O-183 Frequent spontaneous abortion in pregnancies followed by ICSI using frozen sperm from patients with testicular germ cell tumor (TGCT)

Study question

Despite the high rate of sperm chromosome abnormalities in testicular germ cell tumor (TGCT), why is newborn aneuploidy rate in pregnancies with TGCT patient normal?

Summary answer

Miscarriage rate is higher in the pregnancy of TGCT patients than of non-TGCT cancer patients, although the pregnancy rate in ICSI was not significantly different.

What is known already

Previous reports showed higher sperm aneuploidy in TGCT patients than control males. The sperm aneuploidy rate is high before treatment, and after radical treatments peaked at 6 months after treatment and remained high until 24 months after treatment. However, in the Swedish government base study, the rate of newborn malformations including aneuploidy in all pregnancy with TGCT patients was higher than without TGCT, but not statistically significant. In only natural pregnancies, the rate was not significantly different between the two groups. The cause for discrepancy within sperm aneuploidy and newborn aneuploidy was not well clarified.

Study design, size, duration

To clarify the mechanism for the purifying selection of aneuploid sperm in conception, we examined ICSI cases with TGCT patients that did not include natural sperm competition and compared to controls with non-TGCT cancer patient, who have normal rate of aneuploid sperm. By investigating ICSI outcomes, we aimed to determine which stage of embryonic development are affected by the sperm of TGCT patients.

Participants/materials, setting, methods

Under ethical review of Yokohama city university, the 10 TGCT patients (123 oocytes) and 16 non-TGCT cancer patients (251 oocytes) who underwent ICSI with their frozen sperm from 2012 to 2021 were enrolled. Fertilization, embryo viability and embryo transfer outcomes (pregnancy and miscarriage rate) were examined between two groups underwent ICSI with cryopreserved sperm for fertility preservation. Clinical information was retrospectively collected from medical records.

Main results and the role of chance

The patients' age of sperm cryopreservation was 21-56 years old. 10 cases of TGCT were diagnosed as seminoma (3), non seminoma (6), and unknown (2). 15 cases of non-TGCT were diagnosed as malignant blood diseases (9), prostate cancer (2), bladder cancer (1), and others (3). In both groups, all patients were treated by ICSI with cryopreserved sperm obtained prior to chemotherapy. The mean age of female partners in TGCT was 33.2±3.5 years and not different with 35.8±3.4 years in non-TGCT meaning no different age factor. The fertilization rate, viable embryo rate, pregnancy rate and chemical abortion rate of TGCT vs non-TGCT group were 76.4% vs 67.7%, 64.3% vs 61.7%, 37.1% vs 21.7%, 7.1% vs 23.1%, respectively. Those developmental evaluations were not significantly different between two groups. However, spontaneous abortion rate was significantly higher 46.2% in TGCT group than 10% in non-TGCT group (p < 0.05). Further, in our follow-up, no congenital malformations in the babies born in either group (5 babies in TGCT vs 7 babies in non-TGCT group). The outcome of ICSI using sperm in TGCT patients show normal pregnancy rate but include higher spontaneous abortions rate, suggesting aneuploid embryo were negatively purifying selected under post-implantation stage.

Limitations, reasons for caution

Because ICSI with fertility-preserving frozen sperm in TGCT patient is rare even in reproduction center in general university hospital, single center analysis is still small and limited. More case reports and studies for TGCT fertility preservation are needed for more accurate evaluation.

Wider implications of the findings

In TGCT patients, chromosome aberrations and DNA fragmentation of sperm may not be apparent in natural pregnancies with normal sperm competition, but may become apparent as spontaneous abortions when ICSI were performed, suggesting PGT-A can predict and avoid the hidden risk of repeated pregnancy loss in ICSI to TGCT patients.

Trial registration number

not applicable

P–572 Purifying selection for aneuploidy cells in mosaicism embryo at post-implantation stage

Study question

Why low ratio mosaicism embryos develop to normal karyotype babies?

Summary answer

Our in vitro implantation assay clarified purifying selection for aneuploid cells in post implantation embryos.

What is known already

There are some reports about healthy live birth after transfer of mosaic embryos, which was reported for the first time from Italy in 2015. It is also reported that the abnormal cell is screened with the mouse in the embryo development, and only a normal cell contributes to the development. But it has not been examined in human.

Study design, size, duration

To clarify the change of aneuploid cells and mitochondrial activity in human embryo, we biopsied several parts from one blastocyst and examined karyotype. After in vitro implantation assay for biopsied embryos, we compared the karyotype of biopsy sample with that of cultured cell mass.

Participants/materials, setting, methods

Under the ethical review of Yokohama City University and informed consent with patients, we collected human surplus blastocysts those are donated after successful clinical treatment or discarded because of poor development grade. We biopsied multiple parts from one blastocyst and cultured the biopsied embryos, and extracted whole DNA from the biopsy samples and cultured embryos. Karyotyping by next generation sequencing were performed.

Main results and the role of chance

We analyzed 34 samples from 11 embryos, including 25 biopsy sample from 11 embryos and 9 cell mass from 7 cultured embryos. In the karyotype tracking results, even though biopsy sample analysis before the culture were uniformed aneuploid or chromosome mosaic, the developing embryo cell mass had normal karyotype. In one embryo as an example, among the three biopsied extra trophectoderm samples from that, two of them were mosaic, and one of them had uniformed chromosome 21 trisomy and chromosome 16 mosaic monosomy. But the embryo formed multiple cell mass in implantation assay. We examined karyotype of three cell mass, and the result from all were normal karyotype. We suggested that the chromosome aberration cells were screened in the human embryo development, and when the function was not carried out the embryo stopped the development.

Limitations, reasons for caution

Because of small number of samples available, we need more samples for a more accurate evaluation. Furthermore, we cannot evaluate the absolute mechanism that cells with chromosome aberration decreases.

Wider implications of the findings: Conventional PGT-A techniques are based on uniformed embryos developing hypothesized past time. As showed in some clinical reports, PGT-A can reduce of spontaneous abortion and chance of embryo transfer. Thinking about aneuploid cell purifying system in embryo development, effectiveness of PGT-A should be more questionable for infertility treatment.

Trial registration number

A200326004

Innate immune responses through Toll-like receptor 3 require human-antigen-R-mediated Atp6v0d2 mRNA stabilization

Toll-like receptor 3 (TLR3) recognizes double-stranded RNA derived from virus and its synthetic analogue, polyinosinic–polycytidylic acid [poly(I:C)]. Upon poly(I:C) binding, TLR3 activates transcription factors to express inflammatory cytokines and type I interferon. TLR3 is located in the endosomes and its recognition of poly(I:C) and activation of downstream signaling is regulated by endosomal acidification. However, the mechanism of post-transcriptional regulation in TLR3-mediated innate responses remains unclear. Here, we focused on Human antigen R (HuR, also known as ELAVL1) that recognizes and binds to the 3′ untranslated regions (3′UTRs) of target mRNAs, thereby protecting them from mRNA degradation, and found that HuR-deficient murine macrophage cells showed significantly reduced Ifnb1 mRNA expression after poly(I:C) stimulation. HuR-deficient cells also showed a marked reduction in the expression of Atp6v0d2 mRNA, which encodes a subunit of vacuolar-type H⁺ ATPase (V-ATPase), and therefore reduced endosomal acidification. HuR associated with the 3′UTR of Atp6v0d2 mRNA and the stability of Atp6v0d2 mRNA was maintained by its association with HuR. Taken together, our results suggest that HuR stabilizes Atp6v0d2 mRNA, which is required for the TLR3-mediated innate immune responses.

Changes in platelet Bax levels contribute to impaired platelet response to thrombin after cardiopulmonary bypass: prospective observational clinical and laboratory investigations

Background

Anucleate platelets can undergo apoptosis in response to various stimuli, as do nucleated cells. Cardiopulmonary bypass (CPB) causes platelet dysfunction and can also activate platelet apoptotic pathways. We therefore evaluated time-dependent changes in blood platelet Bax (a pro-apoptotic molecule) levels and platelet dysfunction after cardiac surgery.

Methods

We assessed blood samples obtained from subjects having on-pump or off-pump coronary artery bypass graft surgery ( n =20 each). We also evaluated the in vitro effects of platelet Bax increase in eight healthy volunteers.

Results

Thrombin-induced platelet calcium mobilisation and platelet-surface glycoprotein Ib (GPIb) expression were lowest at weaning from CPB and did not recover on postoperative day one. On-pump surgery increased platelet expression of Bax, especially the oligomerised form, along with translocation of Bax from the cytosol to mitochondria and platelet-surface tumour necrosis factor-alpha (TNF-α)-converting enzyme (TACE) expression. In contrast, mitochondrial cytochrome c expression was reduced. While similar in direction, the magnitude of the observed changes was smaller in patients having off-pump surgery. In vitro , a cell-permeable Bax peptide increased platelet Bax expression to the same extent seen during bypass and produced similar platelet changes. These apoptotic-like changes were largely reversed by Bcl-xL pre-administration, and were completely reversed by combined application of inhibitors that stabilise outer mitochondrial membrane permeability and TACE.

Conclusions

CPB increases platelet Bax expression, which contributes to reduced platelet-surface GPIb expression and thrombin-induced platelet calcium changes. These changes in platelet apoptotic signalling might contribute to platelet dysfunction after CPB.

Clinical trial registration

UMIN Clinical Trials Registry (number UMIN000006033).

PtdIns3P phosphatases MTMR3 and MTMR4 negatively regulate innate immune responses to DNA through modulating STING trafficking

The innate immune system plays an essential role in initial recognition of pathogen infection by producing inflammatory cytokines and type I interferons. cGAS is a cytoplasmic sensor for DNA derived from DNA viruses. cGAS binding with DNA induces the production of cGAMP, a second messenger that associates with STING in endoplasmic reticulum (ER). STING changes its cellular distribution from ER to perinuclear Golgi, where it activates the protein kinase TBK1 that catalyzes the phosphorylation of IRF3. Here we found that STING trafficking is regulated by myotubularin-related protein (MTMR) 3 and MTMR4, members of protein tyrosine phosphatases that dephosphorylate 3' position in phosphatidylinositol (PtdIns) and generate PtdIns5P from PtdIns3,5P₂ and PtdIns from PtdIns3P. We established MTMR3 and MTMR4 double knockout (DKO) RAW264.7 macrophage cells and found that they exhibited increased type I interferon production after interferon-stimulatory DNA (ISD) stimulation and herpes simplex virus 1 infection concomitant with enhanced IRF3 phosphorylation. In DKO cells, STING rapidly trafficked from ER to Golgi after ISD stimulation. Notably, DKO cells exhibited enlarged cytosolic puncta positive for PtdIns3P and STING was aberrantly accumulated in this puncta. Taken together, these results suggest that MTMR3 and MTMR4 regulate the production of PtdIns3P, which plays a critical role in suppressing DNA-mediated innate immune responses via modulating STING trafficking.

Search for Boosted Dark Matter Interacting with Electrons in Super-Kamiokande

A search for boosted dark matter using 161.9 kt yr of Super-Kamiokande IV data is presented. We search for an excess of elastically scattered electrons above the atmospheric neutrino background, with a visible energy between 100 MeV and 1 TeV, pointing back to the Galactic center or the Sun. No such excess is observed. Limits on boosted dark matter event rates in multiple angular cones around the Galactic center and Sun are calculated. Limits are also calculated for a baseline model of boosted dark matter produced from cold dark matter annihilation or decay. This is the first experimental search for boosted dark matter from the Galactic center or the Sun interacting in a terrestrial detector.

Digitised evaluation of speech intelligibility using vowels in maxillectomy patients

Among the functional disabilities that patients face following maxillectomy, speech impairment is a major factor influencing quality of life. Proper rehabilitation of speech, which may include prosthodontic and surgical treatments and speech therapy, requires accurate evaluation of speech intelligibility (SI). A simple, less time-consuming yet accurate evaluation is desirable both for maxillectomy patients and the various clinicians providing maxillofacial treatment. This study sought to determine the utility of digital acoustic analysis of vowels for the prediction of SI in maxillectomy patients, based on a comprehensive understanding of speech production in the vocal tract of maxillectomy patients and its perception. Speech samples were collected from 33 male maxillectomy patients (mean age 57.4 years) in two conditions, without and with a maxillofacial prosthesis, and formant data for the vowels /a/,/e/,/i/,/o/, and /u/ were calculated based on linear predictive coding. The frequency range of formant 2 (F2) was determined by differences between the minimum and maximum frequency. An SI test was also conducted to reveal the relationship between SI score and F2 range. Statistical analyses were applied. F2 range and SI score were significantly different between the two conditions without and with a prosthesis (both P < .0001). F2 range was significantly correlated with SI score in both the conditions (Spearman's r = .843, P < .0001; r = .832, P < .0001, respectively). These findings indicate that calculating the F2 range from 5 vowels has clinical utility for the prediction of SI after maxillectomy.

Extensive use of vasodilator agents and functional echocardiography to monitor extremely-low-birth-weight infants in Japan

National surveys were conducted in Japan to assess the current practices for circulatory management of extremely-low-birth-weight infants (ELBWIs) in acute phases. Approximately 80 and 100 institutions were surveyed in 2006 and 2011, respectively. Echocardiography was identified as an important diagnostic tool at 95% of the surveyed institutions. Furthermore, 74% of the institutions survey in 2011 used vasodilator agents. In 2011, the mean velocity of circumferential fiber shortening (mVcfc) and left ventricular end-systolic wall stress (ESWS) were used by 60% of the surveyed institutions to evaluate the relationship between afterload of the left ventricle and left ventricular contractility. Overall, the data collected from these national surveys clarified the current practices for circulatory management of ELBWIs in Japan, particularly the use of echocardiography and cardiovascular agents, including catecholamines and vasodilators.

Cytosolic nucleic acid sensors and innate immune regulation

During viral and bacterial infections, pathogen-derived cytosolic nucleic acids are recognized by the intracellular RNA sensors retinoic acid-inducible gene I and melanoma-differentiated gene 5 and intracellular DNA sensors, including cyclic-di-GMP-AMP synthase, absent in melanoma 2, interferon (IFN)-gamma inducible protein 16, polymerase III, and so on. Binding of intracellular nucleic acids to these sensors activates downstream signaling cascades, resulting in the production of type I IFNs and pro-inflammatory cytokines to induce appropriate systematic immune responses. While these sensors also recognize endogenous nucleic acids and activate immune responses, they can discriminate between self- and non-self-nucleic acids. However, dysfunction of these sensors or failure of regulatory mechanisms causes aberrant activation of immune response and autoimmune disorders. In this review, we focus on how intracellular immune sensors recognize exogenous nucleic acids and activate the innate immune system, and furthermore, how autoimmune diseases result from dysfunction of these sensors.

Negative regulation of melanoma differentiation-associated gene 5 (MDA5)-dependent antiviral innate immune responses by Arf-like protein 5B

RIG-I-like receptors (RLRs), including retinoic acid-inducible gene-I (RIG-I) and MDA5, constitute a family of cytoplasmic RNA helicases that senses viral RNA and mounts antiviral innate immunity by producing type I interferons and inflammatory cytokines. Despite their essential roles in antiviral host defense, RLR signaling is negatively regulated to protect the host from excessive inflammation and autoimmunity. Here, we identified ADP-ribosylation factor-like protein 5B (Arl5B), an Arl family small GTPase, as a regulator of RLR signaling through MDA5 but not RIG-I. Overexpression of Arl5B repressed interferon β promoter activation by MDA5 but not RIG-I, and its knockdown enhanced MDA5-mediated responses. Furthermore, Arl5B-deficient mouse embryonic fibroblast cells exhibited increased type I interferon expression in response to MDA5 agonists such as poly(I:C) and encephalomyocarditis virus. Arl5B-mediated negative regulation of MDA5 signaling does not require its GTP binding ability but requires Arl5B binding to the C-terminal domain of MDA5, which prevents interaction between MDA5 and poly(I:C). Our results, therefore, suggest that Arl5B is a negative regulator for MDA5.

Constant expression of mouse calpastatin isoforms during differentiation in myoblast cell line, C2C12

C2C12 is a myoblast cell line which is used to studydifferentiation into multinucleated cells in vitro. Addition of calpain inhibitors, calpeptin orE-64d, to the culture medium prevented the myoblasticfusion of C2C12 cells. Immunoblot studies usingaffinity-purified antibody, revealed that the expressedlevels of mouse calpastatin remained unaltered duringC2C12 cell fusion. The detected calpastatin migratedas a protein of 130 kDa on SDS-polyacrylamide gelelectrophoresis. The estimated molecular mass wassomewhat greater than that in mouse liver anderythrocytes, and much greater than that reported inrat myoblasts. The 130 kDa isoform may contain anadditional N-terminal region designated XL domainfound in bovine calpastatin.

Cytotoxic T-lymphocyte antigen 4 haplotype correlates with relapse and survival after allogeneic hematopoietic SCT

CTLA-4 is a negative regulator of activated T cells and the association of CTLA-4 polymorphisms with autoimmune diseases and transplant outcome has been reported. We evaluated the effect of donor CTLA-4 polymorphisms on outcome after allogeneic hematopoietic SCT (HSCT). We analyzed 147 Japanese HLA-matched sibling recipients and their donors who had undergone allogeneic HSCT. Genotyping of three single-nucleotide polymorphisms in CTLA-4 (-318, +49, CT60) was performed using TaqMan-PCR. According to the international HapMap database, only these three CTLA-4 haplotypes, classified as C-G-G, C-A-A and T-A-G, are present in the Japanese population. In this study, percentage expression of the C-G-G, C-A-A and T-A-G haplotypes was 59.5, 30.6 and 9.9%, respectively. Recipients of the C-A-A haplotype donor showed a significantly lower risk of relapse (HR: 0.54, 95% CI: 0.30-0.97, P=0.040) and a trend toward higher OS (HR: 0.61, 95% CI: 0.36-1.0, P=0.054) than did recipients of a donor without the C-A-A haplotype. The presence or absence of the C-A-A haplotype did not affect GVHD or non-relapse mortality. As the presence of the C-A-A haplotype reduced relapse risk and improved survival after allogeneic HSCT, this CTLA-4 haplotype may provide useful information for donor selection.

Maturational changes in the feeding behaviour of infants - a comparison between breast-feeding and bottle-feeding

AIM

To obtain a better understanding of the changes in feeding behaviour from 1 to 6 months of age. By comparing breast- and bottle-feeding, we intended to clarify the difference in longitudinal sucking performance.

METHODS

Sucking variables were consecutively measured for 16 breast-fed and eight bottle-fed infants at 1, 3 and 6 months of age.

RESULTS

For breast-feeding, number of sucks per burst (17.8 +/- 8.8, 23.8 +/- 8.3 and 32.4 +/- 15.3 times), sucking burst duration (11.2 +/- 6.1, 14.7 +/- 8.0 and 17.9 +/- 8.8 sec) and number of sucking bursts per feed (33.9 +/- 13.9, 28.0 +/- 18.2 and 18.6 +/- 12.8 times) at 1, 3 and 6 months of age respectively showed significant differences between 1 and 6 months of age (p < 0.05). The sucking pressure and total number of sucks per feed did not differ among different ages. Bottle-feeding resulted in longer sucking bursts and more sucks per burst compared with breast-feeding in each month (p < 0.05).

CONCLUSION

The increase in the amount of ingested milk with maturation resulted from an increase in bolus volume per minute as well as the higher number of sucks continuously for both breast- and bottle-fed infants.

Side population cells have the characteristics of cancer stem-like cells/cancer-initiating cells in bone sarcomas

Background:

Several human cancers have been found to contain cancer stem-like cells (CSCs) having cancer-initiating ability. However, only a few reports have shown the existence of CSCs in bone and soft tissue sarcomas. In this study, we identified and characterised side population (SP) cells that showed drug-resistant features in human bone sarcoma cell lines.

Methods:

In seven osteosarcoma cell lines (OS2000, KIKU, NY, Huo9, HOS, U2OS and Saos2) and in one bone malignant fibrous histiocytoma (MFH) cell line (MFH2003), the frequency of SP cells was analysed. Tumourigenicity of SP cells was assessed in vitro and in vivo. Gene profiles of SP cells and other populations (main population; MP) of cells were characterised using cDNA microarrays.

Results:

SP cells were found in NY (0.31%) and MFH2003 (5.28%). SP cells of MFH2003 formed spherical colonies and re-populated into SP and MP cells. In an NOD/SCID mice xenograft model, 1 × 10³ sorted SP cell-induced tumourigenesis. cDNA microarray analysis showed that 23 genes were upregulated in SP cells.

Conclusions:

We showed that SP cells existed in bone sarcoma cell lines. SP cells of MFH2003 had cancer-initiating ability in vitro and in vivo. The gene profiles of SP cells could serve as candidate markers for CSCs in bone sarcomas.

Insulin resistance and impaired myocardial fatty acid metabolism in dialysis patients with normal coronary arteries

We investigated whether insulin resistance is associated with impaired cardiac fatty acid metabolism in maintenance hemodialysis patients without coronary artery disease. We studied 55 nondiabetic (63+/-11 years old) and 51 diabetic (61+/-10 years old) hemodialysis patients with normal coronary arteries, using single-photon emission computed tomography (SPECT) with an iodinated fatty acid analogue, iodine-123-beta-methyl iodophenyl-pentadecanoic acid ((123)I-BMIPP), to evaluate cardiac fatty acid metabolism. SPECT imaging was graded regionally from 0 (normal) to 4 (absence of tracer) to calculate a summed score for 17 left ventricular segments. Insulin resistance was determined using the homeostasis model assessment index of insulin resistance (HOMA-IR). HOMA-IR correlated with summed BMIPP score in nondiabetic and diabetic patients. Stepwise multiple regression analysis showed that HOMA-IR was independently associated with BMIPP summed score in nondiabetic (beta=0.774, t=9.218, P=0.0001) and diabetic patients (beta=0.792, t=9.079, P=0.0001). Left ventricular ejection fraction was lower in nondiabetic subjects with BMIPP summed score of at least 6 plus HOMA-IR of at least 4 than in others with lower values for both assessments (53.1+/-13.8%, n=20 vs 67.7+/-9.1%, n=23, P=0.0002); this was also true in diabetic subjects (50.9+/-15.2%, n=24 vs 71.0+/-13.6%, n=11, P=0.0007). Association between insulin resistance and impaired cardiac fatty acid metabolism may contribute to left ventricular dysfunction in patients with maintenance hemodialysis without coronary diseases.

Echocardiographic assessment of early circulatory status in preterm infants with suspected intrauterine infection

OBJECTIVE

To assess early circulatory status in very low birthweight (VLBW) infants with suspected intrauterine infections.

PATIENTS

Thirteen VLBW infants who were diagnosed with prenatal infections because of raised serum IgM at birth (infectious group), and 39 infants matched for gestational age and birth weight (control group).

METHODS

Echocardiographic assessments were performed consecutively from birth to day 28 in all VLBW infants. Left ventricular output (LVO) and left ventricular stroke volume (LVSV) were measured using Doppler echocardiography. Pulsed Doppler assessment of pulmonary artery pressure (PAP) was performed using the corrected ratio of the pulmonary artery acceleration time to the right ventricular ejection time (AT/RVET(c)). Blood flow in the superior mesenteric artery (SMA) was also evaluated by Doppler ultrasound.

RESULTS

Mean LVO and LVSV were both significantly higher in the infectious group than in the control group at 12 hours (LVO; 188 v 154 ml/kg/min) and 72 hours (LVO; 216 v 173 ml/kg/min) of life. Pulsed Doppler assessment of PAP showed that mean AT/RVET(c) values were significantly lower in the infectious group than in the control group at 48 hours, 96 hours, day 14, and day 28. In the analysis of SMA flow velocities, both peak systolic velocities and time averaged velocities had decreased significantly in the infectious group compared with the control group at 24 hours, 36 hours, 96 hours, and day 28.

CONCLUSIONS

VLBW infants with suspected prenatal infection showed a unique circulation status, namely high cardiac output, latency of high PAP, and low organ flow.

Early hypocarbia of preterm infants: its relationship to periventricular leukomalacia and cerebral palsy, and its perinatal risk factors

AIM

To clarify clinical interactions between early hypocarbia, periventricular leukomalacia (PVL) and cerebral palsy of preterm infants.

METHODS

Serial measurements of PaCO2 using arterial blood samples at 3, 6, 12, 24 and 48 h of life were performed for 115 very-low-birthweight infants admitted between 1995 and 1999. Severe early hypocarbia, defined when at least two of five PaCO2 values showed 3.3 kPa or less, was observed in eight infants (hypocarbia group). Preterm PVL was diagnosed by serial ultrasonographic examinations and cranial magnetic resonance imaging, and subsequently classified into early-onset PVL diagnosed within 14 d, or late-onset PVL after 14 d. Perinatal risk factors for early hypocarbia were investigated from the mothers' records and interviews with obstetricians.

RESULTS

The average birthweight in the hypocarbia group was significantly smaller than that in the control group (p < 0.01). The occurrence of PVL in the hypocarbia group was not different from that in the control group. Early hypocarbia was significantly related to late-onset PVL (p < 0.001), but not related to early-onset PVL. The incidence of cerebral palsy in the hypocarbia group was significantly higher than that in the control group (p < 0.001). Multivariate analysis showed that both low birthweight and number of maternal previous abortions were predictive for early hypocarbia.

CONCLUSION

Early hypocarbia of preterm infants in our hospital was significantly associated with both cerebral palsy and late-onset PVL, but not with early-onset PVL. The background of the three clinical events, early hypocarbia, PVL, and cerebral palsy, may not be identical in human newborns.

Serial pulsed Doppler assessment of early left ventricular output in critically ill very low-birth-weight infants

Serial, detailed assessments of left ventricular output (LVO) in critically ill very low-birth-weight (VLBW) infants of four different gestational ages were performed in the early neonatal period using pulsed Doppler echocardiography. Initially, the LVO values of all groups at 3 hours of age were relatively high. However, LVO dropped transiently at 12 hours and then increased again after 24 hours reaching a steady level of 160-180 ml/kg/min after 48 hours of age. In all four groups, heart rate also decreased significantly at 12 hours of age but did not increase at 24 hours of age. Both the left ventricular stroke volume and the left ventricular ejection fraction in all groups exhibited similar longitudinal changes to those observed for LVO. The LVO values observed in the lower gestational age group were significantly lower than those observed in the upper gestational group before 24 hours of age. Both patent ductus arteriosus and mechanical ventilation did not significantly influence the changes in LVO of VLBW infants at least before 36 hours of age. Our results suggest that in the early neonatal period, there are drastic changes in LVO of VLBW infants that reflect not only changes in heart rate but also changes in myocardial contractility.

A longitudinal study of disturbances of the hypothalamic-pituitary-adrenal axis in women with progestin-negative functional hypothalamic amenorrhea

OBJECTIVE

To longitudinally evaluate disturbances of the hypothalamic-pituitary-adrenal (HPA) axis in women with secondary progestin-negative hypothalamic amenorrhea.

DESIGN

Retrospective cohort study.

SETTING

Yokohama City University, Yokohama, Japan.

PATIENT(S)

Twenty-four women with progestin-negative hypothalamic amenorrhea.

INTERVENTION(S)

Administration of human corticotropin-releasing hormone (hCRH) and treatment with a combination of estrogen and progesterone.

MAIN OUTCOME MEASURE(S)

Plasma cortisol and ACTH concentrations and period required for recovery from amenorrhea.

RESULT(S)

Plasma ACTH concentrations 30 and 60 minutes after injection of hCRH and the percent maximum increment (%Cmax) of ACTH were significantly lower in the amenorrheic patients compared with the control group patients. The basal cortisol was significantly higher, and the %Cmax of cortisol was significantly lower. In the 16 patients who recovered from amenorrhea, there was a significant positive correlation (Y = 1.93X-10.8, r = 0.629) between the basal cortisol concentrations (X) and the period for recovery (Y). The serum E2 gradually increased before recovery, and this E2 increase was preceded by changes in the plasma cortisol concentration and the %Cmax values of cortisol and ACTH.

CONCLUSION(S)

The CRH test might be useful for evaluating the roles of stress and for estimating the period required for recovery in hypothalamic amenorrhea.

[Surveillance of various enteropathogenic bacteria from diarrheal cases during 1989-1999 in Kobe City]

Incidence of various enteropathogenic bacteria was examined from diarrheal faecal samples that were collected from the patients of Kobe City General Hospital and some station hospitals (23,862), and from overseas travelers (2,855) over a period of decade (1989-1999) in Kobe. A total of 1,580 strains were isolated from domestic and 331 strains from overseas travelers. The results are as follows. 1) Thirteen kinds of enteropathogenic bacteria were isolated from domestic diarrheal cases (6.6%). Salmonella was the most predominant bacteria followed by Campylobacter, Vibrio parahaemolyticus, enteropathogenic Escherichia coli and Shigella. 2) Eleven kinds of enteropathogenic bacteria were isolated from overseas diarrheal travelers (11.6%). The most frequently isolated species was Salmonella, followed by Vibrio parahaemolyticus, Shigella and Plesiomonas shigelloides. 3) Of Salmonella strains isolated from domestic and overseas diarrheal cases, serovar Enteritidis was the most predominant. Other frequent serovars in both cases were Typhimurium, Tennessee, Hadar, Infantis, Blockley and Montevideo. 4) Antibiotics resistant rate of the isolated Salmonella strains was 42.6% for domestic samples and 29.3% for overseas diarrheal cases. In domestic cases. Enteritidis was resistance to streptomycin only and the multiple antibiotic resistance was observed in Typhimurium serovars. In overseas samples, the multiple antibiotic resistance was seen in a few Typhimurium, Anatum and Blockley strains. 5) Among Shigella, S. sonnei was isolated from both domestic and overseas cases. The frequency of acquiring infection was the highest in India, followed by Indonesia, Thailand and Nepal. 6) With reference to the incidence of the members of the genus Vibrio, Aeromonas and Plesiomonas, V. parahaemolyticus were abundant from domestic samples where as V. parahaemolyticus, P. shigelloides, Vibrio cholerae non-O1 and Vibrio cholerae O1 were isolated more frequently from overseas samples. The frequency of acquiring infection was the highest in Thailand, followed by Indonesia and India.

[Perspective of laboratory examination system for infectious disease]

The primary goal of the clinical microbiology laboratory is to provide accurate diagnostic testing and high-quality, rapidly, anytime service at the lowest cost for its customers. In regard to beginning microbiological test as one of emergency test system, the agreement among laboratory staff and the communication with practical conference among clinical divisions are needed, especially about 1. Place and time for receive, 2. Methods of handling and store, 3. Ordering system and information about patients, 4. Selection of items and method, 5. Reporting system and 6. Decision of laboratory staff. As items of microbiological test on this system, smear test, immunoserological test and auto-blood culture equipment are needed. According to the new law of infectious disease, laboratory system should be established in the cases of outbreak. As for the inexperienced cases of import infection, network system of information should be practically used.

Improved preparation of sulfur substituted 3-vinylpyrrole and its application to the syntheses of chuangxinmycin derivatives

Sulfur substituted 3-vinylpyrrole 10 was prepared from 3-thio-acetylpyrrole 9 by alkylation with alkyl halide in the presence of propylene oxide. Functionalized 4-alkylthioindoles were made by Diels-Alder reaction of the 3-vinylpyrrole 10 with dienophiles. Chuangxinmycin analogues were synthesized by using some of the functionalized 4-alkylthioindoles as key intermediates.

[Clinical significance of serum LpA-I levels measured by immunoturbidimetric assay in type 2 diabetes mellitus patients]

Previously, we developed an immunoturbidimetric assay method for lipoprotein A-I(LpA-I) on sera pre-absorbed with anti-apolipoprotein A-II. In the present study, correlations between serum lipoprotein A-I and other serum parameters levels were examined and LpA-I levels were studied in patients with type 2 diabetes mellitus. The serum levels of LpA-I did not correlate with those of diabetic markers such as fasted blood glucose, glycohemoglobin(HbA1c) and fructosamine, but correlated well with the levels of total cholesterol and HDL cholesterol, phospholipids, apolipoprotein A-I and seemed to correlate inversely with arteriosclerosis index. In patients with type 2 diabetes mellitus, LpA-I levels were significantly lower than those in normal subjects. Especially, LpA-I levels of patients with diabetic complications were significantly lower than those in normal subjects and non-complicated diabetic patients. Then, the measurement of LpA-I levels in patients with type 2 diabetes mellitus was considered to be useful for prevention and management of arteriosclerosis.

Evaluation of Immunochromatography Method for Rapid Detection of Shigatoxin

The Shigatoxin detection kit based on the immunochromatography system is commercially available. To obtain the identification result rapidly, we devised the improved method (ICG-Imp) replaced to an original method (ICG). Modification provided that Shigatoxins extracted directly from the strains grown on TSI medium without centrifugation. ICG-Imp was compared with ICG, RPLA and PCR. Comparing with RPLA, the sensitivity, specificity, and concordance rate of Shigatoxin 1 showed 77.5, 100 and 90.5%, respectively on ICG, 93.8, 100 and 97.4%, respectively on ICG-Imp, and 100, 99.1 and 99.5%, respectively on PCR. On the other hand, the patterns of Shigatoxin 2 showed 95.3, 100 and 96.3%, respectively on ICG, 100, 100, and 100%, respectively on ICG-Imp, and 100, 100 and 100%, respectively on PCR. The time required from TSI medium to the final result are 24 h, 30-60 min, 48 h, and 6 h, respectively by ICG, ICG-Imp, RPLA, and PCR. It seems that the ICG-Imp is recommended for the identification by means of the accuracy and rapidness.

Serial pulsed Doppler assessment of pulmonary artery pressure in very low birth-weight infants

We assessed pulmonary artery pressure (PAP) during the early neonatal period in very low birth-weight (VLBW) infants using serial echocardiographic measurements of the ratio of the pulmonary artery acceleration time to the right ventricular ejection time corrected by heart rate [AT:RVET(c)]. Eighty-four VLBW infants weighing less than 1,500 g were examined using serial color Doppler echocardiography from 3 hours to day 7 after birth. The AT:RVET(c) of infants born after 30 weeks of gestation showed a rapid, significant increase during the early neonatal period, whereas those of the groups born at less than 30 weeks showed no significant increase before day 14. At 24 hours after birth, the AT:RVET(c) values of VLBW infants did not correlate well with either the ratio of the right preejection period to the right ventricular ejection time on M-mode echocardiography or the pressure gradient between the right ventricle and the right atrium, as estimated by tricuspid regurgitation on pulsed Doppler echocardiography. The AT:RVET(c) value for the chronic lung disease (CLD) group did not differ significantly from that for the oxygen-dependent group at any assessment point. During the early neonatal period, the AT:RVET(c) of VLBW infants, as calculated by pulsed Doppler echocardiography, differed with their gestational age and did not appear to correlate well with PAP. Our data also suggest that AT:RVET(c) values may not be a good predictor of the subsequent occurrence of CLD in VLBW infants.

Ca2+ dynamics at the frog motor nerve terminal

Rises in free [Ca2+]i in response to various tetanic stimuli (Ca2+ transient) in frog motor nerve terminals were measured by recording fluorescence changes of Ca2+ indicators and analyzed in relation to short-term synaptic plasticity. Ca2+ transients reached a plateau after 10-20 impulses at 100 Hz and decayed in a three-exponential manner, in which the fast component was predominant. The plateau and fast component of the Ca2+ transient were elevated infralinearly with an increase in tetanus frequency. Computer simulation showed that the Ca2+ transients estimated from fluorescence changes faithfully reflect the true changes in [Ca2+]i except for the initial 20 ms. A slow Ca2+ chelator, EGTA, loaded into the nerve terminal, decreased the magnitude of both the fast and slow components of facilitation of transmitter release and the time constant of the former. A fast Ca2+ chelator, BAPTA, decreased the magnitude of fast facilitation but slightly increased its time constant. These results suggest that Ca2+ transients in the frog motor nerve terminals are primarily caused by Ca2+ entry and are dissipated by three components, in which the rate of the fast component is equivalent to that of free Ca2+ diffusion. The residual Ca2+ in the nerve terminals after stimulation accounts for the fast component of facilitation.

Glycated apolipoprotein A-I assay by combination of affinity chromatography and latex immunoagglutination

The degree of glycation of plasma apolipoprotein A-I was measured by a combination of gel filtration, boronate affinity chromatography and latex immunoagglutination. The plasma concentrations of apolipoprotein A-I determined by this combination method (y) correlated well with those determined by turbidimetric immunoassay (x) (y=1.12x + 1.9, r=0.964). The inter- and intra-assay coefficients of variation in the glycated apolipoprotein A-I assay were 4.1-5.0% and 4.0-4.4%, respectively. Interference from plasma glucose at concentrations up to 55.1 mmol/L was eliminated by gel filtration. Labile glycated apolipoprotein A-I did not interfere with the measurement of glycated apolipoprotein A-I. Reference values for glycated apolipoprotein A-I were determined to be 2.4-4.0% (n=140), with no significant difference between men and women. The mean concentration of plasma glycated apolipoprotein A-I in patients with uncontrolled diabetes mellitus (5.11%) was significantly higher than in normal subjects (3.12%, P<0.001). The method is simple, rapid and highly sensitive for determination of the glycation level of plasma apolipoprotein A-I.

[Treatment by corticosteroid and plasma exchange in 5 cases of renal cholesterol embolic disease]

Cholesterol arterial embolization is a systemic disease resulting from cholesterol crystal embolization to multiple organs, including the kidney, skin, brain, eye, gastrointestinal tract and extremities. In general, it is associated with high morbidity and mortality, but no optimal treatment has yet been developed. In this paper, we report five patients with cholesterol atheroembolic renal failure. In three of the five patients, combined therapy with corticosteroids and plasma exchange was performed. The three patients survived. On the other hand, the two remaining patients died of multifactorial causes. In this report, the literature on steroid therapy for cholesterol atheroembolic renal disease is reviewed and the efficacy of combined therapy by use of corticosteroids and plasma exchange is evaluated.

[A case of Chinese herbs nephropathy in which the progression of renal dysfunction was slowed by steroid therapy]

The patients was a 43-year-old woman whose chief complaints were nausea and heaviness of the heads. There was a history of toxemia of pregnancy. The patient had previously taken Tenshin Tokishigyaku-ka-goshuyu-shokyo-to for two years because of cold sensitivity. Fever, thirst, and loss of appetite developed from approximately 18 months after she started treatment with the Chinese herbal preparation, and she presented at our outpatient clinic 2.5 years later. On initial examination, deterioration of renal function was evident and the serum creatinine level was 3.4 mg/dl. A renal biopsy specimen showed marked interstitial fibrosis without inflammatory cell infiltration, leading to the diagnosis of Chinese herbs nephropathy (CHN). Steroid therapy was started on the 36th hospital day after a sharp rise in the serum creatinine level to 5.1 mg/dl. This resulted in the rapid improvement of renal function and reduction of the serum creatinine to 2.6 mg/dl by 8 weeks after the initiation of treatment. In a study on the use of steroids for patients with progressive moderate renal dysfunction caused by Chinese herbs, Vanherweghem et al. reported that the progression of renal failure was appreciably slowed in patients given steroids when compared with the control group. We were also able to slow the progression of renal dysfunction in our patient by steroid therapy, although the prognosis of CHN is generally considered to be very poor.

Repair of leaking postinfarction ventricular septal defect under circulatory arrest via left thoracotomy

We treated a 60-year-old woman for postinfarction ventricular septal defect (VSD) and closed it by the infarction exclusion method. Postoperatively she was complicated by Candida sternal mediastinitis and residual shunt of VSD. After her sternal infection came under control we repaired the leaking VSD via left thoracotomy under hypothermic circulatory arrest. She recovered well and repair of the leaking VSD under circulatory arrest via left thoracotomy seemed to be a safe and promising alternative for VSD repair.

A new concise synthesis of arcyriacyanin A and its unique inhibitory activity against a panel of human cancer cell line

The nucleophilic addition reaction of N-tosyl-4-oxo-4,5,6,7-tetrahydroindole (12) with the lithium salt of 1-methoxyindole (5), followed by dehydration with 2,3-dichloro-5,6-dicyano-1,4-benzoquinone (DDQ) gave the derivative of 2,4'-bi-1H-indole (9) which provides a new concise synthetic method of an indole pigment of the slime mould, arcyriacyanin A. The compound was first demonstrated here to have unique inhibitory activity to a panel of human cancer cell lines and to inhibit protein kinase C and protein tyrosine kinase.

A complete deficiency of coagulation factor XIII A-subunit due to a novel compound heterozygote of Ser 413 Leu missense and an nt 389 (ins G) frameshift mutation

Coagulation factor XIII consists of two A- and two B-subunits, and either gene mutation can cause a complete deficiency. In a newborn patient with persistent bleeding from the umbilical cord stump, the plasma A-subunit protein was not detectable. Direct PCR sequencing revealed an nt 389 (ins G) frameshift mutation in exon 4 resulting in a new stop codon and a Ser 413 Leu missense mutation in exon 10 in either allele. His mother and father were heterozygous for the nt 389 (ins G) and the Ser 413 Leu, respectively, with about 50% reduction of the plasma A-subunit proteins. In all family members examined only those with either mutation showed the reduced subunit A protein levels. Thus, this complete deficiency of factor XIII was due to a novel compound heterozygous mutation in the A-subunit gene.

[In vitro antibacterial activities of carbapenems against clinical isolates]

Antibacterial activities of four carbapenems, imipenem, panipenem, meropenem, and biapenem, were determined using 353 strains belonging to 18 bacterial species which were isolated from clinical materials at Ehime University Hospital. The MIC values of these carbapenems against MRSA were widely distributed between 0.1 and 100 micrograms/ml, and MIC90 values of these 4 carbapenems were 25-50 micrograms/ml. Any of these carbapenems prevented the bacterial growth of enterobacteriaceae of 8 bacterial species excluding S. macrescens at concentrations of 1 microgram/ml or less. The MIC values against P. aeruginosa showed relatively wide distribution, being 0.39-25 micrograms/ml for imipenem, 0.2-25 micrograms/ml for panipenem, 0.1-12.5 micrograms/ml for meropenem, and 0.2-12.5 micrograms/ml for biapenem. From those results, it was confirmed that any of the carbapenems tested had a wide antibacterial spectrum and strong antibacterial activities.

Structure of mouse calpastatin isoforms: implications of species-common and species-specific alternative splicing

Mouse calpastatin cDNAs were cloned by the method of RT-PCR using RNA isolated from myoblast C2C12 cells. Nucleotide sequencing of the isolated clones revealed an in-frame ATG codon upstream of the previously assigned translation initiation methionine. Except for the N-terminal segment, the new translatable region (domain XL) was similar to the sequence of bovine calpastatin in which domain XL was first identified. Among the isolated mouse calpastatin cDNA clones, three isoforms (mCS-a, mCS-b, and mCS-c) were identified. In domain L, mCS-b had a deletion of the region corresponding to exon 3 of the human calpastatin gene. RT-PCR analyses of various mouse tissues revealed that mCS-b was the major form and that the content of mCS-a, nondeleted form, was 5-10% in tissues including skeletal muscle, liver, brain, etc. and about 30% in the myoblast C2C12 cells. Unlike human and rat cDNAs, no other deletions were detected in mouse calpastatin domain L. Isolation of the cDNA clone of mCS-c, which lacked regions corresponding to exons 3 and 12, was obtained by chance because its expression level was under the detectable level in the mouse tissues and even in C2C12 cells.

Study of rapidity and quality for the VITEK susceptibility cards with 45 wells

VITEK 45 wells Card was evaluated. Recent clinical isolates of gram-positive cocci (107) and gram-negative bacilli (179) were antimicrobial susceptibility testing by VITEK system in comparison with MIC-2000 system. The antimicrobial susceptibility results were available within of 8 h for gram-positive cocci without a part of MRSA. Enterobac-teriaceae were available within of 8 h and Pseudomonas aeruginosa were from 8 to 11 h. The antimicrobial susceptibility data had disagreement of 60% with EM, 46% with CLDM for Enterococcus faecium, 50% with CMZ for Citrobacter freundii, and 71% with CTM for Morganella morganii, whereas it was satisfactory agreement of 97.5% for gram-positive cocci and 98.2% for gram-negative bacilli. In using this procedure it was possible to provide accurate and rapid results of anti-microbial susceptibility tests for all organisms.

Characterization of CD4+ CD8alphaalpha+ and CD4-CD8alphaalpha+ intestinal intraepithelial lymphocytes in rats

Intestinal intraepithelial lymphocytes (i-IEL) of aged rats comprise CD4+CD8alphaalpha+ and CD4-CD8alphaalpha+ T cells expressing TCR alphabeta. In the present study, we compared characteristics between CD4+CD8alphaalpha+ and CD4-CD8alphaalpha+ i-IEL, which were purified by a cell sorter from the i-IEL of 6-month-old Lewis rats. Most of the CD4+CD8alphaalpha+ i-IEL were of the CD44(hlgh) phenotype, while CD4-CD8alphabeta+ i-IEL were CD44(low). Vbeta usage in the CD4-CD8alphaalpha+ i-IEL was much diversified, while CD4+CD8alphaalpha+ i-IEL showed a skewed Vbeta repertoire. The CD4+CD8alphaalpha+ i-IEL but not the CD4-CD8alphaalpha+ i-IEL proliferated in response to syngeneic spleen cells, which was partially inhibited by addition of anti-MHC class I mAb. The CD4+CD8alphaalpha+ i-IEL produced IFN-gamma and IL-2 but no IL-4 or transforming growth factor (TGF)-beta in response to syngeneic spleen cells, while CD4-CD8alphaalpha+ i-IEL produced abundant levels of TGF-beta but no IL-2, IFN-gamma or IL-4. CD4+CD8alphaalpha+ i-IEL proliferated in response to exogenous IL-2 but not to IL-15, while CD4-CD8alphaalpha+ i-IEL could respond to IL-15 as well as IL-2. These results suggest that a significant fraction of CD4+CD8alphaalpha+ i-IEL belongs to Th1-type T cells capable of responding to self-MHC class I, while CD4-CD8alphaalpha+ i-IEL are a unique population with a diversified Vbeta repertoire that respond to IL-15 in rats.

[Coronary artery bypass grafting in cases with poor left ventricular function]

From January 1987 through June 1992, 18 patients with poor left ventricular function (left ventricular ejection fraction [LVEF] less than 0.3) underwent elective isolated primary coronary artery bypass surgery. The mean age was 56.4 years (range, 46 to 72 years), and 15 were males and 3 were females. Mean pre-operative LVEF measured by ventriculography was 0.26 +/- 0.03 (range, 0.19 to 0.30). Sixteen patients (88.9%) had a prior myocardial infarction and 9 (50%) had a history of congestive heart failure. Complete revascularization was the goal for all patients, and the mean number of bypass grafts was 3.0 +/- 0.8 per patient. The left anterior descending coronary artery (LAD) was revascularized in all patients. There were no operative deaths. Post-operative LVEF improved significantly from 0.26 +/- 0.03 to 0.42 +/- 0.11 (p = 0.0002), and the regional left ventricular wall motion improved in the diaphragmatic and posterobasal regions (p < 0.01). The patency of the grafts was 93.9% in all, and 100% for LAD. The mean follow-up period was 77 months, and the overall actuarial survival rate was 88.9% at 10 years. During follow-up periods, two patients died of congestive heart failure (CHF), and two required three rehospitalizations because of CHF. The overall cardiac event free rate was 75.8% at 10 years. In patients with poor left ventricular function, surgical revascularization can be performed safely, but congestive heart failure sometimes occurs during follow-up periods and may be the cause of death. Therefore alternate forms of therapy such as cardiac transplantation and/or TMLR should be considered in selected patients.

[A feature of hematological findings in myelodysplastic syndromes]

Myelodysplastic syndromes (MDS) are characterized by ineffective hematopoiesis in one or more hematopoietic lines with abnormal morphology and peripheral blood cytopenia. Primary MDS are more common in elderly patients and rare in children and young adults. The diagnosis of MDS in patients with unexplained cytopenias requires careful morphologic evaluation of both the peripheral blood and bone marrow cells. To examine which abnormalities detected by routine examination suggest MDS, we analyzed the hematological findings of peripheral blood in seventy-six cases of MDS. Anemia (> 60%), leukopenia (> 40%), thrombocytopenia (> 70%) as well as blast (> 40%) were often found. The prevalence of MDS was relatively high in patients with morphological abnormalities such as elliptocyte, dacryocyte, erythroblast, pseudo-Pelger-Huet anomaly, decreased secondary granules and giant platelets. Careful attention should be paid to these findings especially elderly patients, since these may provide clues to the diagnosis of MDS.

A case successfully treated by conservative management for mediastinitis and infected composite graft due to methicillin-resistant coagulase negative staphylococcus

A 72 year-old man underwent a Bentall procedure for aortic regurgitation secondary to annulo-aortic ectasia and ascending aortic aneurysm. On the 11th postoperative day, the C-reactive protein (CRP) level and white blood cell (WBC) count rose. Echocardiography and a computed tomographic scan showed the appearance of pericardial effusion. A diagnosis of mediastinitis and composite graft infection was made, and mediastinal drainage and irrigation were performed. Methicillin-resistant coagulase negative staphylococcus (MRCNS) was identified as the causative organism. Vancomycin, arbekacin and minocycline were used intravenously. Additionally, a continuous mediastinal irrigation was performed through the chest tubes. CRP level and WBC count were gradually reduced to normal range. He has now been free from signs of infection for more than 3 years. Because MRCNS is considered less virulent than methicillin-resistant Staphylococcus aureus, mediastinitis and composite graft infection due to MRCNS might be treatable by such conservative therapy even in patients with prosthetic implants. Since MRCNS often becomes ubiquitous, preventing infections by strict attention to asepsis is important.