLAURA study revealed shorter PFS with osimertinib (OSI) for L858R mutation than Ex19del mutation, with poorer PFS in the Japanese subset than in the overall population. The treatment discontinuation rates of RAM + ERL and OSI in Japanese patients were 18% and 29%, respectively. Consequently, RAM + ERL may exhibit superior efficacy and safety in Japanese patients with the L858R mutation.Objectives:To evaluate the therapeutic efficacy and safety of RAM + ERL as a first-line treatment for advanced or recurrent NSCLC harboring the L858R mutation in Japanese patients.Design:A multicenter, noninterventional, retrospective cohort study.Methods and analysis:This study will involve patients with advanced or recurrent NSCLC (ECOG PS score 0–2) with L858R mutation who received RAM + ERL between November 1, 2020 and August 31, 2023, with the planned sample size of 200 patients. The primary endpoint is time to treatment failure, and the secondary endpoints are overall survival, PFS, PFS2, time to discontinuation of any EGFR-TKI, time to failure of strategy, objective response rate, disease control rate, and safety. Exploratory endpoints are effects of ERL and RAM on PD-L1 expression and neutrophil-to-lymphocyte ratio.Discussion:To the best of our knowledge, this is the first retrospective study focusing on L858R mutations associated with the RELAY regimen, providing the corresponding real-world data.Trial registration:UMIN Clinical Trials Registry identifier: UMIN000052047.

BackgroundSepsis is a leading cause of death in intensive care units (ICU). Sepsis survivors are often left with significant morbidity, termed post-intensive care syndrome (PICS), impacting post-sepsis life. The aim was to present detailed data on the prognostic and functional long-term outcomes of ICU patients with sepsis in Japan, which is currently lacking and therefore prevents development of targeted solutions.MethodsA multicenter prospective study, involving 21 ICUs in 20 tertiary hospitals in Japan, included all consecutive adult ICU patients between November 2020 and April 2022, and diagnosed with sepsis at ICU admission (Sepsis 3). Follow-ups were performed at 3, 6, and 12 months after hospital discharge by telephone and mail. Primary outcome was death or incidence of PICS, defined by any of physical dysfunction (Barthel Index ≤ 90), cognitive dysfunction (Short Memory Questionnaire < 40), or mental disorder (any subscales for anxiety or depression of Hospital Anxiety and Depression Scale ≥ 8, or Impact of Event Scale-Revised ≥ 25). Secondary outcomes included Quality of Life (QOL), employment, and use of hospital, emergency, rehabilitation, and psychiatric services. A multivariable analysis investigated independent factors associated with each dysfunction at each follow-up.ResultsA total of 339 patients were included (median age 74 [67–82] years, 60% male, 77% septic shock, and a median SOFA of 9 [6–12]). Mortality was 23% at hospital discharge, increasing to 37% at 12 months. The rate of death or those who met PICS Criteria at hospital discharge was 89%, with a death or PICS incidence of 73%, 64%, and 65% at 3, 6, and 12 months, respectively. Limited improvements in QOL and return to work (44%), high rates of hospital readmissions (40%), frequent emergency service usage (31%), and low utilization of rehabilitation and psychiatric services (15% and 7%) were identified over the first year. The incidence of any PICS-related dysfunction was consistently an independent factor for the incidence of the same dysfunction at the following follow-ups.ConclusionsThis multicenter study identified the distinct realities of post-sepsis life in Japanese ICU patients, highlighting the unique challenges in improving their functions and returning to daily life.Trial RegistrationUniversity Hospital Medical Information Network UMIN000041433

We estimated the seroprevalence of anti-severe acute respiratory syndrome coronavirus 2 (anti-SARS-CoV-2) immunoglobulin G (IgG) in different island groups in Okinawa. A cross-sectional serosurvey was conducted over three periods between July 2020 and February 2021. A total of 2,683 serum samples were collected from six referral medical centers, each covering a separate region in Okinawa. In the main island, the seroprevalence was 0.0% (0/392; 95% confidence interval (CI), 0.0- 0.9%), 0.6% (8/1,448, 0.2-1.1%), and 1.4% (8/582, 0.6-2.7%) during the 1st, 2nd, and 3rd serosurvey, respectively. In remote islands, the seroprevalence was 0.0% (0/144; 95% CI, 0.0-2.5%) and 1.6% (2/123, 0.2-5.8%) during the 2nd and 3rd survey, respectively. The case detection ratio was 2.7 (95% CI, 1.3-5.3) in the main island and 2.8 (0.7-11.1) in remote islands during the 3rd survey. The case detection ratio was the highest in individuals aged 20-29 years (8.3; 95% CI, 3.3-21.4) in the main island and in those aged 50-59 years (14.1; 2.1-92.7) in remote islands, suggesting underreporting of clinical cases by the surveillance system in these subgroups. A serosurvey conducted during an emerging infectious disease epidemic can be useful for validating the reliability of the surveillance system by providing case detection ratio.

Costal cartilage fractures are associated with poor prognosis in patients with blunt chest trauma. A Computer-Aided Detection (CAD) system for detecting rib fractures has been used in practice, but it is unclear whether this system recognizes costal cartilage fractures. This study investigated whether the CAD system for rib fracture can detect costal cartilage fractures. A total of 89 patients with costal cartilage fractures from participating hospitals over an 18-year period were included in the study. The presence of a costal cartilage fracture was determined by three radiologists. We reviewed fracture location, cartilage calcification, dislocation, and callus formation. The percentage of agreement between the radiologists and the CAD system (Rib fracture CAD, Fujifilm Medical Co., Ltd) was assessed. We detected 246 costal cartilage fractures in 89 patients. The costal cartilage of rib 7 was injured most frequently. Costal cartilage fractures were categorized as either mid-chondral, costochondral, or chondro-sternal. The CAD system detected 33 lesions; 16 were consistent with the costal cartilage fractures determined by the radiologists (costochondral junction 13, mid-chondral 2, chondro-sternal 1). The CAD system for rib fracture can detect costal cartilage fractures at the costochondral junction but is not sufficiently sensitive to detect costal cartilage fractures without calcification. The CAD system for rib fracture needs further development before it can be used to detect rib cartilage fractures.

【目的】ICUに入室した患者の家族における退院後の精神症状発生に関連する要因を探索する。【方法】本研究は本解析に対して事後に実施された症例対照研究である。対象は,ICU に48時間以上滞在し退院した患者と,その患者がICU滞在中に1回以上面会した家族である。 患者データを,家族に精神症状あり〔Hospital Anxiety and Depression Scale(HADS)不安≧8,HADS抑うつ≧8,impact of event scale-revised(IES-R)≧25のうち少なくとも1つを認めた場合〕群となし群に分け,家族の精神症状発生に関連する要因を検討した。【結果】生存退院した患者178人中,退院3ヶ月後調査を完了した患者の家族61人を解析した。家族の精神症状ありは20人(33%)であった。単変量解析において,家族の精神症状ありと患者の退院時Barthel Index(P=0.013)およびHADSによる抑うつ(P=0.010)とが有意に関連していた。しかし,多変量解析では,有意な関連因子が存在しなかった。【結論】患者の退院時の日常生活動作の自立度低下と精神症状が,退院3ヶ月後の家族の精神症状発生に関連している可能性がある。

We have encountered rare cases of two types of gastrointestinal amyloidosis, amyloid light chain (AL) type and amyloid A protein (AA) type. Case 1: An 83-year-old man developed hematochezia after percutaneous coronary intervention. CT scans showed wall thickening of the colon. Colonoscopy revealed submucosal tumor-like protrusions with ulceration in the colon. Biopsies confirmed the diagnosis of colonic amyloidosis. Multiple myeloma-associated AL amyloidosis was suspected based on positive serum M-protein. Case 2: A 79-year-old woman with rheumatoid arthritis (RA) underwent esophagogastroduodenoscopy, which revealed multiple gastric erosions. Biopsies showed amyloidosis. AA amyloidosis with underlying RA was suspected.