BACKGROUND: The effectiveness of surveillance to identify extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) carriers is controversial during a non-outbreak situation. We performed additional stool cultures for ESBL-E among intensive care unit (ICU) patients already under active surveillance by means of sputum and urine cultures. We aimed to assess the efficacy of stool cultures for screening for ESBL-E in a non-outbreak situation. METHODS: We conducted a retrospective cohort study in an ICU. Sputum and urine samples were cultured for ESBL-E surveillance purposes from January to September 2013 (phase 1). Stool cultures were routinely performed in addition from January to September 2014 (phase 2). Antimicrobial use density values and clinical outcomes were investigated and compared between phase 1 and 2. RESULTS: We identified 512 and 478 patients in phase 1 and phase 2, respectively. ESBL-E were found in the feces of 65 (13.6%) patients in phase 2. The antimicrobial use density values (expressed as defined daily doses per 1,000 bed-days) were not significantly different between the two phases for fluoroquinolones (7 vs. 10, p = 0.376), third-generation cephalosporins (24.2 vs. 29.5, p = 0.724), tazobactam/piperacillin (44.6 vs. 57.3, p = 0.489), and carbapenems (73 vs. 55.5, p = 0.222). Moreover, there were no significant differences in ICU mortality and length of stay (11.5% vs. 9.8%, p = 0.412, and 9 vs. 10 days, p = 0.28, respectively). CONCLUSIONS: Stool culture seemed ineffective in improving the antimicrobial use density of broad-spectrum antimicrobials, clinical outcomes, and ICU length of stay, and is not recommended for surveillance of ESBL-E in a non-outbreak situation.
Asian Continental Ancestry Group* ; beta-Lactamases ; Carbapenems ; Cephalosporins ; Cohort Studies ; Critical Care* ; Disease Outbreaks ; Enterobacteriaceae* ; Epidemiology ; Feces ; Fluoroquinolones ; Humans ; Intensive Care Units* ; Length of Stay ; Mass Screening ; Mortality ; Retrospective Studies* ; Sputum

Although sequential bypass with in situ arterial conduits (the left and right internal thoracic arteries; LITA and RITA, the right gastroepiploic artery; GEA) in coronary artery bypass grafting (CABG) is technically demanding, it is one of the most important procedures using a limited number of in situ arterial conduits to revascularize a wide area. In this report, we retrospectively investigated the clinical outcome of CABG with 4 or more distal anastomoses using only in situ arterial conduits. From December 1990 to May 1999, 62 patients underwent CABG with in situ arterial conduits, with at least one sequential bypass. There were 59 men and 3 women patients with mean age of 59.6 years (41 to 82 years). Mean postoperative follow-up period was 32 months (1 to 101 months). The total number of distal anastomoses was 4 (1 sequential bypass) in 54 patients, 4 (2 sequential bypasses) in 6 patients, 5 (1 sequential bypass) in 1 patient and 6 (3 sequential bypasses) in 1 patient. There were 5 emergency operations (8%), 37 patients (60%) had a history of myocardial infarction, 30 patients (48%) had diabetes mellitus and 6 patients (10%) had chronic renal failure and were on hemodialysis. Left ventricular ejection fraction was 40% or less in 15 patients (24%). There were no early deaths. Angiographic patency was satisfactory for each graft (sequential: individual, LITA 96.7%: 100%, RITA 100%: 100%, GEA 89.5%: 97.4%). Patency of a distal anastomoses of GEA was rather poorer than that of proximal (p=0.03). Three patients died during the follow-up period (all of them due to malignancy). The 5-year actuarial survival and cardiac event-free rate was 94.6% and 87.2%, respectively. In conclusion, although an indication of GEA sequential grafting needs further study, in situ arterial grafting with at least one sequential arterial conduit was associated with excellent results and achieved more complete revascularization with exclusive use of in situ arterial conduits in patients with diffuse coronary artery disease.

Approximately 80 % of medical students start medical training in a specific department at their medical school hospital after graduation and do not experience medical practices in other departments. Therefore, a questionnaire survey of conditions in and opinions about the present postgraduate clinical training was conducted among trainees at Osaka University Hospital. Questionnaires were returned by 136 of the 156 trainees (87.2 %). Their average income was ¥255, 000 per month. Approximately 85 % of trainees had less than 1 day's vacation each month. Forty percent of trainees were not satisfied with the present postgraduate clinical training course, because 75 % felt that their training life was too busy and did not allow them to observe a variety of diseases. These results suggest that the postgraduate medical training program in university hospitals should be changed to include various disciplines in several departments in cooperation with other hospitals and clinics for outpatients. To raise the quality of postgraduate medical training, an education system for trainees must be established and duties unrelated to medical examinations and treatment must be reduced.

The results of multi-center RCT of acupuncture and moxibustion for the prevention of the symptoms of common cold conducted by the financial support of the foundation for training and licensure examination in anma-massage-acupressure, acupuncture and moxibustion were briefly reviewed. Traditional acupuncture manipulation to the throat induced significant positive effects, however, more common indirect moxibustion to the neck for longer period did not induce the significant effect compared with no-treatment control. Several issues to be resolved were discussed and the shortage of duration of intervention was pointed out as one of the major issues. Then four pilot studies with long-lasting intervention of acupuncture or moxibustion were con-ducted. The effects tended to be more positive, however, they were still unclear. The selection of subjects (students in the acupuncture school) will be the next important issue to be examined.

BACKGROUND: The effectiveness of surveillance to identify extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) carriers is controversial during a non-outbreak situation. We performed additional stool cultures for ESBL-E among intensive care unit (ICU) patients already under active surveillance by means of sputum and urine cultures. We aimed to assess the efficacy of stool cultures for screening for ESBL-E in a non-outbreak situation. METHODS: We conducted a retrospective cohort study in an ICU. Sputum and urine samples were cultured for ESBL-E surveillance purposes from January to September 2013 (phase 1). Stool cultures were routinely performed in addition from January to September 2014 (phase 2). Antimicrobial use density values and clinical outcomes were investigated and compared between phase 1 and 2. RESULTS: We identified 512 and 478 patients in phase 1 and phase 2, respectively. ESBL-E were found in the feces of 65 (13.6%) patients in phase 2. The antimicrobial use density values (expressed as defined daily doses per 1,000 bed-days) were not significantly different between the two phases for fluoroquinolones (7 vs. 10, p = 0.376), third-generation cephalosporins (24.2 vs. 29.5, p = 0.724), tazobactam/piperacillin (44.6 vs. 57.3, p = 0.489), and carbapenems (73 vs. 55.5, p = 0.222). Moreover, there were no significant differences in ICU mortality and length of stay (11.5% vs. 9.8%, p = 0.412, and 9 vs. 10 days, p = 0.28, respectively). CONCLUSIONS: Stool culture seemed ineffective in improving the antimicrobial use density of broad-spectrum antimicrobials, clinical outcomes, and ICU length of stay, and is not recommended for surveillance of ESBL-E in a non-outbreak situation.
Asian Continental Ancestry Group ; beta-Lactamases ; Carbapenems ; Cephalosporins ; Cohort Studies ; Critical Care ; Disease Outbreaks ; Enterobacteriaceae ; Epidemiology ; Feces ; Fluoroquinolones ; Humans ; Intensive Care Units ; Length of Stay ; Mass Screening ; Mortality ; Retrospective Studies ; Sputum

BACKGROUND/AIMS: Evidence that general anesthesia (GA) reduces the operative time of esophageal endoscopic submucosal dissection (ESD) is currently insufficient. This study aims to evaluate the efficacy and safety of esophageal ESD under GA. METHODS: A total of 227 lesions from 198 consecutive patients with superficial esophageal neoplasms treated by ESD at 3 Japanese institutions between April 2011 and September 2017 were included in this retrospective study. For ESD, GA and deep sedation (DS) were used in 102 (51.5%, GA group) and 96 patients (48.5%, DS group), respectively. RESULTS: There were no statistically significant differences in age, sex, or comorbidities between the groups. In the GA group, the tumor size was larger (21 [3–77] mm vs. 14 [3–63] mm, p<0.001), luminal circumference was larger (≥2/3; 13.9% vs. 5.4%, p=0.042), procedure time was shorter (28 [5–202] min vs. 40 [8–249] min, p<0.001), and submucosal dissection speed was faster (25.2 [7.8–157.2] mm² /min vs. 16.2 [2.4–41.3] mm² /min, p<0.001). The rates of intraoperative perforation and aspiration pneumonia were lower in the GA group, but the difference did not achieve statistical significance (p=0.242 and p=0.242). CONCLUSIONS: GA shortens the procedure time of esophageal ESD.
Anesthesia ; Anesthesia, General ; Asian Continental Ancestry Group ; Comorbidity ; Deep Sedation ; Esophageal Neoplasms ; Humans ; Operative Time ; Phenobarbital ; Pneumonia, Aspiration ; Retrospective Studies

In the areas of home medical care and self-medication, the role of the pharmacist is growing, partly as a result of Japan’s aging society and the need to reduce medical costs. In response, the Kinki University Faculty of Pharmacy implemented a physical assessment practical training seminar in order to improve the physical assessment skills of practicing pharmacists. A series of questionnaires were conducted among pharmacists to investigate their perceptions of physical assessment practical training seminars. The results of the questionnaires were analyzed using Customer Satisfaction (CS) analysis and text mining. Based on a 5-point scale (1-low∼5-high), questionnaires revealed satisfaction for physical assessment practical training seminars was 4.6±0.6 (Ave.±S.D.). CS analysis revealed that the items “lectures” and “case seminars” had the highest level of satisfaction. However, items showing low levels of satisfaction were “auscultation of respiratory sounds” and “SBAR (Situation, Background, Assessment, Recommendation).” Results of text mining suggested a relationship between “physical assessment” and “difficult”. Analysis of the questionnaires showed a high level satisfaction with physical assessment practical training seminars, notably physical assessment practice methods. However, CS analysis and text mining indicate the finer techniques of physical assessment were difficult to acquire.

The objective of this study was to evaluate the magnified endoscopic findings in the diagnosis of follicular lymphoma in the small intestine in comparison with those of intestinal follicular lymphoma and lymphangiectasia. Four patients with follicular lymphoma and 3 with lymphangiectasia in the small intestine were retrospectively analyzed. A prototype magnifying singleballoon enteroscope was used. The findings of the intestinal follicular lymphoma and lymphangiectasia were retrospectively analyzed to determine the magnified endoscopic findings of follicular lymphoma in the small intestine. Opaque white granules were observed in 3 of the 4 patients with follicular lymphoma. Magnified narrow-band imaging (NBI) of the opaque white granules showed stretched microvessels, which had a diminutive tree-like appearance. The remaining patient had no opaque white granules and only displayed whitish villi. Magnified NBI observation of the whitish villi revealed the absence of marginal villus epithelium, which was confirmed by histology. The magnified NBI enteroscopy revealed the diminutive tree-like appearance on the opaque white granules and the absence of marginal villus epithelium of the whitish villi in intestinal follicular lymphoma. These findings may be useful in diagnosing follicular lymphoma.
Diagnosis* ; Epithelium ; Humans ; Intestine, Small ; Lymphoma, Follicular* ; Microvessels ; Narrow Band Imaging ; Retrospective Studies

BACKGROUND/AIMS: There are few prospective studies on cold forceps polypectomy (CFP) using jumbo cup forceps. Therefore, we examined patients with diminutive polyps (5 mm or smaller) treated with CFP using jumbo cup forceps to achieve an adenoma-free colon and also assessed the safety of the procedure and the recurrence rate of missed or residual polyp after CFP by performing follow-up colonoscopy 1 year later. METHODS: We included patients with up to 5 adenomas removed at initial colonoscopy and analyzed data from a total of 361 patients with 573 adenomas. One-year follow-up colonoscopy was performed in 165 patients, at which 251 lesions were confirmed. RESULTS: The one-bite resection rate with CFP was highest for lesions 3 mm or smaller and decreased significantly with increasing lesion size. Post-procedural hemorrhage was observed in 1 of 573 lesions (0.17%). No perforation was noted. The definite recurrence rate was 0.8% (2/251 lesions). The probable recurrence rate, which was defined as recurrence in the same colorectal segment, was 17%. Adenoma-free colon was achieved in 55% of patients at initial resection. Multivariate analysis revealed that achievement of an adenoma-free colon was significantly associated with number of adenomas and years of endoscopic experience. CONCLUSIONS: CFP using jumbo biopsy forceps was safe and showed a high one-bite resection rate for diminutive lesions of 3 mm or smaller. The low definite recurrence rate confirms the reliability of CFP using jumbo biopsy forceps. Number of adenomas and years of endoscopic experience were key factors in achieving an adenoma-free colon.
Adenoma ; Biopsy ; Colon ; Colonoscopy ; Follow-Up Studies ; Hemorrhage ; Humans ; Multivariate Analysis ; Polyps ; Prospective Studies ; Recurrence ; Surgical Instruments

Background/Aims: Crosstalk between the gut microbiota and bile acid plays an important role in the pathogenesis of gastrointestinal disorders. We investigated the relationship between microbial structure and bile acid metabolism in the ileal mucosa of Crohn’s disease (CD). Methods: Twelve non-CD controls and 38 CD patients in clinical remission were enrolled. Samples were collected from the distal ileum under balloon-assisted enteroscopy. Bile acid composition was analyzed by liquid chromatography-mass spectrometry. The gut microbiota was analyzed by 16S rRNA gene sequencing. Results: The Shannon evenness index was significantly lower in endoscopically active lesions than in non-CD controls. β-Diversity, evaluated by the UniFrac metric, revealed a significant difference between the active lesions and non-CD controls (P=0.039). The relative abundance of Escherichia was significantly higher and that of Faecalibacterium and Roseburia was significantly lower in CD samples than in non-CD controls. The increased abundance of Escherichia was more prominent in active lesions than in inactive lesions. The proportion of conjugated bile acids was significantly higher in CD patients than in non-CD controls, but there was no difference in the proportion of primary or secondary bile acids. The genera Escherichia and Lactobacillus were positively correlated with the proportion of conjugated bile acids. On the other hand, Roseburia, Intestinibacter, and Faecalibacterium were negatively correlated with the proportion of conjugated bile acids. Conclusions Mucosa-associated dysbiosis and the alteration of bile acid composition were identified in the ileum of CD patients. These may play a role in the pathophysiology of ileal lesions in CD patients.