[Extended-spectrum beta-lactamase (ESBL) produced by Escherichia coli and Klebsiella pneumoniae isolated from Teikyo University Hospital--the second report]

We studied the high-level resistant to cefotaxime (CTX, MIC > or = 512 micrograms/ml) clinical isolates of Escherichia coli and Klebsiella pneumoniae in Teikyo University Hospital. The CTX-resistance could be transferred to E. coli K-12 chi 1037 or ML4903 strains from 30 of the 33 isolates by conjugation at a frequency of 10(-4). When the hydrolysis rate of benzylpenicillin was 100%, the beta-lactamases which were extracted from the transconjugants hydrolyzed CTX, CAZ and AZT at the rate of 38-95%, 0-8.6% and 0-56%, respectively. These results demonstrate that these enzymes should be categorized into ESBL. The nucleotide sequence of CTX-resistant gene was identified to that of the CTX-M2 gene which was first described in Argentina. It was found to have 99.9% homology to Toho-1 gene in Japan and 99.6% homology to CMY-2 gene. Using a PCR methods for the detection of one of ESBL gene such as CTX-M2, Toho-1 or CMY-2, the DNA was amplified from all strains (11 isolates of E. coli and 21 isolates of K. pneumoniae).

[Detection methods for drug-resistant bacteria in routine examination--VRE]

When testing vancomycin susceptibility against enterococci, plates should be held a full 24 hours then examined using transmitted light. The presence of a haze or any growth within the zone of inhibition indicates resistance. Perform vancomycin MIC and tests for motility and pigment production to distinguish species with acquired resistance(vanA and vanB) from those with intrinsic, intermediate-level resistance to vancomycin(vanC) such as E. gallinarum, E. casseliflavus or E. flavescens.

Bleaching effect of sodium percarbonate on discolored pulpless teeth in vitro

The purpose of this study was to evaluate the bleaching effect of sodium percarbonate on artificially stained pulpless teeth. Twenty extracted human mandibular premolars were stained by immersing them in human blood mixed with iron sulfide, and divided into three test groups and one control group. The following bleaching agents were used: sodium perborate mixed with 30% hydrogen peroxide (WB), sodium percarbonate mixed with distilled water (PW) or 30% hydrogen peroxide (PH). On days 5, 10, and 15, each pulp chamber was refilled with fresh bleaching paste. The L* (average lightness) of the midbuccal area of specimens was measured before and after staining, and on days 5, 10, 15, and 20 by colorimeter. The bleaching effect was evaluated by the lightness recovery rate (LRR) calculated from L*. WB showed the highest LRR among all groups, and PW and PH showed significantly higher LRR when compared with the control group. PW and PH were not significantly different. Results showed that sodium percarbonate had an obvious bleaching effect without hydrogen peroxide and indicated that it could be a safe intracoronal bleaching agent.

Retrospective analysis of type of hepatic resection for hepatocellular carcinoma

BACKGROUND

Hepatic resection for hepatocellular carcinoma is now considered a relatively safe procedure, owing to refined surgical techniques and management.

METHODS

Three hundred different types of hepatic resection performed in one hospital were reviewed retrospectively. The operative morbidity and mortality rates and long-term survival were assessed.

RESULTS

Tumours were extirpated by lobectomy or extended lobectomy in 48 patients, by segmentectomy in 53, by subsegmentectomy in 94 and by partial resection in 105. The overall hospital mortality rate was 4 per cent (13 of 300). No operative death occurred after lobectomy or extended lobectomy. Segmentectomy and subsegmentectomy were associated with high postoperative complication and hospital mortality rates. There was a significant difference in survival rate between patients with and without a cancer-free surgical margin of more than 1.0 cm. The overall 5- and 9-year survival rates were 51 and 9 per cent respectively. Rates were 56 and 24 per cent for lobectomy or extended lobectomy.

CONCLUSION

For tumours of 2.1 cm or more in size lobectomy appears to carry the least risk of postoperative complications and death in hospital and best achieves a cancer-free surgical margin.

Burn due to misuse of an acetylene gas burner: a case report

A rare case of deep penetrating burn injury caused by misuse of a high-pressure acetylene burner is reported. A 35 year old man was admitted with second and third degree burns involving the right arm cubital area and a subcutaneous burn on his right arm caused by a high-pressure acetylene gas flame. Early surgical debridement and secondary skin grafting using a preserved subcutaneous vascular network skin graft (PSVNSG) proved effective in this patient. Skin contracture was prevented and function was recovered. The basis of PSVNSG is that the vascular system existing in the graft is used as a permanent vascular system without degeneration. This case shows that, in this kind of burn injury, subcutaneous tissue damage should be suspected and that it is important to perform surgical debridement early after admission.

Balloon-occluded retrograde transvenous embolization of a pelvic arteriovenous malformation

We successfully performed embolization therapy for a pelvic arteriovenous malformation by the retrograde transvenous approach using a liquid embolic material. This malformation was unique in that it had a single draining vein, which allowed this technique employing an occlusion balloon.

[Extended-spectrum beta-lactamase (ESBL) produced by Escherichia coli and Klebsiella pneumoniae isolated from Teikyou University Hospital--the first report]

We studied the cefotaxime (CTX)-resistant (MIC > or = 32 micrograms/ml) clinical isolates of E. coli and K. pneumoniae in Teikyo University Hospital from 1990 to 1996. The incidence of CTX-resistant isolates was 0.4% (6/1,282) in E. coli and 0.6% (7/1,044) in K. pneumoniae, in 1990. In 1995, the incidence of CTX-resistance increased to 1.7% (50/2,910) in E. coli (p = 0.0013) and 7.2% (144/1,996) in K. pneumoniae (p < 0.0001). These species have been detected in the stool (86 isolates), urine (59 isolates), sputum (15 isolates), pus (15 isolates), throat (10 isolates) and others (12 isolates) in 1995. MIC50 of ampicillin (ABPC), ABPC with clavlanic acid (CVA) 5 micrograms/ml, piperacillin (PIPC), PIPC with CVA 5 micrograms/ml, ceftazidime, CTX, ceftizoxime, cefpodoxime, cefepime, aztreonam, cefmetazole, latamoxef, and imipenem used against 33 isolates (11 isolates of E. coli, 22 isolates of K. pneumoniae), which were detected in 1996-1997, was > 512 micrograms/ml, 8 micrograms/ml, > 512 micrograms/ml, 8 micrograms/ml, 4 micrograms/ml, > 512 micrograms/ml, 16 micrograms/ml, > 512 micrograms/ml, 256 micrograms/ml, 32 micrograms/ml, 2 micrograms/ml, 0.25 microgram/ml and 0.25 microgram/ml, respectively. This susceptibility pattern were very similar to the Toho-1 type beta-lactamases producing strains.

MT neurons in the macaque exhibited two types of bimodal direction tuning as predicted by a model for visual motion detection

We previously proposed a model for detecting local image velocity on the magnocellular visual pathway (Kawakami & Okamoto (1996) Vision Research, 36, 117-147). The model detects visual motion in two stages using the hierarchical network that includes component and pattern cells in area MT. To validate the model, we predicted two types of bimodal direction tuning for MT neurons. The first type is characteristic of component cells. The tuning is bimodal when stimulated with high-speed spots, but unimodal for low-speed spots or for bars. The interval between the two peaks widens as the spot's speed increases. The second type is characteristic of pattern cells. The tuning is bimodal when stimulated with low-speed bars, but unimodal for high-speed bars or for spots. The interval widens as the bar's speed decreases. To confirm this prediction, we studied the change of direction tuning curves for moving spots and bars in area MT of macaque monkeys. Out of 35 neurons measured at various speeds, six component cells and four pattern cells revealed the predicted bimodal tunings. This result provided neurophysiological support for the validity of the model. We believe ours is the first systematic study that records the two types of bimodality in MT neurons.

[Sarcomatoid carcinoma of the urinary bladder in a hemodialysis patient: a case report]

The following is a case report bladder of sarcomatoid carcinoma in a Japanese 65-year old female patient treated with hemodialysis. She developed chronic renal failure due to chronic glomerulonephritis. Fifteen months after the beginning of the hemodialysis, continuous gross hematuria was noticed, and cystoscopy revealed a broad-based bladder tumor spreading from the right lateral wall to the posterior wall. The histopathologic diagnosis of the TUR-Bt specimens was sarcoma. Radical cystectomy was performed under the diagnosis clinical stage III, T3bN0M0. The post-operative histopathologic diagnosis of the tumor was sarcomatoid carcinoma, composed of nests of transitional cell carcinoma (G 3) and predominant areas of spindle cell sarcomatoid transformation. Sarcomatoid carcinoma of the bladder in a hemodialysis patient is extremely rare, and to date this may be only the second case in Japanese medical literature.

Lens-free in-line optical isolators

We constructed a lens-free in-line optical isolator by embedding an isolator chip in a thermally expanded core (TEC) fiber without complicated optical alignment. The chip consists of two pairs of rutile wedges and garnet plates. We fabricated the TEC fibers by heating a single-mode fiber with a 200-mum outer diameter; low loss and a spot diameter as large as 49 mum were successfully obtained. The fabricated isolator has excellent optical properties, an insertion loss of 0.45 dB, and an isolation of more than 50 dB at a 1.55-mum wavelength, which confirms the usefulness of the integration techniques.

[Effect of preventive measures against central venous catheter-related infection: retrospective study in our division for recent 10 years]

A study was made of 2202 central venous catheters (CVC), which were inserted for recent 10 years, to know the effect of preventive measures against CVC-related infection. We divided 10 years in 3 periods: 1987-1990 (the first period), 1991-1993 (the second period), and 1994-1996 (the third period). Preventive measures such as thorough antiseptic precaution, shortening of CVC dwelling time, and prohibition of injection from three-way stopcocks were taken after the second period. In the third period, semiclosed infusion system (I-system) was introduced to our division. A febrile catheterized patient (higher than 38 degrees C) was diagnosed as CVC-related infection when the fever dropped immediately (within 72 hours) after removal of CVC, or when the tip of the CVC was positive for culture. The rate of CVC-related infection in the second (9.9%) or the third (7.3%) period was significantly lower than that (14.0%) of the first period (p < 0.05 and p < 0.001, respectively). The mean dwelling time of CVC was 31.5 days for the first period, 27.0 days for the second period, and 24.8 days for the third period. The rate of long-term dwelling catheters (more than 29 days) in the second (34.5%) or the third (28.7%) period was significantly lower than that (40.5%) in the first period (p < 0.01 and p < 0.001, respectively). The index of CVC-related infection (incidence of infection per 1,000 days) was 4.8 for the first period, 3.7 for the second period, and 2.9 for the third period. The rate of infection of short-term dwelling CVC (less than 28 days) in the second (9.5%) or the third (6.3%) period was significantly lower than that (16.0%) of the first period (p < 0.01 and p < 0.001, respectively). As to cultures of CVC and/or blood sample, the isolation rate of fungi decreased significantly (p < 0.001), and that of gram-negative rods showed a tendency to increase after the second period. It was concluded that shortening of CVC dwelling time and application of semiclosed infusion system were effective to reduce the rate of CVC-related infection.

Rupture of a pancreatic pseudocyst into the portal venous system

Pseudocyst formation is a well-known complication of acute or chronic pancreatitis. We report a case in which pseudocyst ruptured into the splenic and portal veins.

Phosphorylation and/or presence of serine 37 in the movement protein of tomato mosaic tobamovirus is essential for intracellular localization and stability in vivo

The P30 movement protein (MP) of tomato mosaic tobamovirus (ToMV) is synthesized in the early stages of infection and is phosphorylated in vivo. Here, we determined that serine 37 and serine 238 in the ToMV MP are sites of phosphorylation. MP mutants in which serine was replaced by alanine at positions 37 and 238 (LQ37A238A) or at position 37 only (LQ37A) were not phosphorylated, and mutant viruses did not infect tobacco or tomato plants. By contrast, mutation of serine 238 to alanine did not affect the infectivity of the virus (LQ238A). To investigate the subcellular localization of mutant MPs, we constructed viruses that expressed each mutant MP fused with the green fluorescent protein (GFP) of Aequorea victoria. Wild-type and mutant LQ238A MP fusion proteins showed distinct temporally regulated patterns of MP-GFP localization in protoplasts and formation of fluorescent ring-shaped infection sites on Nicotiana benthamiana. However mutant virus LQ37A MP-GFP did not show a distinct pattern of localization or formation of fluorescent rings. Pulse-chase experiments revealed that MP produced by mutant virus LQ37A was less stable than wild-type and LQ238A MPs. MP which contained threonine at position 37 was phosphorylated, but the stability of the MP in vivo was very low. These studies suggest that the presence of serine at position 37 or phosphorylation of serine 37 is essential for intracellular localization and stability of the MP, which is necessary for the protein to function.

Regulation of lutenizing hormone secretion and subunit messenger ribonucleic acid expression by gonadal steroids in perifused pituitary cells from male monkeys and rats

The mechanisms by which gonadal steroids regulate gonadotropin secretion remain incompletely understood. As previous studies suggest that the pituitary actions of testosterone (T) and estradiol (E) differ in male primates and rodents, we compared the effects of 10 nM T, 0.1 nM E, and 10 nM dihydrotestosterone (DHT) on the LH response to hourly pulses of GnRH as well as the GnRH receptor (GnRH-R) and LH subunit messenger RNA (mRNA) levels in dispersed pituitary cells from intact male monkeys and rats. T suppressed (P < 0.01) and E increased (P < 0.05) GnRH-stimulated LH secretion by rat pituitary cells. With monkey pituitary cells, on the other hand, there was no significant effect of either T or DHT on GnRH-stimulated LH secretion. In E-treated monkey cells, a period of initial enhancement (P < 0.05) was followed by significant suppression (P < 0.05) of LH secretion. GnRH-R mRNA was unchanged by T or E in either rat or monkey cells. T suppressed LHbeta (P < 0.01) and alpha-subunit (P < 0.01) mRNAs, whereas E increased alpha-subunit (P < 0.01), but did not alter LHbeta mRNA levels in rat cells. In monkey cells, however, neither T nor E affected LHbeta or alpha-subunit mRNA levels significantly. Our results identify different regulatory mechanisms by which testicular steroid hormones control LH secretion by the pituitary in male primates and rodents. We propose that the primary site of androgen negative feedback in the male primate is to restrain GnRH pulsatile secretion, whereas in the male rat T also decreases gonadotropin synthesis and secretion by directly affecting the pituitary. E suppresses GnRH-stimulated LH secretion in the primate pituitary, but amplifies the action of GnRH in the rat. Our data also reveal that the action of T to suppress LH secretion and subunit mRNA in male rats is not through decreased GnRH-R gene expression.

Detection of disseminated urothelial cancer cells in peripheral venous blood by a cytokeratin 20-specific nested reverse transcriptase-polymerase chain reaction

More than half of all patients with invasive urothelial cancer subsequently develop metastatic disease even after radical resection of the primary cancer. In these patients, neoplastic cells may be disseminated prior to or during the operation. A nested reverse transcriptase-polymerase chain reaction (nested RT-PCR) assay which amplifies cytokeratin (CK) 20 transcripts was used to detect cancer cells in the peripheral blood of urothelial patients. This assay was able to detect 10 bladder cancer cell line cells in a sample of ten million peripheral-blood mononuclear (PBMN) cells. CK 20-specific signals were detected in 9 (22.5%) of 40 PBMN cell samples prepared from 40 urothelial cancer patients in relation to the tumor stage, including 0/13 patients with a superficial tumor, 4/21 (19%) with a regionally invasive tumor and 5/6 (83%) with a metastatic tumor (P = 0.0002 in chi 2 test). No signals were detected in any of 25 healthy donor PBMN cell samples. The present results indicate that the CK 20 RT-PCR assay is applicable for detection of urothelial cancer cells in the peripheral blood. The assay also confirms that hematogenic dissemination occurs in invasive urothelial cancers but rarely in superficial ones.

Radical surgery for Budd-Chiari syndrome. Direct excision and repair for obstruction of the vena cava (Budd-Chiari syndrome) under hepatic vascular exclusion using a centrifugal pump

OBJECTIVE

To attempt to reduce the incidence of hepatic and cardiac failure after radical surgery for the Budd-Chiari syndrome.

DESIGN

Retrospective case study.

SETTING

University hospital, Japan

SUBJECTS

Three patients with obstruction of the vena cava (Budd-Chiari syndrome) by a thick membrane, thrombus, and a long stenosis, respectively.

INTERVENTION

Direct excision and repair by patch dilatation under hepatic vascular exclusion using a Biomedicus centrifugal pump.

RESULTS

Hepatic vascular exclusion provides good visibility and enables accurate assessment of the obstruction, proper treatment, and relatively little blood loss. There were no complications, particularly liver failure or heart failure, and the inferior vena cava stayed patent in all cases. Liver function was improved in all three patients.

CONCLUSION

This technique is safe and reliable for removal of obstruction of the inferior vena cava (Budd-Chiari syndrome).

Adhesion preventive effect of hyaluronic acid after intraperitoneal surgery in mice

Prevention of intraperitoneal adhesion after gynaecological surgery is essential for maintaining postoperative fertility. In this study, the adhesion prevention effect was examined of a hyaluronic acid (HA) solution obtained from the fermentation method and having a molecular weight of 1.9x10(6) with high viscosity. Laparotomy was conducted on female mice 7 weeks old, whose menstrual periods were synchronized by pregnant mare serum gonadotrophin (PMSG) to injure the uterine horn surface. Intraperitoneal adhesions were favourably formed in 91.7% of cases induced with iodine abrasion, compared with 50% induced by electrosurgery. Intraperitoneal administration of HA was evaluated for its effect on the prevention of adhesions made by iodine abrasion. Adhesion prevention effects of HA were observed at concentrations of 0.3, 0.5, 0.75 and 1.0%, among which the most pronounced effect was with the use of a 0.3% solution (92.3% of cases). Compared with the control group adhesion score of 2.0 +/- 0. 8, significant decreases in adhesion scores were observed at all concentrations. HA with a molecular weight of 1.9x10(6) was recognized to have a definitive prevention effect on postoperative adhesions in mice after laparotomy and is considered to be a prospective material for future clinical use.

Use of the free medialis pedis flap in orofacial reconstruction: report of two cases

The medialis pedis flap is a fasciocutaneous flap based on a branch of the medial plantar artery. The authors have used this flap in the reconstruction of skin defects of the hands and fingers because its skin is very similar in texture, color, and thickness. Because of its characteristics, this flap can also be applicable for orofacial reconstruction, when small or thin skin coverage is needed. Two cases are reported in which free medialis pedis flaps were used to reconstruct the eye socket in one patient and the alveolar ridge in the other. The authors concluded that the skin of the medialis pedis flap is not flexible enough and thus less suitable than the radial forearm flap for reconstruction of defects in which flexible skin is required, such as eye-socket reconstruction. However, reduced flexibility of the medialis pedis flap may provide an advantage in reconstruction of the gingiva and palate, where thin and rigid coverage is necessary.

[Long-term efficacy of the Gittes bladder neck suspension with use of ultrasonography for genuine stress urinary incontinence]

Thirty-eight patients with genuine stress incontinence underwent the Gittes procedures of the bladder neck suspension under ultrasonical monitoring. We performed the following two procedures. Original Gittes procedure: the puncture of the needle made twice through the different holes of the rectus fascia for each side and the bilateral helical suture was tied down separately above the rectus fascia. Modified Gittes procedure: the needle was passed through the rectus fascia once for each side and the both end of the helical suture was drawn up to suprapubic area, then the bilateral threads were tied over the rectus fascia. Original Gittes procedure was performed for twenty-nine patients and modified Gittes procedure for nine patients. Tightness of the suspension was decided by monitoring the posterior urethrovesical angle with use of the transrectal ultrasonography during the operation. A long term follow up survey was made up by means of a questionnaire by the phone or the mail. A total of thirty-six patients responded the questionnaire for a 94.7% response rate. The mean follow up was 33.1 months. 83.3% of the patients were cured and 5.6% were significantly improved. None of the patients claimed dysuria. There was no difference between the continent rates of the two procedures. We conclude that the Gittes bladder neck suspension with use of ultrasonography is effective for correction of female stress urinary incontinence.

[Management of invasive carcinoma of bladder and abdominal aortic aneurysm (AAA); technique of radical total cystectomy and simultaneous AAA repair]

BACKGROUND

There is no consensus on the optimal surgical treatment for patients with concomitant invasive carcinoma of bladder and abdominal aortic aneurysm (AAA). We experienced two patients who were treated successfully with simultaneous radical cystectomy and AAA repair. The techniques required for the combined procedure and case reports are discussed.

PROCEDURE

The goal of the one-stage operation was to minimize the risk of graft infection without compromising postoperative morbidity and mortality secondary to carcinoma of bladder. Initially pelvic lymph node dissection and radical cystectomy were performed. We preferred retrograde cyctoprostatectomy because most of the cystectomy procedure can be performed without opening the peritoneal cavity and the extent of the retroperitoneal dissection can be minimal. A single-stoma ureterocutaneostomy was preferable urinary diversion. Urinary diversions which utilize intestine such as ileal conduit or ileal urinary reservoir may cause contamination of a graft with bowel content and should be avoided. Before or after urinary diversion, aneurysmal resection and a bifurcated graft replacement were performed. The replaced graft was wrapped with the aneurysmal wall. The major omentum was mobilized and fixed in front of the graft, thereby serving as a protective barrier of the graft. A Dacron graft which was sealed with rifampicin-bonding gelatin was used to further reduce the risk of graft infection.

RESULT

Two male patients were treated with the one stage radical cystectomy and AAA repair. Single-stoma ureterocutaneostomy and bilateral ureterocutaneostomy were selected as a urinary diversion. No major postoperative complications, except for paralytic ileus in one case, were observed.

CONCLUSION

Our experience and reports of others indicate that radical cystectomy and simultaneous AAA repair can be safely performed with less morbidity than staged operations for the management of concomitant invasive carcinoma of bladder and AAA.

Extrahepatic biliary cystadenocarcinoma arising from the left hepatic duct

A 54-year-old man, who had no clinical symptoms, underwent a routine health checkup at our hospital. Abdominal ultrasonography disclosed a well demarcated tumor containing a solid portion occupying the dilated left hepatic duct and a cystic portion expanding into the parenchyma of the left hepatic lobe, with mild dilatation of the intrahepatic bile ducts. These findings were later confirmed by computed tomography (CT) and magnetic resonance imaging. Endoscopic retrograde cholangiography revealed a complete defect at the level of the left hepatic duct, while drip infusion cholangiographic-CT (DIC-CT) disclosed a defect of the left hepatic duct only, with the distal portions of the left intrahepatic ducts being visualized on the image. Hepatic angiography revealed light stains in the solid portion in the parenchymal phase. At left lobectomy, a multiloculated polyp-like tumor was found arising from the left hepatic duct and expanding into the parenchyma of the left hepatic lobe. Microscopically, all the lining cells in the cysts and the tumor cells in the solid portion showed the features of papillary adenocarcinoma. In this patient with extrahepatic biliary cystadenocarcinoma, DIC-CT was useful in identifying the site of origin of the tumor, and hepatic angiography was also useful in differentiating this rare malignant tumor from benign cystadenoma.

Excitatory amino acids act on the median eminence nerve terminals to induce gonadotropin-releasing hormone release in female rats

The present study is designed to examine the terminal regulation of gonadotropin-releasing hormone (GnRH) release by excitatory amino acids in the median eminence of ovariectomized (OVX) rats. In in vitro experiments, median eminence tissues were superfused in the medium containing glutamate or excitatory amino acid agonists, such as N-methyl-d,l-aspartate or kainate. These drugs induced a Ca2+-dependent GnRH release from median eminence fragments. The agonists also stimulated GnRH release from superfused synaptosome prepared from the median eminence tissues in a Ca2+-dependent manner. In the immunocytochemical study, immunoreactivity for glutamate or its ionotropic receptor subtypes, such as NR1, GluR1, GluR2/3, GluR6/7, and KA2, was examined in the median eminence of OVX rats under electron microscopy. Immunoreactivities for glutamate or its receptor subtypes were observed on the nerve terminals, most of which were located in close proximity to the other nerve terminals without forming synaptic contacts. In addition, quite a few synaptic contacts which were immunopositive for GluR1, GluR2/3, KA2, or glutamate were found in this area. The present results indicate that excitatory amino acids stimulate GnRH release by acting at the nerve terminals of the median eminence in a Ca2+-dependent manner in the absence of gonadal steroid. The effect of excitatory amino acids in this area might be mediated by glutamate receptors mainly in nonsynaptic fashion, such as by volume transmission.