Close cooperation between infectious disease physicians and attending physicians can result in better management and outcome for patients with Staphylococcus aureus bacteraemia

Staphylococcus aureus bacteraemia (SAB) is a serious infection that demands prompt clinical attention for good outcome. To assess the impact of intervention by infectious diseases physicians (IDPs) in cases with SAB, a retrospective cohort study of patients with SAB was performed in a 1240-bed, university hospital in Japan, with the aim of comparing the management and outcome of patients during the initial and the latter half of the intervention period,. Three hundred and forty-six patients with SAB during the 7-year period, from 2002 to 2008, were included, and 194 patients in the initial half of the period (from 2002 to 2005) were compared with 152 patients in the later period (from 2006 to 2008). There was no significant difference between the two groups with respect to patient's clinical background, although more patients in the later period were receiving immunosuppressive treatment. The proportion of methicillin resistant S. aureus was lower during the later period (56.2% vs. 43.3%; p 0.02). Echocardiography was used more frequently (37.1% vs. 64.5%; p < 0.001). Infective endocarditis and metastatic infections were diagnosed more frequently (10.8% vs. 20.4%; p 0.01). Follow-up blood cultures were obtained more regularly (52.1% vs. 73.7%; p <0.001) and therapy was more frequently administered for at least 14 days (47.4% vs. 82.2%; p <0.001). The 30-day mortality improved during the intervention period (25.8% vs. 16.4%; p 0.04). The total number of blood cultures received by the laboratory increased annually and the total number of consultations increased by approximately 1.6-fold compared to 2002. Proactive intervention by IDPs raised awareness of optimal management of bacteraemia and improved the adherence to the standards of care, which subsequently resulted in an improvement in the outcome.

Development of ICF code selection tools for mental health care

BACKGROUND

The International Classification of Functioning, Disability and Health (ICF) has been available as a means of coding life functions but the coding process is cumbersome due to the large number of ICF codes. In the current study, we developed ICF code selection tools to support the coding of activity and participation data recorded in domiciliary mental health care reports.

METHODS

We first developed a search system to facilitate the selection of ICF codes by tracking back through codes' conceptual trees using a directory tool. We performed a morphological analysis on the training data set to correlate nouns with the ICF codes and obtained an analysis corpus to which numerical scores representing the frequencies of associated ICF codes for each noun were assigned. Based on the obtained corpus we developed a full-text search tool, which could simplify ICF coding relative to that performed using the directory tool. We then evaluated the usefulness of the former tool on the test data set.

RESULTS

Using the full-text search tool, correct ICF codes were recorded in the first candidate list for only 54.2% of sentences. However, correct ICF codes appeared on the combined candidate lists for 90.1% of sentences and on the top three candidate lists for 71.7%. In a specific case (General Tasks and Demands), 100% of the correct codes were included on the combined candidate lists.

CONCLUSION

We developed selection tools that effectively supported ICF coding, although it was impossible to fully automate ICF coding. This indicated that ICF codes could more effectively be applied to mental health care.

[Thoracoscopic surgery of mediastinal tumor]

The successful key of video-assisted thoracic surgery (VATS) to mediastinal tumors (MTs) should be the correct choice of surgical approach according to anatomical positions and relationships between large vessels and tumors. The middle and posterior MTs are good indications of VATS with intercostal approach under lateral position. The superior MTs are usually not indicated to VATS because of anatomical complexity of nerves and vessels of this area Thymus is the most frequent site of MTs and is in the narrow anterior mediastinum between sternum and heart. So that VATS to the anterior MTs needs some sternal lifting devices to get working space with appropriate combinations of intercostal, infrasternal and cervical approaches under supine position. Benign neurogenic tumors and congenital cysts are good indications of VATS. Thymic cyst, benign thymic tumor. such as mature teratoma, and small thymoma [noninvasive, diameter less than 5 cm, caudal position from left brachiocephalic vein (LBCV)] are now also indicated to VATS. Vessel sealing system LigaSure V is a computer control bipolar electric scalpel and be able to seal and cut safely up to diameter 7 mm vessels. LigaSure is suitable instrument for thymic vein handling, for esophageal muscle cutting, and for inflammatory teratoma dissection. This device is an essential device for VATS of MTs. The cases of mature teratoma and esophageal cyst were presented.

Isolation and characterisation of antibodies which specifically recognise the peptide encoded by exon 7 (v2) of the human CD44 gene

Aims-Exon 7 of the human CD44 gene is overexpressed in many commonly occurring carcinomas. The aim of the study was to explore the diagnostic and therapeutic potential of this frequent abnormality.Methods-A new monoclonal antibody (mAb, M-23.6.1) and a polyclonal antibody (pAb,S-6127) to the corresponding antigen were raised by immunising mice and sheep, respectively, with a specially constructed fusion protein HIV2 (gp32)-CD44 exon 7.Results-Characterisation of mAb, M-23.6.1 by ELISA, western blotting, immunocytochemistry, and FACS analysis confirmed that it specifically recognises an epitope in the region between amino acids 19 and 33 of the peptide encoded by this exon. Western blotting experiments with two cell lines, RT112 and ZR75-1, known from RT-PCR data to be overtranscribing the exon, yielded a monospecific band of approximately 220 kDa, and immunocytochemistry showed discrete membrane staining on the same cell lines. Fluorescent antibody cell sorting (FACS) revealed binding to greater than 90% of the cells of each of these lines. Specificity of recognition of the antigen was shown by inhibition of the precise immunoreactivity typically seen in ELISA and Western blots, by pre-incubation with synthetic exon 7 peptide or fragments of it.Conclusions-The new antibodies will be useful tools for the further analysis of abnormal CD44 isoforms and their clinical implications.

Non-invasive detection of bladder cancer by identification of abnormal CD44 proteins in exfoliated cancer cells in urine

Aims-To investigate the expression of CD44 proteins in exfoliated urothelial cells and in tumour tissues from bladder cancer patients. A further objective was to evaluate the diagnostic potential of the changes observed in the expression of these proteins as a marker for non-invasive detection of bladder cancer.Methods-Naturally voided urine specimens were collected from 47 patients with bladder cancer or severe urothelial dysplasia (n=3) and from a control group of 43 people with no evidence of neoplastic disease. Exfoliated urothelial cells floating in the urine were pelleted by centrifugation and lysed, and their constituent proteins extracted. The pattern of expression of CD44 proteins in each sample was examined by western blot analysis using a monoclonal antibody, Hermes 3, which recognises an epitope on the polypeptide backbone of the CD44 protein. Immunohistochemical studies were performed on neoplastic (n=10) and normal (n=4) bladder tissue specimens which were snap frozen in liquid nitrogen before examination with antibodies to CD44 gene products (CD44s and CD44v6).Results-Western blot analysis revealed several high molecular weight CD44 isoforms > 160 kDa in urine cell lysates from 75% of patients with histologically confirmed bladder cancer and in two of the three patients with severe dysplasia. Such patterns were not detected in the urine cell pellets from any persons in the control group. Immunohistochemical studies of the tissue distribution of CD44s and CD44v6 showed that the differentiation and maturation of the epithelial cells in the normal bladder mucosa is accompanied by a decrease in CD44 protein expression. However, carcinoma cells overexpress standard and variant CD44 isoforms and continue to do so as they proceed through the thickened epithelial layer to the luminal surface and after they are shed into the urine.Conclusions-The abnormal expression of CD44 proteins in exfoliated cancer cells may be a useful marker for the noninvasive diagnosis of bladder cancer.

[Obvious enlargement of the pulmonary hamartoma: report of a case]

A 72-year-old man was admitted to our hospital due to abnormal shadow in the right hilum by a routine chest X-ray. When we had another look at a chest X-ray that had been taken 6 years before, we had found a pulmonary nodule of 18 mm in size. The chest X-ray and computed tomography (CT) taken at admission showed a round nodule with calcification in the same site, with increasing in size to 30 mm. The tumor could not be clinically diagnosed and the surgery was scheduled because the nodule had grown and the possibility of a malignant tumor was suggested. At surgery, the tumor was easily enucleated and the pathological diagnosis was chondromatous hamartoma. Although pulmonary hamartoma is a benign tumor, operation should be performed when the tumor had grown.

Time process study with UML

OBJECTIVES

We propose a new business-process analysis approach, Time Process Study (TPS), which comprises process analysis and time and motion studies (TMS). TPS offsets weaknesses of TMS; the cost of field studies and the difficulties in applying them to tasks whose time span differs from those of usual tasks.

METHODS

In TPS, the job procedures are first displayed using a unified modeling language (UML). Next, time and manpower for each procedure are studied through interviews and TMS, and the information is appended to the UML diagram. We applied TPS in the case of a hospital-based cancer registry (HCR) of a university hospital to clarify the work procedure and the time required, and investigated TPS's availability.

RESULTS

Meetings for the study were held once a month from July to September in 2008, and one inquirer committed a total of eight hours to the hospital survey. TPS revealed that HCR consisted of three tasks and 14 functions. The registration required 123 hours/month/person, the quality control required 6.5 hours/ 6 months/person and filing data into the population-based cancer registry required 0.5 hours/6 months/person. Of the total tasks involved in registration, 116.5 hours/month/person were undertaken by a registration worker, which shows the necessity of employing one full-time staff.

CONCLUSION

With TPS, it is straightforward to share the concept among the study-team because the job procedure is first displayed using UML. Therefore, it requires a few workload to conduct TMS and interview. The obtained results were adopted for the review of staff assignment of HCR by Japanese government.

[Emergency distal arch replacement for traumatic thoracic aortic dissection with subarachnoid hemorrhage]

A 77-year-old woman was transferred as traumatic thoracic aortic dissection with subarachnoid hemorrhage soon after a traffic accident. Her consciousness was slightly compromised and cardiogenic shock was developed. Serial computed tomography (CT) scans revealed an unchanging subarachnoid hemorrhage and a progressive mediastinal hemorrhage and pericardial effusion due to traumatic type B aortic dissection. An emergency distal arch replacement was performed under cardiopulmonary bypass 4 hours after the injury. She woke up 3 days after the operation without progression of subarachnoid hemorrhage on a cerebral CT scan. She was discharged 36 days after the injury.

[Early malignant pleural mesothelioma; report of a case]

We report a case who had undergone operation of very early malignant pleural mesothelioma (MPM). A 58-year-old woman admitted to first visited hospital because of pleural effusion of the right side. She received a diagnosis of epithelial type MPM which had been confirmed from a pleural biopsy spacemen obtained by thoracoscopy under local anesthesia. An abnormal change of the pleura could not be detected on chest X-ray and thoracic computed tomography (CT) scan after chest drainage. She was referred to our hospital for surgery, and was undergone an extrapleural pneumonectomy followed by postoperative treatment with cisplatin puls gemcitabine. Pathologically, the disease was diagnosed as stage IA based on the classification of International Mesothelioma Interest Group (IMIG). There is a no evidence of the relapse 9 months after the operation. An early diagnosis of the MPM is very difficult. The thoracoscope with local anesthesia was very effective for early diagnose of a MPM.

[Evaluation of airway obstruction compressed by thoracic great vessels or their branches using multi-slice helical computed tomography]

Airway obstruction due to compression by the thoracic great vessels or their branches sometimes appears in patients with congenital heart disease. However, to make a definitive diagnosis may not be easy, because respiratory symptoms are common and stem from a variety of causes in this cohort. Thus, some invasive evaluation, including angiography, bronchial fiberscopy, and bronchography has usually been required. We employed multi-slice helical computed tomography (MSCT) and 3-dimensional (3D) image reconstruction in 7 cases (median age, 107 days ; range, 21 days to 6 years) who were suspected of complicating external vascular compression as a cause of respiratory symptoms. The CT scan clearly showed detailed anatomy of the thoracic vessels and interrelationship with the airway systems. It also disclosed a culprit artery compressing the trachea or bronchus. Different from other invasive or noninvasive examination modalities, MSCT allows precise evaluation of 2 independent organ systems, such as vascular and respiratory systems. We conclude that MSCT with 3D image reconstruction represents a reliable less-invasive technique for assessment of symptomatic airway obstruction caused by vascular compression.

Antitumor activity of NK012 combined with cisplatin against small-cell lung cancer and intestinal mucosal changes in tumor-bearing mouse after treatment

e13522

Background: The novel SN-38-incorporating polymeric micelles NK012 has been shown to have significant antitumor activity against several cancer mouse models compared with CPT-11. The phase I study demonstrated that patients treated with NK012 did not develop grade 3/4 diarrhea, one of the major adverse effects of CPT-11. The aim of this study is to investigate the advantages of NK012 combined with cisplatin (cis-dichlorodiammineplatinum (II): CDDP) over CPT-11/CDDP, one of the most active regimens against small-cell and non-small-cell lung cancers in the clinic, in mice bearing a small-cell lung cancer (SCLC) xenograft in terms of antitumor activity and toxicity, particularly intestinal toxicity. Methods: Cytotoxic effects were evaluated in human SCLC cell lines (H69, H82, vascular endothelial growth factor [VEGF]-secreting cells, SBC-3/VEGF and its mock transfectant SBC-3/Neo). In vivo antitumor effects were evaluated in SBC-3/Neo-and SBC-3/VEGF-bearing mice after NK012/CDDP or CPT-11/CDDP administration on days 0, 7, and 14. Drug distribution was analyzed by high-performance liquid chromatography or fluorescence microscopy, and the small intestine was pathologically examined. Results: The in vitro growth inhibitory effects of NK012 were 198- to 532-fold more potent than those of CPT-11. A significant difference in the relative tumor volume on day 30 was found between NK012/CDDP and CPT- 11/CDDP treatments (P=0.0058). Inflammatory changes in the small intestinal mucosa were rare in all NK012-treated mice, but were commonly observed in CPT-11-treated mice. Moreover, a large amount of CPT-11 was excreted into the feces and high CPT-11 concentration was detected in the small intestinal epithelium. On the other hand, a small amount of NK012 was found in the feces and NK012 was weakly and uniformly distributed in the mucosal interstitium. Conclusions: NK012/CDDP combination may be a promising candidate regimen against lung cancer without severe diarrhea toxicity, and therefore warrants further clinical evaluation.

No significant financial relationships to disclose.

Asymptomatic pericardial effusion in patients with systemic lupus erythematosus

To determine the frequency and clinical correlates of asymptomatic pericardial effusion (PE) in patients with systemic lupus erythematosus (SLE), echocardiography and electrocardiography were performed in 50 consecutive patients with SLE. Among 50 patients with SLE, 12 patients (24%) had PE and 17 patients (34%) had hypoalbuminaemia. Patients with PE had a significantly lower serum albumin (P < 0.001), higher incidence of proteinuria (P = 0.003), higher C-reactive protein (P = 0.036) and pulmonary artery systolic pressure (P = 0.011) and tended to have a higher incidence of PR-segment depression (P = 0.082) compared with those without PE. When four variables (PR-segment depression, C-reactive protein, serum albumin and pulmonary artery systolic pressure) were used in the multivariate analysis, serum albumin (P = 0.005, odds ratio = 0.016) and pulmonary artery systolic pressure (P = 0.010, odds ratio = 1.106) emerged as significant variables related to the occurrence of asymptomatic PE. Thus, an increase in hydrostatic pressure of the right heart cavities and a decrease in colloid osmotic pressure were important factors associated with the presence of asymptomatic PE in patients with SLE.

[Extended septoplasty for left ventricular outflow tract obstruction after the intracardiac repair of double outlet right ventricle]

A 14-year-old boy with a left ventrivular outflow tract obstruction (LVOTO) after the repair of double outlet right ventricle (DORV) at the age of 7 months was successfully treated with an extended septoplasty. A significant pressure gradient occurred between the left ventricle and the ascending aorta of 70 mmHg in spite of the previous surgery for LVOTO with muscle resection and the ventricular septal defect (VSD) patch enlargement at the age of 5. An extended septoplasty was performed including extensive resection of the conus muscle and the previously placed patch, long incision on the interventricular septum toward the apex, and reconstruction of the outflow tract using a Hemashield patch. The cathterization 10 months after the operation revealed an effective relief of LVOTO with left ventricle (LV) and aorta (Ao) pressure of 115 and 103 mmHg, respectively. An extended septoplasy is effective for the relief of LVOTO, but further follow-up is mandatory of both the left ventricular function and mitral valve function.

[Local recurrence of Castleman disease]

A rare case of recurrent Castleman disease is reported. A 49-year-old man was referred to our division under the suspicion of mediastinal tumor. We performed tumor resection successfully, and the tumor was shown to be Castleman disease by histology. The patient had a past history of this disease, therefore it was suggested that the tumor recurred at the same site 20-years after removal.