JANUARY 2021 Volume 3-1

ISSN 2436-018X

JOURNAL OF HOSPITAL GENERAL MEDICINE

JHGM 2021：3(1)：1-10

Original article

Improvements in Quality Indicators for the Treatment
of Infectious Diseases with Intervention by
an Antimicrobial Stewardship Team

Hiroshi Sasano 1)　　Toshihiro Yoshizawa 1)　　Takaaki Kawakami 2)
Toshihiro Takahashi 2)　　Mai Suzuki 3)　　Yukiko Fukui 3)
Yuki Uehara 3)4)5)　　Ryutarou Arakawa 1)　　Takashi Miida 2)
Satoshi Hori 6)　　Toshio Naito 3)

1）Department of Pharmacy, Juntendo University Hospital
2）Department of Clinical Laboratory, Juntendo University Hospital
3）General Medicine, Hirosaki University Graduate School of Medicine
4）Department of Clinical Laboratory, St Luke’s International Hospital
5）Department of Infectious Diseases, St Luke’s International Hospital
6）Department of Infection Control Science, Juntendo University Graduate School of Medicine

[Objective] The objective was to describe the activities and present the results of the in-house Antimicrobial Stewardship Team (AST) of Juntendo University Hospital, which undertook activities to achieve the “4R” concept (Right drug, Right time, Right dose, Right duration), including appropriate interventions targeting physicians to ensure proper prescribing practices.
[Methods] Taking into account the previous mode of in-house antimicrobial drug prescription,quality indicators were defined for the individual Rs：(1) proportion of blood culture tests implemented prior to administration of carbapenems, with monitoring started in January 2018, and in May, the results fed back to the primary physicians involved；(2) therapeutic monitoring of vancomycin (VCM) via pharmacist intervention, with training for doctors and nurses since 2016, and a full-time working schedule introduced for the AST pharmacists in 2018；(3) proportion of rightdose prescription of cefmetazole (CMZ), with feedback of the preceding data on CMZ usage to the primary physicians and the prescription ordering system revamped in August 2017；and (4) the proportion of patients who underwent hotline system-mediated interventions during long-term carbapenem treatment, which checked the target patient once every 10 days in 2016, and then the check interval was changed to once per week since 2017. The AST monitored these indicators, providing periodic feedback of data and interventions to the healthcare providers, if necessary.
[Methods] Healthcare providers (prescribers)
[Results] Following the AST interventions, the proportion of blood culture tests reached > 80%. The mean proportion of therapeutic VCM monitoring improved to involve nearly all cases in 2018. The validity of CMZ prescription improved through data feedback to the physicians and a revamped drug ordering system that presented a warning message for the right-dose prescription. The fourth indicator also improved by increasing the intervention frequency from once per 10 days to once per 7 days, with nearly all relevant patients followed up during long-term carbapenem use.
[Conclusion] AST activities are promising in terms of the 4R concept, the goal of antimicrobial
stewardship.

Key Words：antimicrobial stewardship, 4R concept, drug resistance

JHGM 2021：3(1)：11-20

Original article

The diagnostic value of Reversed Carnett’s sign
for detecting intra-abdominal lesion in patients
with acute abdominal pain

Takanobu Hirosawa 1)　　Yukinori Harada 1)　　Toshihiro Nishinobu 2)
Yuki Honda 3)　　Kohei Morinaga 1)　　Hiroshi Takase 4)　　Taro Shimizu 1)

1）Department of Diagnostic and Generalist Medicine, Dokkyo Medical University
2）Department of General Internal Medicine, Kaisei Hospital
3）Department of General Internal Medicine, Seirei Hamamatsu General Hospital
4）Department of Emergency Medicine, Sendai City Hospital

　　Physical examinations that can be used to accurately diagnose intra-abdominal diseases important to high-value care because they reduce the number of unnecessary computed tomography (CT) studies for patients with acute abdominal pain. This prospective study was conducted to evaluate the diagnostic accuracy of the reversed Carnett’s (rCarnett’s) sign for intra-abdominal diseases detectable on abdominal CT. It was done in the outpatient department of the division of general internal medicine at a tertiary university hospital in Japan. Adult patients presenting with acute abdominal pain between August 2019 and January 2020 were included. The primary outcome was the diagnostic accuracy of rCarnett’ s sign for intraabdominal disease confirmed by abdominal CT. The diagnostic accuracy of each univariate and multivariate variable in logistic regression models was assessed by calculating the area under the receiver operating characteristic curve (AUROC). The data of 51 patients were included in this analysis. The rCarnett’s sign showed low diagnostic ability (AUROC：0.46, 95% confidence interval (CI)：0.31 to 0.60, P = 0.54), sensitivity (32.4%, 95% CI：17.4% to 50.5%), and specificity (58.8%, 95% CI 32.9% to 81.6%). Thus, the rCarnett’s sign cannot be considered as an effective examination for the diagnosis of intra-abdominal diseases.

JHGM 2020：3(1)：21-28

Case report

Heart rate reduction during favipiravir therapy
for hospitalized COVID-19 patients：
experience from 6 cases

Megumi Shimada 1)※　　Sakurako Tajiri 2)　　Raisuke Nishiyama 3)
Hiroyuki Kato 1)　　Hirotake Sugiyama 1)　　Tadashige Ikeda 2)
Masako Sato 2)　　Eriko Goto 1)　　Kenzo Nishiya 2)

1）Department of General Internal Medicine, Tokai University Oiso Hospital
2）Department of Pulmonary Medicine, Tokai University Oiso Hospital
3）Department of Emergency and Critical Care Medicine, Tokai University Oiso Hospital

　　Favipiravir is an RNA polymerase inhibitor that was developed in Japan, and its antiviral effect is expected to be useful against coronavirus disease 2019 (COVID-19). We examined the therapeutic effect of favipiravir use for 6 patients with COVID-19. We analyzed body temperature, heart rate, blood pressure, respiratory rate, oxygen saturation, electrocardiographic changes, and clinical symptoms before and after oral administration of favipiravir. Normalization of body temperature (<37 ℃) was achieved by the third day of hospitalization by all patients. Heart rate reduction was observed after the start of treatment and was almost correlated with body temperature. Cough, fatigue, olfactory and gustatory dysfunction, headache, and digestive symptoms were observed on the first and second days of illness, but improved after the third day of illness. We examined changes in heart rate, PR interval, QRS duration, and QTc interval by electrocardiography. Favipiravir reduced heart rate and increased the PR interval for most patients；however, the QRS duration and QTc interval did not change except in one case. In conclusion, heart rate reduction by favipiravir was well-correlated with the clinical course；thus, heart rate could be a useful indicator of the therapeutic efficacy of favipiravir use for patients with COVID-19.

Key Words：COVID-19, favipiravir, therapeutic effect

JHGM 2020：3(1)：29-32

Brief report

A case report of sarcoidosis with asymmetrical hilar
lymphadenopathy in a young woman：Use of closed
questions on eye symptoms for diagnosis

Takashi Akimoto 1)2)※　　Tadashi Kobayashi 1)　　Hiroki Maita 3)
Hiroshi Osawa 1)　　Hiroyuki Kato 1)2)3)

1）Department of General Medicine, Hirosaki University School of Medicine and Hospital
2）General Medicine, Hirosaki University Graduate School of Medicine
3）Development of Community Healthcare, Hirosaki University Graduate School of Medicine

Abstract
　　A 31-year-old woman had been developing a gradually worsening general fatigue and cough over the past 2 years. In an orthopedic clinic, spinal magnetic resonance imaging (MRI) revealed an incidental finding of left hilar lymphadenopathy, which was also shown on her chest radiograph. She had no spontaneous pain, joint pain, numbness, or weight loss. Her vital signs were normal. On physical examination, no abnormal findings of tenderness and swelling of joints, palpable superficial lymph nodes, or skin rashes were found. An open question revealed general fatigue and cough, and an additional closed question revealed her ocular symptoms. No abnormal laboratory findings were noted. Through endobronchial ultrasonography-guided transbronchial needle aspiration, we diagnosed her with sarcoidosis. Physicians should consider the possibility of sarcoidosis in young patients with asymmetrical hilar lymphadenopathy. Closed questions assuming specific diseases can help provide an accurate diagnosis, since asking open questions exclusively may not reveal all of the patient’s symptoms to the physician.

Key Words：eye symptom, hilar lymphadenopathy, medical interview

JHGM 2020：3(1)：33-35

Brief report

Extreme Hyperferritinemia due to
Alcoholic Liver Disease：Secondary Hemochromatosis

Koichiro Yamamoto 1)　　Yoshito Nishimura 1)※ 　　Mai Yamane 1)
Reina Son 1)　　Daisuke Omura 1) 　　Kou Hasegawa 1)
Youhei Marukawa 2) 　　Fumio Otsuka 1)

1）Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
2）Department of Radiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences

JHGM 2020：3(1)：36-37

Brief report

Salivary gland enlargement manifested
in recurred acromegaly

Koichiro Yamamoto ※　　Kosuke Oka 　　Kou Hasegawa　　Tomoko Miyoshi
Mikako Obika　　Hiroko Ogawa　　Hitomi Kataoka 　　Fumio Otsuka

Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences

JHGM 2020：3(1)：38-39

Brief report

Acute ascending pattern of sensory and
motor symptoms due to metastatic epidural spinal
cord compression

Kiyoshi Shikino 1)※　　Hiraku Funakoshi 2)3) 　　Masatomi Ikusaka 1)

1）Department of General Medicine, Chiba University Hospital
2）Department of Emergency and Critical Care Medicine, Tokyo-bay Urayasu Ichikawa Medical Center
3）Department of Interventional Radiology, Tokyo-bay Urayasu Ichikawa Medical Center

JHGM 2020：3(1)：40-41

Letters to the editor

A Hand Shield for Healthcare Workers
-A Brief Report of New Type of
Personal Protective Equipment

Tomoya Tsuchida 1)※　　Yukitaka Yamasaki 2) 　　Masanori Hirose 1)
Hiroyuki Kunishima 2)　　Shigeki Fujitani 3) 　　Takahide Matsuda 1)

1）Division of General Internal Medicine, St Marianna University School of Medicine
2）Department of Infectious Diseases, St Marianna University School of Medicine
3）Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine