Assessment of a protocol for prophylactic antibiotics to prevent perioperative infection in urological surgery: A preliminary study

BACKGROUND: The aim of the present study was to assess the usability and efficacy of our new protocol of prophylactic antibiotic use to prevent perioperative infection in urological surgery. METHODS: We prospectively investigated 339 cases of typical urological surgery in our department between April 2001 and March 2002 (group I). We classified surgical procedures into four categories by invasiveness and contamination levels: category A, clean less invasive or endoscopic surgery; category B, clean invasive or clean contaminated surgery; category C, urinary tract diversion using the intestine; and category D, infected surgery. Antibiotics were administrated intravenously according to our protocol: category A, first or second generation cephems or penicillins during the operative day only; category B, first and second generation cephems or penicillins for 3 days; and category C, second or third generation cephems for 4 days. Category D was excluded from the analysis. To judge perioperative infections, the wound condition and general conditions were evaluated in terms of the surgical site infection (SSI) as well as remote infection (RI) up to postoperative day (POD) 14. We retrospectively reviewed 308 patients who underwent urological surgery between April 2000 and March 2001 (group II) as reference cases that were administered antibiotics without any restriction. RESULTS: Perioperative infection rates (SSI + RI) in group I and group II were 25 of 339 (7.4%) and 35 of 308 (11.4%), respectively. Surgical site infection rates of categories A, B, and C in group I were 1.8%, 7.6%, and 30.0%, respectively, while those in group II were 2.0%, 7.4%, and 46.2%, respectively. There was no significant difference in infection rates in terms of RI and SSI between group I and group II. The amounts, as well as the prices, for intravenously administrated antibiotics and oral antibiotics decreased to approximately half and one-fifth, respectively. CONCLUSION: Our protocol effectively decreased the amount of antibiotics used without increasing perioperative infection rates. Thus, our protocol of prophylactic antibiotic therapy would be recommended as an appropriate method for preventing perioperative infection in urological surgery.     

Home-based rehabilitation program for older adults with cognitive impairment: preliminary results

Background: While there is a growing interest in cognitive rehabilitation for older adults, not enough data is available regarding its feasibility and effectiveness in an older population. The present study implemented a home‐based cognitive rehabilitation program for older adults in order to explore the program’s feasibility and effectiveness. Methods: The 8‐month rehabilitation program consisted of multiple workbooks targeted at improving attention, memory and executive function. Study participants worked on the workbooks at home with family members, while professional cognitive rehabilitation staff periodically evaluated their progress. Attention, memory and executive function were evaluated at outset, at month 4 and at the end of month 8. Results: The nine initial participants had histories of subarachnoid hemorrhage or traumatic brain injury, or were outpatients of a memory clinic who had memory impairment. Six participants (66.7%) completed the 8‐month program; one subject intentionally withdrew from the program while two others withdrew due to hospitalization. Among the six remaining participants, attention improved significantly between the month 4 and month 8 evaluations, and between the initial and month 8 evaluations. Within subsets of the attention test, significant improvement was seen in the visual selective attention domain. There was no change in memory or executive function, as well as the subjective difficulties in daily lives. Conclusions: This study suggests that a home‐based cognitive rehabilitation program for older adults is feasible and may improve attention, especially visual selective attention. An 8‐month rehabilitation program may have been of insufficient duration to generate significant improvements in memory or executive function.     

Bacteria of preoperative urinary tract infections contaminate the surgical fields and develop surgical site infections in urological operations

BACKGROUND: The risk factors for surgical site infection (SSI) following urological operations have not been clearly identified, although the presence of a preoperative urinary tract infection (UTI) is thought to be one risk factor. We studied potential risk factors to clarify when and how bacteria contaminate wounds and SSI develop. METHODS: Objects of the present study were patients with SSI after open urological operations that were performed at the Department of Urology, Miyazaki Medical College Hospital, University of Miyazaki, Kiyotake, Miyazaki, Japan, during the period between June 1999 and December 2000. Endourological operations, operations on children and short operations of less than 2 h duration were excluded. Patients were screened for the presence of UTI before the operation and subcutaneous swabs for culture were collected at the end of the operation by brushing with a sterile cotton-swab just before skin closure. RESULTS: Surgical site infections occurred in 20 of 134 patients. Bacteria from the subcutaneous swabs were detected in 15 (75.0%) of the patients with SSI. All patients received antimicrobial prophylaxis (AMP), but bacteria from the subcutaneous swabs of patients with SSI were less susceptible to the agents (20.0%). Preoperative UTI were observed in 11 (55.0%) of the patients with SSI. In these patients, four had the same species of bacteria detected from urine, swab and wound, three had the same species from swab and wound and one had the same species from urine and wound. CONCLUSIONS: Preoperative UTI was the most important risk factor for SSI following urological operations. It is most likely that the bacteria in the urine contaminated the surgical fields and the AMP resistant strains produced SSI.     

Relationship between behavioral disturbances and characteristics of patients in special units for dementia

Abstract The aim of the present study was to examine the relationships between behavioral disturbances and patient characteristics of inpatients with dementia nationwide. The five patient characteristics used were age, gender, years of education, cognitive status, and walking ability. The subjects consisted of 730 inpatients selected by systematic sampling from 180 units that have specialized psychiatric beds for acute/long‐term care of dementia. Clinical staff members assessed the 730 patients with the Mini‐Mental State Examination (MMSE), and filled out a questionnaire for long‐term care insurance, including 19 items relating to behavioral disturbances and walking scale. Five meaningful factors were identified out of the 19 behavioral disturbances by factor analysis. Linear regression analysis revealed that the factor ‘psychotic/neurotic’ was not related to any patient characteristics; ‘aggression/negativistic’ was related to male gender and a lower MMSE score; and ‘dirty/destructive’ and ‘disorientation/fire management’ were related to a lower MMSE score and higher walking score. The factor ‘sexual behavior’ included only one behavior at a very low frequency. These findings suggest that different behavioral disturbance factors have different correlations with patient characteristics, while cognitive dysfunction has a relatively important role in behavioral disturbances of inpatients with dementia.     

Disseminated Adenovirus (Type 19) Infection in a Neonate Rapid Detection of the Infection by Immunofluorescence

ABSTRACT. A case of fatal disseminated adenovirus infection in a neonate who suffered from severe keratoconjunctivitis and pneumonitis is reported. The diagnosis was made seven days after the onset of illness based on the detection of adenovirus antigen in the smears of the tracheal suction and conjunctival swab by immunofluorescence. Viral antigen was detected in the frozen or formalin-fixed autopsy specimens of the lungs, kidneys, spleen, liver and lymph nodes. Typical crystal arrangement of adenovirus virions was observed in the alveolar epithelial cells by electron microscopy. The isolated virus was identified to be of type 19 by a neutralization test. The IF examination using adenovirus group specific immune reagents on the smears of clinical specimens appears to be useful for rapid diagnosis of viral infections.     

An early-onset case of multiple sclerosis with thalamic lesions on MRI

We present here an early-onset case of multiple sclerosis (MS) with thalamic lesions. The patient first experienced an episode of ataxic gait at 2 years 3 months of age, with spontaneous remission within 1 month. At 5 years 4 months, she was admitted because of cerebellar ataxia, oculomotor restriction and feeding difficulty. Magnetic resonance imaging (MRI) showed multiple well-defined lesions in the white matter of the cerebellum, mid-brain, periventricle and right frontal lobe. Cerebrospinal fluid (CSF) showed a mild elevation of both immunoglobulin G (IgG) and myelin basic protein (MBP). Serum anti-myelin antibody was also positive, although leukocytosis and elevation of C-reactive protein were not found. Methylprednisolone pulse therapy relieved symptoms within 2 weeks and the abnormal MRI and CSF findings gradually improved. At 6 years 6 months of age, she incurred a third episode of cerebellar ataxia and disturbance of consciousness. Magnetic resonance imaging revealed recurrence and extension of the previous lesions as well as new lesions in the thalamus and internal capsule. CSF IgG and MBP level showed a higher elevation than in the second episode. The combination of the cerebellar, brain-stem, cerebral and thalamic lesions with remission and exacerbation, supported by MRI and CSF findings, allowed the diagnosis of clinically definite MS to be made. This is one of the youngest cases of MS yet described, with the first attack occurring at 27 months of age. In addition, this case is unique for the involvement of the gray matter in the thalamus.     

Follow-up of clinical stage I testicular cancer patients: Cost and risk benefit considerations

BACKGROUND: Regardless of the way it is managed, a high cure rate has been achieved for recurrent low-stage testicular cancer. Achieving a balance between survival and the patient's inconvenience and expense during follow-up, has therefore become an important issue. METHODS: Prognoses and recurrence patterns were investigated in 39 patients with stage I non-seminomatous germ cell tumor of the testis (NSGCT), and 82 patients with stage I seminomatous germ cell tumor of the testis (SGCT), who underwent high orchiectomy between 1970 and 1997 at our institution. We considered the cost benefits and the risks by reviewing our results together with other reported results. RESULTS: Patients with clinical stage I NSGCT under surveillance showed no progression later than 4 years after orchiectomy. The ability to detect progression using chest X-ray alone appeared very low. There was no infradiaphragmatic recurrence after adjuvant radiotherapy for patients with stage I SGCT. Only two of 204 patients showed progression, which included eight of our patients who underwent two cycles of adjuvant carboplatin therapy. CONCLUSIONS: Four years of intensive follow-up is probably sufficient for patients with stage I NSGCT under surveillance, and routine chest X-rays may be required only during the first year of surveillance. The benefit of using adjuvant radiotherapy for patients with stage I SGCT is that we could remove abdominal and pelvic CT scans from the routine follow-up protocol. Randomized trials will clarify whether the adjuvant carboplatin therapy is less toxic, provides better prognosis and is more cost-effective than adjuvant radiotherapy.     

Medical Treatment for Inoperable Insulinoma: Clinical Usefulness of Diphenylhydantoin and Diltiazem

This report describes a 78-year-old woman with insulinoma, treatedwith a combination of diphenylhydantoin and a calcium antagonist.The effectiveness of 200 mg of diphenylhydantoin and 180 mgof diltiazem was evaluated by measuring the levels of plasmaglucose, immunoreactive insulin and immunoreactive insulin/plasmaglucose after fasting or by the oral glucose tolerance test,and by the appearance of hypoglycemic symptoms. The mean concentrationof fasting plasma glucose increased significantly during thetreatment. The levels of immunoreactive insulin/plasma glucoseand C-peptide imniunoreactivity/plasma glucose significantlydecreased. Symptomatically. no episode of hypoglycemia was notedduring the combined treatment.     

Actinic prurigo: a case report with successful induction of skin lesions

A 7-year-old girl with actinic prurigo, probably the first ever published case in Japan, is reported. Intensive irradiation of UV-B and light application of carbon dioxide snow induced the characteristic papules indicating that the patient seemed to respond to various kinds of external stimuli. However, pruritus did not always accompany the appearance of these induced skin lesions. The presentation of skin lesions of actinic prurigo on covered skin and in the winter may partly be explained by these observations.