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Junko Iwatsuki,1,2 Takeshi Kondo,3 Noriyuki Takahashi,3– 5 Hideki Takami,3 Hiroshi Nishigori,6 Itzel Bustos-Villalobos,7 Branko Aleksic,7,8 Hideki Kasuya,7 Nobutaro Ban,9 Tetsuya Yagi,10 Norbert Skokauskas11,12 1International Collaboration Planning Center, Institute of International Education and Exchange, Nagoya University, Nagoya, Japan; 2Present Affiliation is Office for International Education and Exchange, Faculty and Graduate School of Economics, Kobe University, Kobe, Japan; 3Center for Postgraduate Clinical Training and Career Development, Nagoya University Hospital, Nagoya, Japan; 4Department of General Medicine/Family & Community Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan; 5Department of Education for Community-Oriented Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan; 6Center for Medical Education, Nagoya University Graduate School of Medicine, Nagoya, Japan; 7Department of International Medical Education, Nagoya University Graduate School of Medicine, Nagoya, Japan; 8Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya, Japan; 9Medical Education Center, Aichi Medical University School of Medicine, Nagakute, Japan; 10Department of Infectious Diseases, Nagoya University Graduate School of Medicine, Nagoya, Japan; 11Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Norwegian University of Science and Technology, Trondheim, Norway; 12Department of Child and Adolescent Psychiatry, St. Olavs University Hospital, Trondheim, NorwayCorrespondence: Branko AleksicNagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-ku, Nagoya, 466-8550, JapanTel +81 52 7442282Fax +81 52 7442293Email branko@med.nagoya-u.ac.jpPurpose: Japanese higher education institutions have long been striving for the globalization of medical education. Nagoya University (NU) adopted PBL as a means of enhancing intercultural awareness in globalizing medical education by working with the Norwegian University of Science and Technology (NTNU), Faculty of Medicine and Health Science, under the Trondheim NTNU-Nagoya (TroNa) partnership for mobility and internationalization of child and mental health studies. This study aims to assess students’ attitudes towards PBL and to suggest future developments in this form of education by introducing common PBL scenarios experienced at NTNU and NU.Methods: Two 90-minute PBL sessions were conducted at NU. Ten groups of medical students were formed, each consisting of up to 10 students, and students were asked to fill in a questionnaire developed to assess their understanding of, attitudes to and satisfaction with the classes. We investigated three different groups of questions on: NU medical students’ general impressions of PBL; their impressions of PBL in child and adolescent psychiatry (CAP); and their impressions of PBL in specific case scenarios. Correlations between each of the questions from the three groups were evaluated using multivariate analysis.Results: Overall, a majority of the NU medical students were satisfied with PBL, while a small number preferred traditional lecture-style learning (5%). More than half of the students agreed that PBL increased their understanding and interest in CAP (53%), although some male students felt that the amount of time spent was insufficient (20.3%). Correlations were seen for students who thought that PBL enhanced their understanding of and interest in CAP. Regarding case scenarios, most students (82.5%) agreed that PBL helped them to develop clinical problem-solving skills.Conclusion: The study found an overall positive attitude towards PBL, PBL in CAP and the specific PBL case scenario presented.Keywords: problem-based learning, child psychiatry, children and mental health, English medical education, internationalization

Daisuke Kobayashi,1,2 Yuichiro Shindo,2 Ryota Ito,2,3 Mai Iwaki,4,5 Junya Okumura,2,6 Toshihiro Sakakibara,2,7 Ikuo Yamaguchi,8 Tetsuya Yagi,9 Tomohiko Ogasawara,4 Yasuteru Sugino,6 Hiroyuki Taniguchi,7 Hiroshi Saito,10 Hideo Saka,11 Takashi Kawamura,1 Yoshinori Hasegawa2 On behalf of the Central Japan Lung Study Group 1Kyoto University Health Service, Kyoto, Japan; 2Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan; 3Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; 4Department of Respiratory Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan; 5Department of Respiratory Medicine, Kasugai Municipal Hospital, Kasugai, Japan; 6Department of Respiratory Medicine, Toyota Memorial Hospital, Toyota, Japan; 7Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan; 8Department of Central Laboratory, Toyohashi Municipal Hospital, Toyohashi, Japan; 9Department of Infectious Diseases, Nagoya University Hospital, Nagoya, Japan; 10Department of Respiratory Medicine, Aichi Cancer Center Aichi Hospital, Okazaki, Japan; 11Department of Respiratory Medicine, National Hospital Organization, Nagoya Medical Center, Nagoya, Japan Background: Appropriate initial antibiotic treatment and avoiding administration of unnecessary broad-spectrum antibiotics are important for the treatment of pneumonia. To achieve this, assessment of risk for drug-resistant pathogens (DRPs) at diagnosis is essential.Purpose: The aim of this study was to validate a predictive rule for DRPs that we previously proposed (the community-acquired pneumonia drug-resistant pathogen [CAP-DRP] rule), comparing several other predictive methods.Patients and methods: A prospective observational study was conducted in hospitalized patients with community-onset pneumonia at four institutions in Japan. Pathogens identified as not susceptible to ceftriaxone, ampicillin–sulbactam, macrolides, and respiratory fluoroquinolones were defined as CAP-DRPs.Results: CAP-DRPs were identified in 73 (10.1%) of 721 patients analyzed. The CAP-DRP rule differentiated low vs high risk of CAP-DRP at the threshold of ≥3 points or 2 points plus any of methicillin-resistant Staphylococcus aureus specific factors with a sensitivity of 0.45, specificity of 0.87, positive predictive value of 0.47, negative predictive value of 0.87, and accuracy of 0.79. Its discrimination performance, area under the receiver operating characteristic curve, was 0.73 (95% confidence interval 0.66–0.79). Specificity of the CAP-DRP rule against CAP-DRPs was the highest among the six predictive rules tested.Conclusion: The performance of the predictive rules and criteria for CAP-DRPs was limited. However, the CAP-DRP rule yielded high specificity and could specify patients who should be treated with non-broad-spectrum antibiotics, eg, a non-pseudomonal β-lactam plus a macrolide, more precisely. Keywords: antibiotic resistance, algorithms, community-acquired pneumonia, healthcare-associated pneumonia

Motoi Ugajin, Kenichi Yamaki, Natsuko Hirasawa, Takanori Kobayashi, Takeo Yagi Department of Respiratory Medicine, Ichinomiya-Nishi Hospital, Ichinomiya City, Japan Background: The credibility of prognostic indicators in nursing-home-acquired pneumonia (NHAP) is not clear. We previously reported a simple prognostic indicator in community-acquired pneumonia (CAP): blood urea nitrogen to serum albumin (B/A) ratio. This retrospective study investigated the prognostic value of severity indicators in NHAP versus CAP in elderly patients. Methods: Patients aged ≥65 years and hospitalized because of NHAP or CAP within the previous 3 years were enrolled. Demographics, coexisting illnesses, laboratory and microbiological findings, and severity scores (confusion, urea, respiratory rate, blood pressure, and age ≥65 [CURB-65] scale; age, dehydration, respiratory failure, orientation disturbance, and pressure [A-DROP] scale; and pneumonia severity index [PSI]) were retrieved from medical records. The primary outcome was mortality within 28 days of admission. Results: In total, 138 NHAP and 307 CAP patients were enrolled. Mortality was higher in NHAP (18.1%) than in CAP (4.6%) (P

Motoi Ugajin, Kenichi Yamaki, Natsuko Hirasawa, Takanori Kobayashi, Takeo YagiDepartment of Respiratory Medicine, Ichinomiya-Nishi Hospital, Ichinomiya City, Aichi Prefecture, JapanBackground: The efficacy of systemic corticosteroids in community-acquired pneumonia (CAP) has not yet been confirmed. We prospectively investigated the clinical features of patients treated with early adjunctive systemic corticosteroids and its clinical impact in very severe CAP.Methods: One hundred and one consecutive CAP patients having a pneumonia severity index of >130 points were enrolled from August 2010 through February 2013. Early adjunctive systemic corticosteroids were defined as administration of systemic corticosteroids equivalent to prednisone of ≥20 mg/day added to initial antibiotics. The multivariate analysis was performed to evaluate the independent factors associated with mortality.Results: Thirty-two patients (31.7%) died within 28 days of admission. Early adjunctive systemic corticosteroids were administered in 30 patients (29.7%), who more frequently had alteration of mental status, serious respiratory failure, or underlying lung diseases and received fluoroquinolones as initial antibiotics. In most patients treated with early adjunctive systemic corticosteroids, the dosage was less than 60 mg/day of an equivalent to prednisone by bolus intravenous infusion for a period shorter than 8 days. The occurrence of adverse events did not differ between the groups. Factors independently associated with mortality were blood urea nitrogen (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1.00–1.04), serum albumin (HR 0.44, 95% CI 0.22–0.86), a requirement for intensive care (HR 4.93, 95% CI 1.75–13.87), and the therapy with early adjunctive systemic corticosteroids (HR 0.29, 95% CI 0.11–0.81).Conclusion: Early adjunctive systemic corticosteroids may have an effect to reduce the mortality in very severe CAP, although a larger-scale study is necessary.Keywords: pneumonia severity index, initial antibiotics, mortality, intensive care, community-acquired pneumonia, corticosteroids

Yoshitsugu Matsui, Hideyuki Tsukitome, Eriko Uchiyama, Yuko Wada, Tatsuya Yagi, Hisashi Matsubara, Mineo KondoDepartment of Ophthalmology, Mie University Graduate School of Medicine, Tsu, JapanAbstract: We report a patient with frosted branch-like appearance retinal vasculitis associated with peripheral capillary nonperfusion and full-field electroretinographic changes. A 62-year-old man presented with sudden bilateral decreased vision accompanied by headaches. His best-corrected visual acuity was 0.01 in both eyes. Fundus examination and fluorescein angiography showed bilateral frosted branch-like appearance retinal vasculitis, and spectral-domain optical coherence tomography showed severe macular edema in both eyes. The cerebrospinal fluid analyses showed an increased lymphocyte count and protein levels. He was treated with systemic corticosteroid therapy, and his best-corrected visual acuity improved to 0.8 OD and 1.0 OS at 6 months after onset. However, fluorescein angiography showed a lack of capillary perfusion in the periphery, and the oscillatory potentials on full-field electroretinography were severely reduced in both eyes. These findings indicated extensive retinal ischemia and inner retinal dysfunction, and that fluorescein angiography and full-field electroretinograms can be useful during follow-up of eyes with frosted branch-like appearance retinal vasculitis.Keywords: frosted branch angiitis, aseptic meningitis, optical coherence tomography, electroretinogram, oscillatory potentials

Motoi Ugajin, Kenichi Yamaki, Natsuko Iwamura, Takeo Yagi, Takayuki AsanoDepartment of Respiratory Medicine, Ichinomiya-Nishi Hospital, Ichinomiya City, Aichi Prefecture, JapanBackground: Early studies of community-acquired pneumonia showed that nonsurvivors had higher blood urea nitrogen levels and lower serum albumin levels than survivors. Therefore, elevation of the blood urea nitrogen to serum albumin (B/A) ratio may identify patients with community-acquired pneumonia who are becoming critically ill. This study investigated the correlation between commonly used laboratory markers, in particular the B/A ratio, and clinical outcomes of community-acquired pneumonia.Methods: This observational study was performed in consecutive patients with community-acquired pneumonia admitted to our hospital over a period of one year. Blood counts, commonly used laboratory markers, microbiological tests, and calculation of Pneumonia Severity Index (PSI) and CURB-65 were done on admission. The endpoints were mortality within 28 days of admission and requirement for intensive care.Results: One hundred and seventy-five patients with community-acquired pneumonia were enrolled. Nineteen patients died within 28 days of admission and 29 patients required intensive care. Using multivariate analysis, independent factors associated with mortality were the requirement for intensive care (odds ratio [OR] 14.96, 95% confidence interval [CI] 3.73–60.03, P < 0.001), PSI class (OR 3.55, 95% CI 1.08–11.66, P = 0.037), and B/A ratio (OR 1.10, 95% CI 1.01–1.20, P = 0.037). Similarly, independent factors associated with need for intensive care were PSI class (OR 5.35, 95% CI 1.90–15.06, P = 0.002), CURB-65 (OR 2.37, 95% CI 1.26–4.45, P = 0.007), and B/A ratio (OR 1.27, 95% CI 1.09–1.47, P = 0.002).Conclusion: The B/A ratio is a simple but independent predictor of mortality and severity of community-acquired pneumonia.Keywords: blood urea nitrogen to serum albumin ratio, Pneumonia Severity Index, CURB-65, community-acquired pneumonia, mortality, severity

Chikako Suto1,2, Masahiro Morinaga1,2, Tomoko Yagi1,2, Chieko Tsuji3, Hiroshi Toshida41Department of Ophthalmology, Saiseikai Kurihashi Hospital, Saitama; 2Department of Ophthalmology, Tokyo Women's Medical University, Tokyo; 3Department of Clinical Laboratory, Saiseikai Kurihashi Hospital, Saitama; 4Department of Ophthalmology, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, JapanObjective: To determine the trends of conjunctival sac bacterial flora isolated from patients prior to cataract surgery.Subjects and methods: The study comprised 579 patients (579 eyes) who underwent cataract surgery. Specimens were collected by lightly rubbing the inferior palpebral conjunctival sac with a sterile cotton swab 2 weeks before surgery, and then cultured for isolation of bacteria and antimicrobial sensitivity testing. The bacterial isolates and percentage of drug-resistant isolates were compared among age groups and according to whether or not patients had diabetes mellitus, hyperlipidemia, dialysis therapy, oral steroid use, dry eye syndrome, or allergic conjunctivitis.Results: The bacterial isolation rate was 39.2%. There were 191 strains of Gram-positive cocci, accounting for the majority of all isolates (67.0%), among which methicillin-sensitive coagulase-negative staphylococci was the most frequent (127 strains, 44.5%), followed by methicillin-resistant coagulase-negative staphylococci (37 strains, 12.7%). All 76 Gram-positive bacillary isolates (26.7%) were from the genus Corynebacterium. Among the 16 Gram-negative bacillary isolates (5.9%), the most frequent was Escherichia coli (1.0%). The bacterial isolation rate was higher in patients >60 years old, and was lower in patients with dry eye syndrome, patients under topical treatment for other ocular disorders, and patients with hyperlipidemia. There was no significant difference in bacterial isolation rate with respect to the presence/absence of diabetes mellitus, steroid therapy, dialysis, or a history of allergic conjunctivitis. Methicillin-resistant coagulase-negative staphylococci showed a significantly higher detection rate in diabetic patients than nondiabetic patients (20.3% versus 7.0%, P < 0.05). The percentage of all isolates resistant to levofloxacin, cefmenoxime, and tobramycin was 14.0%, 15.2%, and 17.9%, respectively, with no significant differences among these drugs.Conclusion: The high bacterial isolation rate in patients >60 years old and the high methicillin-resistant coagulase-negative staphylococci isolation rate in patients with diabetes are important to consider for prevention of perioperative infections.Keywords: endophthalmitis, cataract surgery, conjunctival sac, bacterial flora, diabetes mellitus