Clinical Utility of 4C Mortality Scores among Japanese COVID-19 Patients: A Multicenter Study

Background: We analyzed data from COVID-19 patients in Japan to assess the utility of the 4C mortality score as compared with conventional scorings. Methods: In this multicenter study, COVID-19 patients hospitalized between March 2020 and June 2021, over 16 years old, were recruited. The superiority for correctly predicting mortality and severity by applying the receiver operating characteristic (ROC) curve was compared. A Cox regression model was used to compare the length of hospitalization for each risk group of 4C mortality score. Results: Among 206 patients, 21 patients died. The area under the curve (AUC) (95% confidential interval (CI)) of the ROC curve for mortality and severity, respectively, of 4C mortality scores (0.84 (95% CI 0.76-0.92) and 0.85 (95% CI 0.80-0.91)) were higher than those of qSOFA (0.66 (95% CI 0.53-0.78) and 0.67 (95% CI 0.59-0.75)), SOFA (0.70 (95% CI 0.55-0.84) and 0.81 (95% CI 0.74-0.89)), A-DROP (0.78 (95% CI 0.69-0.88) and 0.81 (95% CI 0.74-0.88)), and CURB-65 (0.82 (95% CI 0.74-0.90) and 0.82 (95% CI 0.76-0.88)). For length of hospitalization among survivors, the intermediate- and high- or very high-risk groups had significantly lower hazard ratios, i.e., 0.48 (95% CI 0.30-0.76)) and 0.23 (95% CI 0.13-0.43) for discharge. Conclusions: The 4C mortality score is better for estimating mortality and severity in COVID-19 Japanese patients than other scoring systems

Deployment of Infectious Disease Experts an Prevalence of Antimicrobial Resistance in Okayama: A Call for Training of Specialists

Objective During the ongoing global pandemic of novel coronavirus disease 2019 (COVID-19), an emerging infectious disease, the implementation and execution of infection prevention and control (IPC) is of paramount importance. In this study, we aimed to assess the current deployment of infection control medical personnel in Okayama prefecture, who are supposed to play an essential role to prevent the outbreak of infectious diseases, and the current prevalence of antimicrobial-resistant (AMR) bacteria isolated in Okayama. Materials and methods This was a descriptive study using publicly available data. The numbers of infectious disease (ID)-doctors and the certified nurses in infection control (CNIC) per 100,000 population in 47 prefectures in Japan were calculated. We then compared the detected proportions of AMR pathogens among the prefectures in 2019 to be employed as a comparative parameter, which was obtained from Japan Nosocomial Infections Surveillance (JANIS) data. Results The number of ID-doctors was the 11th highest in Japan; however, they were unevenly distributed in southern Okayama, particularly at three tertiary hospitals. While the deployment of CNIC was geographically less uneven in the prefecture, their number was lower than the domestic average. According to the JANIS data, isolation rates of AMR pathogens were high in Okayama compared to other prefectures in Japan: vancomycin-resistant Enterococcus faecium (the third-worst); cefotaxime-resistant Escherichia coil and Klebsiella pneunioniae (the third-worst and the second-worst, respectively); and meropenem-resistant Pseudomonas aeruginosa (the worst). Conclusions Our assessment provides underlying data and reinforces the need for educating multi-professional experts in the field of infectious diseases to prevent future public health threats in Okayama

Increased Serum KL-6 Levels Induced by Pulmonary Mycobacterium Avium Complex Infection in a Patient with RA-associated Lung Disease

KL-6 is a glycoprotein found predominantly on type II pneumocytes and alveolar macrophages, and often shows increased serum levels in patients with interstitial pneumonia. We report a case of mycobacterium avium complex (MAC) infection whose disease activity was correlated with KL-6 levels in serum. During treatment of rheumatoid arthritis (RA)-associated interstitial lung disease (ILD) with prednisolone, chest image findings improved in association with decreased KL-6 levels. Following tapering of prednisolone, chest image findings deteriorated again as levels of KL-6 increased, suggesting recurrence of RA-ILD. Bronchoscopic examination revealed active MAC infection. Treatment of MAC infection not only improved chest image findings but also decreased KL-6 levels in serum, suggesting that KL-6 was increased by active MAC infection by itself, not by recurrence of RA-ILD. To the best of our knowledge, this is the first documentation of KL-6 elevation in serum in association with active MAC infection

Severe Gastritis after Administration of Nivolumab and Ipilimumab

Immune checkpoint inhibitors such as ipilimumab, a cytotoxic T-lymphocyte-associated antigen-4 inhibitor, have been widely used for advanced malignancies. As these inhibitors improve antitumor immunity via T-cell modulation, immune-mediated adverse events associated with T-cell activation, such as colitis, might occur. Herein, we describe a 75-year-old Japanese woman with metastatic malignant melanoma who developed hemorrhagic gastritis after ipilimumab treatment. There was no macroscopic or clinical improvement of gastritis after proton pump inhibitor treatment. However, her condition improved after approximately 3 weeks of corticosteroid therapy and Helicobacter pylori eradication. This case suggests a potential association between severe gastritis and immune checkpoint inhibitor treatment. Although several reports have mentioned ipilimumab-associated colitis, gastritis is considered to be rare. In the present case, H. pylori-associated gastritis might have been exacerbated by the T-cell modulation effect of ipilimumab. To date, no report has clarified the mechanism by which ipilimumab modifies H. pylori infection. The present treatment course provides a helpful perspective for similar cases

A Rare Case of Diffuse Large B-cell Lymphoma in a Patient with IgG4-Related Autoimmune Pancreatitis

A 61-year-old Japanese man with IgG4-related autoimmune pancreatitis was referred to our hospital because of perspiration during food intake. Abdominal computed tomography (CT) with contrast media revealed multiple mesenteric lymphadenopathies. An open surgical abdominal biopsy and subsequent histopathological analysis revealed abnormally large lymphoid cells that were negative for CD3, CD5, and c-myc and positive for CD20 and bcl-2, leading to a diagnosis of diffuse large B-cell lymphoma. Here, we discuss the risk of malignancies, particularly malignant lymphoma in patients with IgG4-related disease. The importance of pathological analysis to reach the appropriate diagnosis in such cases should be emphasized

Clinical Utility of 4C Mortality Scores among Japanese COVID-19 Patients: A Multicenter Study

Background: We analyzed data from COVID-19 patients in Japan to assess the utility of the 4C mortality score as compared with conventional scorings. Methods: In this multicenter study, COVID-19 patients hospitalized between March 2020 and June 2021, over 16 years old, were recruited. The superiority for correctly predicting mortality and severity by applying the receiver operating characteristic (ROC) curve was compared. A Cox regression model was used to compare the length of hospitalization for each risk group of 4C mortality score. Results: Among 206 patients, 21 patients died. The area under the curve (AUC) (95% confidential interval (CI)) of the ROC curve for mortality and severity, respectively, of 4C mortality scores (0.84 (95% CI 0.76–0.92) and 0.85 (95% CI 0.80–0.91)) were higher than those of qSOFA (0.66 (95% CI 0.53–0.78) and 0.67 (95% CI 0.59–0.75)), SOFA (0.70 (95% CI 0.55–0.84) and 0.81 (95% CI 0.74–0.89)), A-DROP (0.78 (95% CI 0.69–0.88) and 0.81 (95% CI 0.74–0.88)), and CURB-65 (0.82 (95% CI 0.74–0.90) and 0.82 (95% CI 0.76–0.88)). For length of hospitalization among survivors, the intermediate- and high- or very high-risk groups had significantly lower hazard ratios, i.e., 0.48 (95% CI 0.30–0.76)) and 0.23 (95% CI 0.13–0.43) for discharge. Conclusions: The 4C mortality score is better for estimating mortality and severity in COVID-19 Japanese patients than other scoring systems

An in-hospital relapse case of an elderly COVID-19 patient on steroids

　During a pandemic like the novel coronavirus infection 2019 (COVID-19), the availability of inpatient beds is always a major issue. Thus, it is extremely important to release patients from isolation efficiently in order to maintain stable bed operations. However, in clinical practice, patients may develop fever again, before or after the timing specified by the Ministry of Health, Labor and Welfare (MHLW) for lifting isolation, and hence it may be difficult to determine whether the fever is due to a delay in recovery or due to relapse. The diagnosis of relapse is based primarily on the recurrence of symptoms consistent with COVID-19 and a positive PCR result, but few reports have focused on comparing the patterns of variation in two or more blood test findings over the course of the disease. In the present study, we study a case of relapse in an elderly patient on immunosuppressive drugs. 　Understanding the unique patterns of variability between baseline blood test values and acute infection test values in each individual patient may serve as an adjunctive tool to help diagnose COVID-19 relapse

Experience with a nosocomial cluster of novel coronavirus infection and the cluster response algorithm

　The novel coronavirus disease (COVID-19) pandemic that began in 2019 is yet to end, as of the summer of 2022. During the pandemic, community-acquired infections spread easily to healthcare-associated facilities, resulting in COVID-19 clusters among high-risk individuals that have been difficult to contain. Our regional base hospital also experienced a nosocomial cluster of COVID-19 in October 2020 that took 30 days to contain and affected 9 hospital staff and 14 patients. Six patients died due to COVID-19, and six died due to COVID-19-related complications. Two patients were discharged alive. Patient characteristics included ① advanced age (79.0±8.1 years), ② dementia (64.3%), ③ low Prognostic Nutrition Index (31.1 ±7.9), ④ zinc deficiency (50.2±13.1μg/dL), ⑤ vitamin C deficiency (1.6±1.9μg/mL), ⑥ elevated urea nitrogen-to-creatinine ratio (27.4±23.5), ⑦ anticancer and immunosuppressive drug use (78.6%), and ⑧ malignancy (75.6%). This cluster had a very high mortality rate, but the viral spread was contained in a short period. Algorithmizing the cluster response was crucial to controlling this cluster. We report on our actual cluster response algorithm, as well as our strategy and response procedure during the pandemic