小佐見 光樹

Aim: To investigate the items that are considered by physicians when making decisions regarding the resumption of oral intake among patients with aspiration pneumonia who have undergone short-term fasting. Methods: We surveyed 2490 Japanese hospitals that had internal medicine and respiratory medicine departments. We mailed questionnaires that contained 24 items related to oral intake resumption after aspiration pneumonia to the head of the department at each hospital. Cronbach statistics, principal component analysis and cluster analysis were used to analyze the results. Results: We received responses from 350 hospitals; 89.7% of the respondents answered that they "Strongly agree" that "level of consciousness" is a useful criterion for resuming oral intake. Furthermore, 66%, 66%, 63.4%, 58.5% and 51% of the respondents answered that they "strongly agree" regarding the use of SpO(2), the discretion of the attending physician, body temperature, swallowing function test results, mental state and respiratory rate, respectively. In the cluster analysis, level of consciousness, body temperature, SpO(2), respiratory rate, mental state and the discretion of the attending physician belonged to the first cluster. The second cluster consisted of the patient's request, the family's request, the opinions of the medical staff and non-physician healthcare providers, and performance status. Conclusions: Physicians consider several criteria during decision-making regarding oral intake resumption, which can be assigned to two clusters. Future studies are required to develop generalizable and objective criteria.

Purpose: To assess the factors involved in oral intake discontinuation in elderly patients with recurrent aspiration pneumonia. Patients and methods: This study included patients with pneumonia who were treated at Jichi Medical University Hospital between 2007 and 2013, at Toyooka Public Hospital between 2011 and 2013 and at Yuzawa Community Medical Center between 2010 and 2012. We consecutively enrolled patients with aspiration pneumonia. The primary study point was oral intake discontinuation after the initiation of oral intake during hospitalization in cases of recurrent aspiration. Various parameters were recorded at admission, at the initiation of intake, and during hospitalization; these parameters were statistically evaluated. Results: A total of 390 patients were assigned to either a "no reaspiration of intake" group (n=310) or a "reaspiration of intake" group (n=80), depending on whether intake was discontinued owing to aspiration during hospitalization. At admission, the following items significantly differed between the groups: level of consciousness, respiratory rate, oxygen saturation, CURB-65 score, extent of infiltration/opacity on chest radiography, albumin levels, blood urea nitrogen levels, and application of swallowing function assessment. At the initiation of intake, level of consciousness, pulse rate, and albumin levels significantly differed between the groups. The following items did not significantly differ between groups: systolic blood pressure, pulse rate, C-reactive protein, bacteremia, use of ventilator at admission, oxygen administration, respiratory rate, and systolic blood pressure at initiation of intake. Multivariate analysis revealed that application of swallowing function assessment, level of consciousness at the initiation of intake, and extent of infiltration/opacity on chest radiography were significant predictive variables for discontinuation of intake. Conclusion: A low level of consciousness at the initiation of intake and a greater extent of infiltration/opacity on chest radiography and the application of a swallowing function are important factors. These factors may be helpful to determine a suitable timing for resumption of oral intake.

In Japan, aspiration pneumonia is common among the elderly and patients are often treated by temporary discontinuation of meals. However, there are few published studies on the fasting duration for aspiration pneumonia treatment. Therefore, we conducted the present study to assess the opinions of clinicians regarding the fasting duration for the treatment of patients with aspiration pneumonia and the actual medical practice with regard to oral ingestion in hospitalized patients with aspiration pneumonia. We targeted hospitals with internal medicine and respiratory medicine departments across Japan. A questionnaire regarding the fasting duration for aspiration pneumonia treatment and oral ingestion in hospitalized patients with aspiration pneumonia was mailed to physicians treating patients with pneumonia at 2,490 hospitals. We received appropriate responses from 350 facilities (response rate, 14.1%). Most clinicians (78.3%) responded that it best to keep the fasting duration for treatment as short as possible and considered that fasting is absolutely unnecessary. Regarding oral ingestion in hospitalized patients, more than 25% of clinicians restricted oral intake for a certain number of days. The majority of these clinicians (53.3%) preferred prolonged fasting for 3 to 7 days. Although most physicians preferred the fasting duration to be as short as possible, there was a difference between the ideal and actual scenarios in reintroducing oral intake early in patients with aspiration pneumonia. Improving physicians' knowledge and experience will bridge the gap between the ideal situation and what currently occurs. Further studies should investigate the acceptable fasting duration for the treatment of aspiration pneumonia.

Hypergranulation tissue formation around a gastrostomy tube insertion site is a common feeding tube-related complication that affects patients who receive long-term enteral nutrition. Some clinicians recommend use of a topical corticosteroid in patients with gastrostomy tube insertion site hypergranulation. However, documentation is scant regarding appropriate treatment for this condition. This case report describes a 67-year-old bedridden man with spinocerebellar degeneration who presented with hypergranulation at the site of the gastrostomy tube, inserted 1 week earlier. The tissue was raw and inflamed, with bleeding and exudation. The gastrostomy site was gently cleansed with gauze dampened with tap water, and topical 0.05% clobetasol propionate ointment was applied directly to the hypergranulation tissue twice daily. After 4 days of treatment, the hypergranulation tissue almost completely disappeared, redness markedly decreased, and bleeding and exudation ceased, with no recurrence observed during the 6 months of follow-up. This case study supports other reports that short-term corticosteroid treatment may be a safe, quick, noninvasive, and effective treatment for hypergranulation at the gastrostomy tube insertion site. Further studies are needed to evaluate the safety, effectiveness, appropriate dosage, and duration of topical corticosteroid for the treatment of hypergranulation tissue.

Background: Clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) is a mild encephalopathy caused by various pathological processes, but encephalopathy due to bacteria is rare. Case presentation: We report the case of a 45-year-old Japanese woman who on receiving chemotherapy for advanced breast cancer developed an altered mental status and dysarthria soon after fever from infection of a subcutaneous implantable port. Staphylococcus aureus was detected in her blood cultures. Magnetic resonance imaging (MRI) revealed an ovoid lesion in the central portion of the splenium of the corpus callosum (SCC). Although hypotension was not observed, we diagnosed probable toxic shock syndrome (TSS) based on fever (temperature: >38.9 degrees C), altered mental status, erythema, desquamation, thrombocytopenia, liver dysfunction, and creatine phosphokinase elevation. We administered antimicrobial therapy and her neurological symptoms improved gradually. The lesion in the SCC completely disappeared on MRI 7 days after disease onset. Conclusions: We diagnosed this case as MERS caused by S. aureus bacteremia with TSS. This is the first report of such a case, and we suggest that when a TSS patient presents with neurological symptoms, the possibility of MERS should be considered.

Objectives The present study investigated the incidence of hyperammonemia in urinary tract infections and explored the utility of urinary obstruction relief and antimicrobial administration to improve hyperammonemia. Methods This was an observational study. Subjects were patients who were diagnosed with urinary tract infection and hospitalized between June 2008 and June 2009. We measured plasma ammonia levels on admission in patients who were clinically diagnosed with urinary tract infection and hospitalized. We assessed each patient's level of consciousness on admission using the Glasgow Coma Scale (GCS) and performed urine and blood cultures. We also assessed hearing prior to hospitalization using the Eastern Cooperative Oncology Group performance status (ECOG-PS). In cases with high ammonia levels on admission, plasma ammonia and GCS were measured 24 hours and 5-7 days later. Results Sixty-seven candidates were enrolled; of these, 60 cases (89.6%) with bacterial cell counts >= 10(4) CFU/mL were studied. Five cases (8.3%) presented with high plasma ammonia levels. Cases with hyperammonemia were significantly more likely to present with low GCS scores and urinary retention rate. All five cases received antimicrobial therapy with an indwelling bladder catheter to relieve urinary retention. The case 5 patient died shortly after admission due to complicated aspiration pneumonia; in the remaining cases, plasma ammonia levels were rapidly normalized and the level of consciousness improved. Conclusions The occurrence of hyperammonemia in urinary tract infections is not rare. The cause of hyperammonemia is urinary retention obstruction. Therefore, along with antimicrobial administration, relief of obstruction is important for the treatment of hyperammonemia caused by this mechanism.

Intravascular large B-cell lymphoma (IVLBCL) is a rare subtype of B-cell lymphoma characterized by selective growth of clonal B-cells in the lumen of the small vessels of various organs including the liver, spleen, lungs, skin, brain, and kidney. An 86-year-old male presented with weight loss, fever and night sweats (known as B symptoms). Blood examination revealed pancytopenia, high lactate dehydrogenase and high soluble interleukin-2 receptor, suggesting hematopoietic malignancy. However, there were no abnormal hematopoietic cells in the peripheral blood. No lymph node swelling was identified on examination by whole-body computed tomography scan. Therefore, IVLBCL was suspected, and random skin biopsies and a skin biopsy from a senile hemangioma were carried out. A small number of large atypical lymphoid cells resided in the small blood vessels in the deep dermis and subcutaneous tissue of the random skin biopsies, and numerous atypical lymphoid cells were identified in the small vessels of the senile hemangioma. These results suggest the usefulness of skin biopsy from senile hemangiomas in the diagnosis of IVLBCL.

定期外来通院中の高齢者の抑うつ傾向に関連する要因を明らかにすることを目的に、65歳以上の当該患者72名(男性39名、女性33名)へ老年期うつ病評価尺度であるGDS-15(Geriatric Depression Scale 15)、およびソーシャルネットワークの尺度であるLSNS-6(Lubben Social Network Scale-6)を用いたアンケート調査を行った。その結果、抑うつ傾向を有する患者は男性10名(25.6%)、女性12名(36.3%)で、女性ではLSNS-6値が12未満のソーシャルネットワークが小さい者、男性では1日の歩数が少ない者に抑うつとの有意な関連が認められた。