Collaboration between medical institutions and community pharmacies is crucial for sharing patient’s treatment status and chemotherapy regimens in order to give safe and effective cancer chemotherapy for outpatient. In Kagoshima Medical Association Hospital, we established a framework for sharing this information with community pharmacies through a multidisciplinary approach. We conducted a questionnaire survey among community pharmacists to evaluate the usefulness of patient’s treatment status and chemotherapy regimens available on our hospital’s website. Most respondents found these resources “very useful.” Furthermore, respondents expressed a desire for additional information on chemotherapy regimen that was not currently available on our website but accessible from other institutions. This survey helped us understand the specific information required by community pharmacists regarding patient treatment status and chemotherapy regimens from medical institutions.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is useful for diagnosing mediastinal lymph node lesions. Cell blocks prepared from the needle washing fluid and flow cytometry of tissue samples are helpful in making the diagnosis, but the combination of both examinations is not routinely performed. A 77-year-old woman with fever, dyspnea, and anorexia was admitted to our hospital. Computed tomography showed enlarged mediastinal lymph nodes with calcification and left ureteral calculus; however, no focus of infection was identified. We suspected lymph node tuberculosis or malignant lymphoma, and EBUS-TBNA was performed to evaluate the mediastinal lymph node lesions. Because a cell block prepared from the needle rinse fluid was suspicious for malignant lymphoma, we changed the puncture needle from 22 G to 19 G and performed a second EBUS-TBNA. Diffuse large B-cell lymphoma (DLBCL) was diagnosed based on the results of flow cytometry of the EBUS-TBNA samples. Here we report this case of DLBCL in which mediastinal lymph node tuberculosis was suspected and cell block preparation and flow cytometry using EBUS-TBNA specimens were useful for the diagnosis.

Objective: Antibiogram preparation is important for the proper selection of antimicrobial agent in empiric therapy. It is recommended to prepare the antibiogram separately for inpatients and outpatients. However, the antimicrobial agent susceptibility of bacteria detected from an inpatient is thought to be different when detected at an early date after admission and after a certain period after admission.Methods: In this study, we defined the bacteria detected from an inpatient within 3 days after admission as “brought bacteria” and those over 3 days after admission as “bacteria detected after admission.” Antimicrobial agent susceptibilities of brought bacteria and bacteria detected after admission in our hospital between April 2018 and March 2019 were compared for Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa.Results: The occurrence rate of Escherichia coli producing an extended β-lactamase of bacteria detected after admission was found to be significantly higher compared with that of brought bacteria. The sulbactam/ampicillin susceptibility rate of bacteria detected after admission was significantly lower than that of brought bacteria. The occurrence rate of the two drug-resistant Pseudomonas aeruginosa detected after admission tends to be higher compared with that of brought bacteria.Conclusion: Our findings showed that the susceptibility rate of some drugs differed substantially between brought bacteria and bacteria detected after admission. Therefore, the inpatient’s antibiogram is thought to be prepared by separating bacteria detected at an early date after admission and after a certain period after admission, leading to the proper selection of antimicrobial agent in empiric therapy tailored to a patient’s number of days in the hospital.

We reviewed 7 patients with unsuccessful endoscopic hemostasis using covered self-expandable metal stent (CSEMS) placement for post-endoscopic sphincterotomy (ES) bleeding. ES with a medium incision was performed in 6 and with a large incision in 1 patient. All but 1 of them (86%) showed delayed bleeding, warranting second endoscopic therapies followed by CSEMS placement 1–5 days after the initial ES. Subsequent CSEMS placement did not achieve complete hemostasis in any of the patients. Lateral-side incision lines (3 or 9 o’clock) had more frequent bleeding points (71%) than oral-side incision lines (11–12 o’clock; 29%). Additional endoscopic hemostatic procedures with hemostatic forceps, hypertonic saline epinephrine, or hemoclip achieved excellent hemostasis, resulting in complete hemostasis in all patients. These experiences provide an alert: CSEMS placement is not an ultimate treatment for post-ES bleeding, despite its effectiveness. The lateral-side of the incision line, as well as the oral-most side, should be carefully examined for bleeding points, even after the CSEMS placement.

Objective: Drugs that are excreted by the kidneys may require dose adjustments, depending on the patient’s renal function. The pharmacist must ask the prescribing physician about the prescription if a dose is deemed inappropriate. In the current study, we investigated the economic effects of prescription questions associated with renal function and the antibiotics treatment completion rate.Methods: The current study included inpatient prescription inquiries by pharmacists at our institution between January and December 2018. For all cases that were inquired prescription, the economic effects were estimated as follows; the drug costs were calculated based on drug prices at April 2018 edition, and the reduced medical care costs associated with avoiding adverse reactions due to prescription questions were calculated based on the number of benefits and the total cost of benefits in the Relief System for Sufferers from Adverse Drug Reactions. The antibiotics treatment completion rates were calculated based on the number of cases in which drug and dose maintained after prescription questions.Results: The study included 279 cases, 266 of which involved inappropriate doses due to deteriorated renal function. Most prescriptions were for antibiotics. The drug costs were reduced due to the prescription question in 213 cases; the total reduced cost was 699,483 Japanese yen. The economic effects associated with avoiding adverse reactions due to prescription questions were worth approximately 11,481,056 Japanese yen. The completion rate of antibiotic treatment in cases where doses were reduced due to prescription questions was 63.0% (treatment of 75 cases completed/all cases were 119), compared with 63.6% (7 cases/11 cases) in cases in which doses were not changed. Thus, dose reduction due to questions regarding the prescription did not lead to reduced completion rates of antibiotics treatment (p=0.621).Conclusion: Dose adjustments due to prescription questions about drugs excreted by the kidneys led to reduced drug costs and adverse reactions, and did not result in negative effects during infectious disease therapy.

Background/Aims: Although endoscopic transpapillary gallbladder drainage (ETGBD) has been reported as an alternative procedure for acute cholecystitis, it requires advanced endoscopic techniques. In terms of the certainty of achieving drainage, it remains a challenging procedure. The aim of the current study was to elucidate the practical efficacy of cholangioscopic assistance and to develop a new classification that could be used to evaluate the technical difficulty of ETGBD and provide a theoretical strategy to apply cholangioscopy appropriately for difficult ETGBD. Methods: A total of 101 patients undergoing ETGBD were retrospectively studied. The characteristics and technical outcomes of ETGBD with conventional ETGBD (C-ETGBD) and SpyGlass DS-assisted ETGBD (SG-ETGBD) were evaluated. The characteristics and technique-dependent factors of unsuccessful C-ETGBD/SG-ETGBD were evaluated using the classification based on the steps of the procedure. The predictive factors of successful C-ETGBD/SG-ETGBD were examined. Results: C-ETGBD was successful in 73 patients (72.3%). SG-ETGBD was successful in 11 of 13 patients (84.6%) who had C-ETGBD failure. Optional SG-ETGBD significantly increased the final success rate (94.1%) compared to C-ETGBD alone (p=0.003). ETGBD procedures could be classified into four steps. SG-assistance worked as an excellent troubleshooter in step 1 (failure to identify the cystic duct orifice) and step 2 (failure of guidewire advancement across the downturned angle of cystic duct takeoff). Magnetic resonance cholangiopancreatography could provide predictive information based on the classification. Conclusions Optional SG-ETGBD achieved a significantly higher success rate than C-ETGBD alone. Step classification is helpful for determining the technical difficulty of ETGBD and developing a theoretical strategy to apply cholangioscopy in a coordinated manner.

Background/Aims: Although endoscopic transpapillary gallbladder drainage (ETGBD) has been reported as an alternative procedure for acute cholecystitis, it requires advanced endoscopic techniques. In terms of the certainty of achieving drainage, it remains a challenging procedure. The aim of the current study was to elucidate the practical efficacy of cholangioscopic assistance and to develop a new classification that could be used to evaluate the technical difficulty of ETGBD and provide a theoretical strategy to apply cholangioscopy appropriately for difficult ETGBD. Methods: A total of 101 patients undergoing ETGBD were retrospectively studied. The characteristics and technical outcomes of ETGBD with conventional ETGBD (C-ETGBD) and SpyGlass DS-assisted ETGBD (SG-ETGBD) were evaluated. The characteristics and technique-dependent factors of unsuccessful C-ETGBD/SG-ETGBD were evaluated using the classification based on the steps of the procedure. The predictive factors of successful C-ETGBD/SG-ETGBD were examined. Results: C-ETGBD was successful in 73 patients (72.3%). SG-ETGBD was successful in 11 of 13 patients (84.6%) who had C-ETGBD failure. Optional SG-ETGBD significantly increased the final success rate (94.1%) compared to C-ETGBD alone (p=0.003). ETGBD procedures could be classified into four steps. SG-assistance worked as an excellent troubleshooter in step 1 (failure to identify the cystic duct orifice) and step 2 (failure of guidewire advancement across the downturned angle of cystic duct takeoff). Magnetic resonance cholangiopancreatography could provide predictive information based on the classification. Conclusions Optional SG-ETGBD achieved a significantly higher success rate than C-ETGBD alone. Step classification is helpful for determining the technical difficulty of ETGBD and developing a theoretical strategy to apply cholangioscopy in a coordinated manner.

No abstract available.
Anti-Bacterial Agents/pharmacology/therapeutic use ; Bacteremia/*diagnosis/drug therapy/microbiology ; Clostridium tertium/drug effects/isolation & purification/*metabolism ; Humans ; Male ; Microbial Sensitivity Tests ; Middle Aged ; *Spectrometry, Mass, Matrix-Assisted Laser Desorption-Ionization

Objective: We have used therapeutic drug monitoring (TDM) analysis software to set the initial dose of vancomycin in our hospital.  In contrast, the TDM guideline, in which the initial dose of vancomycin per body weight was set, was published in 2012.  We looked forward with utilizing the TDM guideline in the clinical setting, after which we conducted multiple surveys to determine the important points of the TDM guideline.
Methods: We surveyed patients treated with vancomycin, in whom the initial dose was set using the TDM analysis software and the concordance rate between the vancomycin dose set with the software and that set with the TDM guideline.
Results: The concordance rate of vancomycin dose was 42.1%.  The mean age of the high-dose group (vancomycin dose higher than that recommended by the TDM guideline), was younger than that of the recommended-dose group.  Additionally, the mean body weight of the high-dose group was significantly lower than that of the recommended-dose group.  The corrected creatinine clearance of the low-dose group was significantly lower than that of the recommended-dose group.
Conclusion: Our results suggest that when the initial dose is set after referring the TDM guideline in patients who are not very high age, and having low body weight and decreased renal function, the dose may differ from the dose set by using TDM analysis software.  In addition, since the recommended dose per body weight is a range and not a single value, setting the dose appropriate to target trough concentration is necessary.

Palliative care is sometimes difficult for medical staff to say to patients with cancer and their families. The late of using the term “palliative care” decrease the opportunity to know about palliative care for the patients and their families. The primary aims of this study were to reveal physicians’ and nurses’ usage of the term “palliative care”, time to use the term for the first time, and a synonym. We conducted a questionnaire survey to 387 physicians and 518 floor nurses at Hiroshima University Hospital in February, 2010. We analyzed the results of physicians and nurses separately. Two hundred and seventy-two physicians (response rate 70.3%) and 284 nurses (54.8%) answered the questionnaire. Many physicians (77.2%) and the majority of nurses (56.0%) explain with the term “palliative care”. the majority of physicians use the term when cancer cause any symptoms and at early stage. Some nurses (31.4%) couldn’t use the term “palliative care” before physicians explained the term. Nurses having longer experience tend to use the term regardless of physicians’ use. Many physicians use the term “palliative care” at early stage of cancer. Many nurses also use the term at early stage of cancer, but some nurses couldn’t use before physicians’ use.