Financial incentives for infection prevention and antimicrobial stewardship to reduce antibiotic use: Japan's nationwide observational study

BACKGROUND

The Japanese government introduced financial incentives to reduce nationwide antibiotic use in hospital settings.

AIM

This study aimed to determine whether the nationwide financial incentives for creating infection prevention and control (IPC) teams introduced in 2012 and antimicrobial stewardship (ASP) teams introduced in 2018 were associated with changes in antibiotic use and health resource utilization at a national level.

METHODS

We conducted time-series analyses and a difference-in-differences study consisting of 3,057,517 inpatients with infectious diseases from 472 medical facilities during fiscal years 2011-2018 using a nationally representative inpatient database in Japan. The primary outcome was the days of therapy (DOT) of antibiotic use per 100 patient-days (PDs). The secondary outcomes consisted of types of antibiotic used, health resource utilization, and mortality.

RESULTS

A total of 5,201,304 financial incentives were observed during 2012-2018, which resulted in a total of 12.1 billion JPY (≈110 million USD). Time-series analyses found decreasing trends in total antibiotic use (79.3-72.5 DOTs/100 PDs (8.6% reduction)) and carbapenem use (9.0-7.0 DOTs/100 PDs (7.8% reduction)) from 2011 to 2018 without adversely affecting other healthcare outcomes (e.g., mortality). In the difference-in-differences analyses, we did not observe meaningful changes in total antibiotic use between the incentivized and unincentivized hospitals for ASP teams, except for the northern part of Japan. No dose-response relationships were observed between the amount of financial incentives and reductions in antibiotic use during 2011-2019.

CONCLUSIONS

Further research and efforts are needed to accelerate antimicrobial stewardship in hospital settings in Japan.

Postoperative evaluation of changes in extracranial-intracranial bypass graft using superficial temporal artery duplex ultrasonography

BACKGROUND AND PURPOSE

Extracranial-intracranial (ECIC) bypass grafts have been assessed postoperatively by various neuroradiologic techniques. The aim of this prospective study was to evaluate postoperative changes in ECIC bypass graft by using superficial temporal artery duplex ultrasonography (STDU). Furthermore, this study assessed the ability of STDU to predict cerebrovascular reserve capacity (CVR).

MATERIALS AND METHODS

Forty-five consecutive patients who underwent ECIC bypass procedure for atherosclerotic internal carotid artery occlusion were enrolled in this prospective study. All patients underwent single-photon emission CT and STDU preoperatively, 14 days after, 3 months after, 1 year after, and 2 years after ECIC bypass.

RESULTS

The diameter and flow velocities of the ipsilateral superficial temporal artery (STA), and regional cerebral blood flow (rCBF) showed increase during the first 2 weeks and then remained stable, whereas CVR showed a constant improvement up to 2 years after surgery. The STA diameter and mean STA flow velocity correlated significantly with CVR at 1 year after surgery (r2 = 0.1232 and r2 = 0.08716, respectively; P < .05). A cutoff value of 1.8 mm STA diameter was determined as the most reliable value to predict CVR greater than 10% at 1 year after surgery. The positive predictive value was calculated as 96.6%, the negative predictive value as 43.8%, the sensitivity as 75.7%, the specificity as 87.5%, and the likelihood ratio as 6.056.

CONCLUSIONS

ECIC bypass grafts can be assessed postoperatively in a noninvasive fashion with STDU. This technique provides information regarding patency as well as quantitative assessment of bypass function. Moreover, STDU is useful to predict CVR improvement.

Unique evolution of Bivalvia arginine kinases

The clams Pseudocardium, Solen, Corbicula and Ensis possess a unique form of arginine kinase (AK) with a molecular mass of 80 kDa and an unusual two-domain structure, a result of gene duplication and subsequent fusion. These AKs also lack two functionally important amino acid residues, Asp(62) and Arg(193), which are strictly conserved in other 40-kDa AKs and are assumed to be key residues for stabilizing the substrate-bound structure. However, these AKs show higher enzyme activity. The cDNA-derived amino acid sequences of 40-kDa AKs from the blood clam Scapharca broughtonii and the oyster Crassostrea gigas were determined. While Asp(62) and Arg(193) are conserved in Scapharca AK, these two key residues are replaced by Asn and Lys, respectively, in Crassostrea AK. The native enzyme from Crassostrea and both of the recombinant enzymes show an enzyme activity similar to that of two-domain clam AKs and at least twofold higher than that of other molluskan AKs. Although the replacement of Asp(62) or Arg(193) by Gly in normal AK causes a considerable decrease in V(max) (6-15% of wild-type enzyme) and a two- to threefold increase in K(m) for arginine, the same replacement in Scapharca AK had no pronounced effect on enzyme activity. Together with the observation that bivalve AKs are phylogenetically distinct from other molluskan AKs, these results suggest that bivalve AKs have undergone a unique molecular evolution; the characteristic stabilizing function of residues 62 and 193 has been lost and, consequently, the enzyme shows higher activity than normal.

Cutaneous necrosis after superficial temporal artery-to-middle cerebral artery anastomosis: is it predictable or avoidable?

OBJECTIVE

This study was carried out to determine whether a relationship exists between cutaneous necrosis after superficial temporal artery-to-middle cerebral artery anastomosis and background risk factors or surgical methods, and to determine whether such necrosis is predictable or avoidable.

METHODS

Forty-seven patients (a total of 51 sides) with atherosclerotic lesions of the internal carotid artery or middle cerebral artery who underwent superficial temporal artery-to-middle cerebral artery anastomosis at the National Kyushu Medical Center Hospital between September 1, 1994, and August 31, 1999, were reviewed. Each procedure was analyzed to determine whether cutaneous necrosis was present postoperatively around the donor site, whether preexisting risk factors (hypertension, diabetes mellitus, hyperlipidemia, ischemic heart disease, and arteriosclerosis obliterans) were present, and whether a flap or cutdown method or a single or double anastomosis was performed.

RESULTS

Postoperative necrosis was clearly related to arteriosclerosis obliterans (P < 0.003). The tendency for a relationship between necrosis and smoking was noted. Although statistical analysis failed to demonstrate a significant difference, necrosis was found with the flap method but not with the cutdown method.

CONCLUSION

Further study is needed using greater numbers to clarify the relationship between the surgical method and the presence of necrosis. To prevent cutaneous necrosis, however, it may be preferable to use the cutdown method in patients with the preexisting risk factors of arteriosclerosis obliterans or in smokers.

Endovascular treatment of basilar artery trunk aneurysms with Guglielmi detachable coils: clinical experience with 41 aneurysms in 39 patients

OBJECT

The authors present a retrospective analysis of their clinical experience in the endovascular treatment of basilar artery (BA) trunk aneurysms with Guglielmi detachable coils (GDCs).

METHODS

Between April 1990 and June 1999,41 BA trunk aneurysms were treated in 39 patients by inserting GDCs. Twenty-seven patients presented with subarachnoid hemorrhage, six had intracranial mass effect, and in six patients the aneurysms were found incidentally. Eighteen lesions were BA trunk aneurysms, 13 were BA-superior cerebellar artery aneurysms, four were BA-anterior inferior cerebellar artery aneurysms, and six were vertebrobasilar junction aneurysms. Thirty-five patients (89.7%) had excellent or good clinical outcomes; procedural morbidity and mortality rates were 2.6% each. Thirty-six aneurysms were selectively occluded while preserving the parent artery, and in five cases the parent artery was occluded along with the aneurysm. Immediate angiographic studies revealed complete or nearly complete occlusion in 35 aneurysms (85.4%). Follow-up angiograms were obtained in 29 patients with 31 aneurysms: the mean follow-up period was 17 months. No recanalization was observed in the eight completely occluded aneurysms. In 19 lesions with small neck remnants, seven (36.8%) had further thrombosis, three (15.8%) remained anatomically unchanged, and nine (47.3%) had recanalization caused by coil compaction. In one patient (2.6%) the aneurysm rebled 8 years after the initial embolization.

CONCLUSIONS

In this clinical series the authors show that the GDC placement procedure is valuable in the therapeutic management of BA trunk aneurysms. The endovascular catheterization of these lesions tends to be relatively simple, in contrast with more complex neurosurgical approaches. Endosaccular obliteration of these aneurysms also decreases the possibility of unwanted occlusion of perforating arteries to the brainstem.

Medium-chain triglyceride-rich enteral nutrition is more effective than low-fat enteral nutrition in rat colitis, but is equal in enteritis

BACKGROUND

Although enteral nutrition (EN) therapy for Crohn's disease has been confirmed to be as effective as steroid therapy, the precise mechanism responsible for the effects of EN remains unclear, although some of the therapeutic effects of EN are believed to be due to a low dietary fat content. In order to elucidate the influence of fat in EN, it is important to investigate not only the quantity of fat, but also the source of the fat.

METHODS

We compared two enteral nutritional formulae: Elental (Ajinomoto) (elemental diet; ED), which contains only 1.5% fat, provided as long-chain triglycerides (LCT), versus Twinline (Snow Brand Milk Products) (TL), which contains a high percentage of fat (20.4%), provided mainly as medium-chain triglycerides (MCT). These formulae were tested on rat enteritis and rat colitis induced by trinitrobenzene sulfonic acid (TNBS).

RESULTS

Both ED and TL reduced the manifestations of enteritis. TL had a stronger anti-inflammatory effect than ED for colitis. TL also had nutritional advantages as compared with ED, as shown by the total serum protein in the TL group being significantly higher than that in the ED group.

CONCLUSION

The results indicate that intraluminal MCT is suitable as a fat energy source during intestinal inflammation in rats. We suggest that Twinline may be more useful to improve nutritional status and to reduce the mucosal inflammation in rat colitis, but that Twinline is equal in effect to Elental for rat enteritis.

Hearing restoration from deafness after resection of a large cerebellopontine angle meningioma--case report

A 61-year-old man presented with a large cerebellopontine angle meningioma manifesting as a 1-year history of deafness on the right side, in whom hearing was restored from the deaf state immediately after tumor resection. Neuroimaging demonstrated a large mass in the right cerebellopontine angle, originating at the region adjacent to the jugular foramen. Audiometry showed his hearing was off-scale (> 105 dB) on the right. The tumor was successfully removed through the retrosigmoid approach, and the integrity of the 7th and 8th cranial nerves was maintained. The patient regained hearing on the day after the operation, which continued to improve until near-normal. The 8th cranial nerve function may recover dramatically after removal of non-acoustic tumors, even if preoperative hearing loss is profound. To maximize the opportunity to regain hearing, approaches which devastate cochlear function should be avoided and more meticulous manipulation during tumor removal is needed.

An evaluation of the Physical Properties of Current Microcatheters and Guidewires. The Development of the "Catheter-glide Approach" in Response to Weaknesses of Current Materials

SUMMARY

The physical properties of the 16 microcatheters and 7 guidewires currently available were evaluated to assess their manoeuvrability. This investigation included the latest varieties of these products. The test results showed that there was a wide variation in flexibility and friction between the distal segments of the catheters. Even the recently developed hydrophilic polymer-coated catheters show this variation. Comparisons between guidewires also showed differing degrees of flexibility and friction. Torque transmission was also a variable factor. A combination of the most flexible microcatheter with the lowest friction and the most responsive guidewire with the lowest friction was picked for clinical evaluation. The effectiveness and safety of this combination of equipment was proved by embolising various cerebral arteriovenous malformations( AVMs) and thrombolysing cerebral emboli of arteriosclerotic patients. However it remains difficult to reach the nidus of distally located AVMs with extremely long and tortuous feeding pedicles such as parietal lobe AVMs. The efforts to overcome the weaknesses of current materials by further improving equipment and technique is another subject of the current paper.

Hepatic resection for liver metastasis of sigmoid colon cancer after incomplete percutaneous microwave coagulation therapy

We report a case of colon cancer with liver metastasis that had been treated previously by sigmoidectomy and partial hepatic segmentectomy. A 55-year-old woman presented with two asynchronous liver metastases, which were treated with percutaneous microwave coagulation therapy. However, evaluation by dynamic computed tomography one week later showed incomplete necrosis in at least one tumor. Surgical resection was subsequently performed and histopathological examination showed the presence of viable cancer cells in both tumors. We conclude that surgical resection is perhaps the best curative method of treatment of metastatic liver tumors of colorectal carcinomas and that dynamic computed tomography is not always accurate for evaluating the effect of microwave coagulation therapy.

Diagnosis and endovascular treatment of vertebral arteriovenous fistulas in neurofibromatosis type 1

SUMMARY

We present diagnostic problems, strategies, techniques and material selection for endovascular treatment of high flow arteriovenous fistula (AVF) of tortuous and fragile vertebral artery (VA) with neurofibromatosis type 1 (NF1). Diagnosis of NF1 was easy in four of our cases because of neurofibromatosis, skin pigmentation and various skeletal abnormalities. These stigmas of NF1 were lacking in one case, and the only clue to the diagnosis was ovoid bone defects of the skull vault. Diagnosis was made by performing biopsy of scalp neurofibromas incidentally found on CT. In two initial cases, venous varix were packed with coils by transvenous approach after the transarterial embolisation failed to completely cure the fistula. In three recent cases, blood flow through the fistula was markedly reduced as an initial step by placing detachable coils into the distal and proximal stumps of the afferent VA. Then a liquid adhesive was injected under systemic hypotension to completely occlude the fistula. Control angiography revealed that the AVFs were completely occluded in all cases. Longterm angiographical and clinical status have been stable in all cases. Trying to attain complete occlusion of fistulas using detachable balloons is not an appropriate treatment option for high flow fistulas situated on markedly dilated, tortuous and fragile VAs of patients with NF1. Also, trapping of fistulas is not justified because of the numerous potential feeding pedicles, and makes the following procedure difficult.

Efficacy of oral adsorbent for treatment of peristomal fistula associated with Crohn's disease

Perianal fistulae are frequently seen complications in Crohn's disease. Although surgical procedures such as Seton's method have been devised, many patients still suffer from fistulae that are resistant to conventional therapy. We administered oral adsorbent to a patient with disease Crohn's who had a complicated peristomal fistula that did not improve with conventional therapy. Six grams of oral adsorbent (AST-120) were added daily to a regimen of elemental diet therapy and prednisolone. The fistula gradually decreased in size after the administration of the oral adsorbent, and had healed completely after 40 days' treatment. There were no side effects from the oral adsorbent. This case report suggests that oral adsorbent is an effective treatment for peristomal fistula associated with Crohn's disease.

Acute intrathoracic incarceration of the stomach after laparoscopic Nissen fundoplication

A rare case of paraesophageal hernia with complete intrathoracic incarceration of the stomach after laparoscopic Nissen fundoplication is described. An 85-year-old woman who had undergone laparoscopic Nissen fundoplication for gastroesophageal reflux disease presented 14 months later with nausea and vomiting. Esophagogastroendoscopy showed obstruction of the esophagogastric junction and gastric mucosal necrosis. Emergency laparotomy showed the stomach to be entirely strangulated into the thorax, with areas of necrosis. Gastrotomy was followed by resection of the necrotic anterior wall of the stomach, closure of the hiatus, and suturing of the stomach to the diaphragm. Appropriate closure of crura and anchoring suture between the stomach and diaphragm are helpful to prevent recurrent hernia after laparoscopic Nissen fundoplication.

[Infratemporal fossa approach for mid-skull base lesion: its usefulness, surgical anatomy, and intraoperative device]

The usefulness of the infratemporal fossa type C approach is reported through a presentation of a case of clival chordoma, which was successfully treated by this approach. Although it is complicated and includes some demerits, this approach gives a shorter and wider access to mid-skull base pathology than other approaches. Among the demerits, deformity of the temporal region caused by extensive drilling of the bone could be minimized by cosmetic mastoidectomy, which was first applied during this approach by the authors. The surgical anatomy for this approach is demonstrated using a cadaver specimen.

Clinical importance of n-3 fatty acid-rich diet and nutritional education for the maintenance of remission in Crohn's disease

Elemental diet (ED) therapy has been established as primary therapy for Crohn's disease, and home enteral nutrition (HEN) has been reported to control relapse at a dose of more than 30kcal/kg of ideal body weight. However, a decrease in ED compliance with long-term use is becoming problem. We developed an n-3 fatty acid-rich diet and carried out nutritional education specifically for Crohn's disease patients using HEN to facilitate compliance and to improve their nutritional status. After the introduction of this n-3 rich diet, disease activity was not altered, and nutritional status, especially serum n-3 fatty acid levels, improved. The remission periods in patients with poor compliance seemed to be prolonged by the nutritional education. Thus, a n-3 rich diet in combination with nutritional education specific for Crohn's disease patients is very important for the in maintenance of high compliance and for maintaining nutritional balance.

Surgical correction of cryptotia with superiorly based superficial mastoid fascia and skin paddle

An approach for the correction of cryptotia using a superiorly based superficial mastoid fascial flap and a skin paddle is introduced. The buried portion of the auricle was exposed through an incision made along the upper part of the helix, followed by an appropriate correction of the deformed cartilage. Protrusion of the upper portion of the auricle was accomplished using anchoring sutures. A small skin paddle was elevated from the caudal portion of the auricular sulcus with the superiorly based superficial mastoid fascia as the nutrient pedicle and transferred to the temporal skin defect. The procedure was performed in eight auricles in a total of seven patients with cryptotia. A satisfactory contour and protrusion of the auricle were maintained postoperatively, leaving the scar within the auricular sulcus.

Medium-chain triglycerides modulate ileitis induced by trinitrobenzene sulfonic acid

BACKGROUND

It is important to develop an appropriate animal model for further investigation into inflammatory bowel disease (IBD). We therefore investigated a trinitrobenzene sulfonic acid (TNBS) ileitis model. Dietary fat in Crohn's disease is still a controversial risk factor for IBD. We therefore also studied the effects of medium-chain triglycerides (MCT) and long-chain triglycerides (LCT) on TNBS ileitis.

METHODS AND RESULTS

An intraileal injection of TNBS induced ulceration and inflammation with thickening of the intestinal wall, which were characterized histologically by infiltration of polymorphic nuclear leucocytes and by granuloma formation. The mucosal damage score and serum sialic acid levels reached their highest 7 days after the TNBS injection and then gradually decreased. The mucosal damage series in the MCT group was significantly lower than in the LCT group, and levels of tumour necrosis factor-alpha (TNF-alpha) and leukotriene B4 (LTB4) tended to be lower in the MCT group.

CONCLUSIONS

These results suggested that TNBS enteritis might be useful as an IBD animal model and that MCT modulates intestinal inflammation and is less damaging than LCT.

Changes in serum diamine oxidase activity during chemotherapy in patients with hematological malignancies

Serum diamine oxidase (DAO) activity is very low, but is considered to reflect quantitative changes in small intestinal mass. Therefore, we measured DAO activity during chemotherapy in patients with hematological malignancies in order to evaluate mucosal injury. DAO activity decreased from 1-3 weeks after chemotherapy but returned to initial levels after 4 weeks. As the dosage of anti-cancer drugs increased, DAO activity decreased more, but its activity was not related to other parameters. These findings suggest that serum DAO could be used as an indicator of mucosal injury during chemotherapy.

Laparoscopic low anterior resection using a triple stapling technique

Laparoscopic low anterior resections using a triple stapling technique in five patients with rectal cancers (four Dukes A and one Dukes C) were performed. The location of the tumors was between 5 and 18 cm from the anal verge. For easy maneuverability, a 33-mm suprapubic port was used. In this technique, the Endo TA (the first stapler) is applied at the distal margin of the rectum to occlude the bowel. The bowel is irrigated with povidone-iodine solution and transected by an endolinear (the second) stapler. Anastomosis is completed by firing the circular (the third) stapler. The operative time was 177 +/- 28.0 minutes, estimated blood loss was 41.7 +/- 28.6 g, and flatus appeared 1.8 +/- 0.8 days after surgery. Follow-up studies have showed no local recurrence or distant metastasis. This procedure is safe and useful for performing laparoscopic low anterior resection.

[A case of cervical myelopathy due to dural arteriovenous fistula at the craniocervical junction]

A 70-year-old woman noted paresthesia ascending from both legs to her thighs 27 months previously. She also suffered from urinary urgency and incontinence. Thereafter, weakness in both legs developed and gradually became worse. At the time of admission, a neurological examination revealed diffuse atrophy and mild spasticity in all four extremities, bilateral mild weakness in both upper extremities, and severe weakness in both lower extremities. Her superficial sensation was moderately impaired below the Th 3 level on her right side, and below the Th 4 level on her left side along with a mildly decreased sense of vibration in her left leg. Marked hyperreflexia in all four extremities and bilateral pathological reflexes were also observed. Pollakisurea, urinary incontinence and constipation were also present. Cervical MRI showed a swelling of the spinal cord at the C3 to C7 levels. Inside the spinal cord, low signal intensity lesions were seen on the T1-weighted MRI, and high signal intensity lesions were observed on the T2-weighted MRI, and the rim of the cervical cord was also enhanced by gadolinium-DTPA. MR angiography revealed enlarged and tortuous vessels at the craniocervical junction, thus suggesting the presence of a dural arteriovenous fistula (AVF). Vertebral arteriography demonstrated abnormal vessels at the spinomedullary junction supplied by the right vertebral artery, which drained into the anterior and posterior spinal veins. After surgically treating the dural AVF, the swelling of the spinal cord, the abnormal signals on MRI, and the clinical symptoms all markedly improved. Although most of the spinal dural AVF were located at the thoracic and lumbar levels, the present case was considered to be a very rare case of dural AVF, since it was located at the craniocervical junction and thus led to the development of cervical myelopathy.

Embolization of cerebral arteriovenous malformations (AVMs)--material selection, improved technique, and tactics in the initial therapy of cerebral AVMs

Successful embolization can be achieved only when the following three factors are correct and in co-operation: catheter tip position, flow control, and the setting time of normal-butyl cyanoacrylate (NBCA). Otherwise, the procedure may end with unsatisfactory results or complications. The current principle of safe and efficient embolization of cerebral arteriovenous malformation (AVM) is based on superselective cannulation of every strategically important feeding pedicle and injection of liquid embolic material under flow control. This study was based upon our experiences of embolizing 92 cases with cerebral AVM performed under the above conditions at our department. Results showed very encouraging new observations with implications for further procedures: total removal of the AVM nidus after embolization was achieved in 90% of the cases, preradiosurgical embolization achieved 52% volume reduction and successfully maneuvered all cases into the gamma knife focal spot. Recently improved microcatheters with increased flexibility and minimal friction made it possible to place the tip of the microcatheter into the nidus with a higher success rate and better safety factors. In order to obliterate a substantial amount of the AVM nidus and prevent penetration into the draining veins, the creation of optimal flow status, and optimal setting time of NBCA have paramount importance.

Stable human calcitonin analogues with high potency on bone together with reduced anorectic and renal actions

Various derivatives of human calcitonin have been synthesized and their biological characteristics compared with those of existing calcitonins. The acute effects of these analogues in reducing serum calcium levels and suppressing appetite were assessed in rats. A calcitonin analogue, PO-1 (CGNLSTCMLGKLSQELHKLQTYPQTAIGVGAP-NH2), having both the N- and C-terminal ten amino acid sequences those of human calcitonin, and the 12 amino acid central region that of salmon calcitonin, was found to have equal effectiveness with salmon calcitonin and elcatonin for reducing serum calcium levels. Strong hypocalcemic activity was also exhibited by PO-23 ([cyclo-Asp1, Lys7]-[des-Gly2]-[Leu8]-PO-1) and PO-29 ([Asp15, Asn17 , Phe19, His20]-PO-23). PO-23 was prepared by replacing the N-terminal Cys-Cys S-S bond of PO-1 with a ring structure composed of an Asp-Lys peptide bond to enhance physicochemical stability. PO-29 was prepared by modifying the central area of the PO-23 molecule to more closely mimic human calcitonin. When tested in vitro, human calcitonin analogues with a [cyclo-Asp1, Lys7] structure showed biological activities on osteoclast-like cells comparable to those of existing calcitonins (salmon calcitonin and elcatonin) in keeping with their relative potencies for in vivo hypocalcemic action. Acute anorectic activity in rats was strong with salmon calcitonin and elcatonin but relatively reduced with human calcitonin analogues having a [cyclo-Asp1, Lys7] structure. The activities of these analogues on kidney cells were also weaker than that of salmon calcitonin or elcatonin. These results suggest that stable human calcitonin analogues with a [cyclo-Asp1, Lys7] structure suppress bone resorption to a degree similar to that of salmon calcitonin or elcatonin with weaker activities on non-osseous tissues which might be related to adverse reaction.

Vertebral arteriovenous fistula that developed in the same place as a previous ruptured aneurysm: a case report

BACKGROUND

Aneurysms of the extracranial vertebral artery (VA) and vertebral arteriovenous fistulas (VAVFs) are relatively rare diseases. The most frequent cause of both diseases is trauma. Atraumatic lesions are less common. Presented here is a case of atraumatic AVF of the extracranial VA that developed in the same location as a previous ruptured aneurysm of the ipsilateral VA that was originally treated by proximal occlusion 11 years earlier.

METHODS

A 40-year-old woman presented with a massive hematoma in the upper posterior neck region caused by the rupture of an extracranial VA aneurysm. Proximal occlusion of the VA was performed by use of a detachable balloon. She enjoyed good health for 11 years, then she noticed a pulsatile bruit. Angiograms revealed an AVF between the left VA that was fed by collateral circulation and the paravertebral venous plexus. Incidentally found were soft tissue masses in the left retroauricular and the right suboccipital regions. Also, skull X-ray films showed multiple bony defects. Biopsy of the subcutaneous mass was performed in the hope of obtaining clues as to which pathological processes had weakened the artery.

RESULTS

As direct transarterial access to the fistula was out of the question, the fistulous compartment of the paravertebral venous plexus was tightly packed with multiple platinum coils effected by the transfemoral approach. A histological examination of the specimen revealed features of a neurofibroma, and a diagnosis of neurofibromatosis Type 1 was established.

CONCLUSIONS

In this case, transvenous embolization of the VAVF was successfully performed. The fragility of the arterial wall, related to neurofibromatosis Type 1, was considered to contribute to the development of the aneurysm and AVF.

Embolization of cerebral aneurysms using Guglielmi detachable coils--problems and treatment plans in the acute stage after subarachnoid hemorrhage and long-term efficiency

This study investigated the problems in treating ruptured aneurysms using Guglielmi detachable coils (GDCs) in the acute stage and evaluated the long-term efficacy in a series of 25 patients with 29 aneurysms. Eight patients with ruptured aneurysm treated within 2 weeks of the onset of subarachnoid hemorrhage (SAH) suffered no mortality or morbidity related to the procedure. Five patients achieved good outcomes despite severe SAH and returned to their previous lives. Three patients had poor clinical outcomes, two related to vasospasm and one related to pulmonary complication. More than 9 months follow-up was completed in 14 patients with 16 aneurysms. All six small aneurysms with small necks were completely obliterated and no recanalization was seen, and two of the eight large or giant aneurysms were completely obliterated. Recanalization was seen in four large or giant aneurysms and one small aneurysm due to coil compaction within 13 months. One patient died of rupture of a large aneurysm 18 months after complete obliteration of the aneurysm. Embolization using GDCs in the acute stage after SAH can prevent rerupture of cerebral aneurysms. However, recanalization due to coil compaction was the major problem in the chronic stage. Intensive follow-up and additional embolization, if necessary, is important.

Interleukin-1 receptor antagonist modifies the changes in vital organs induced by acute necrotizing pancreatitis in a rat experimental model

OBJECTIVE

Interleukin-1 (IL-1) is a mediator in some critical conditions such as septic shock and multiple organ failure. Acute pancreatitis is one of the noted causes of multiple organ failure but the mechanism by which local inflammation progresses to systemic disease is unknown. In this study, we used an IL-1 receptor antagonist (IL-1ra) to investigate whether multiple organ failure due to acute pancreatitis is mediated by IL-1, as in other causes such as severe infection, trauma, and major surgery.

DESIGN

Prospective, randomized, controlled trial.

SETTING

Research laboratory of a university medical school.

SUBJECTS

Specific pathogen-free male Wistar rats weighing 200 to 250 g.

INTERVENTIONS

Necrotizing pancreatitis was induced by retrograde injection of deoxycholate solution into the biliopancreatic duct. IL-1ra was injected intravenously at a dose of 10 mg/kg 15 mins before induction of acute pancreatitis and then infused continuously at a rate of 5 mg/kg/hr for the following 24 hrs.

MEASUREMENTS AND MAIN RESULTS

Although treatment with recombinant human IL-1ra did not affect the degree of local pancreatic insult, it significantly reduced mortality, improved urine output as an indicator of the state of shock, and ameliorated the accumulation of neutrophils into the lung in a rat experimental pancreatitis model.

CONCLUSIONS

We concluded that multiple organ failure in severe pancreatitis is mediated, at least in part, by IL-1 through the activation of neutrophils. Furthermore, we concluded that circulatory collapse may also be important in the mechanism of the lethal effect of pancreatitis.

Intracranial epidermoid carcinoma: CT and MRI

We report a patient with an epidermoid carcinoma an extremely rare brain tumour, in the right cerebellopontine angle cistern. Contrast enhancement is the most important feature for differential diagnosis of epidermoid carcinomas from atypical benign epidermoid cysts.

Small intestinal perforation due to cytomegalovirus infection in patients with non-Hodgkin's lymphoma

We describe two patients with non-Hodgkin's lymphoma (NHL) who suffered cytomegalovirus (CMV)-related small intestinal perforations during the course of chemotherapy. Surgical specimens from both patients revealed histologic evidence of occlusive vasculitis and tissue destruction caused by CMV-affected cells in the submucosa and muscular walls, that may have played an important role in the pathogenesis of these perforations. Although such intestinal perforations are rare complications in NHL patients, CMV infection should be recognized as a primary etiological factor in acute abdominal crises when treating NHL patients with pharmaceutical agents including steroids. Emergency surgery and the anti-CMV agent, ganciclovir, would improve the prognoses of such patients.

Primary peripheral-postthymic T-cell lymphoma in the central nervous system: immunological and molecular approaches to diagnosis

Primary intracranial T-cell lymphoma is a very rare clinical entity, and only limited biological studies of this disease have been undertaken. A tumor specimen from a patient with a primary leptomeningeal and perivascular presentation of a T-cell lymphoma was analyzed using cellular and molecular techniques. Frozen sections of the sample were examined by immunohistochemical techniques using monoclonal antibodies to phenotypic marker antigens expressed on human lymphoid cells. Intercellular adhesion molecules expressed on the tumor were studied, as was expression of messenger ribonucleic acid (mRNA) transcripts of the T-cell receptor variable alpha and beta chain genes. The immunophenotypical analysis of lymphoma revealed that the tumor expressed CD2, CD3, CD4, CD5, CD25 and HLA-DR. In addition, all of the adhesion molecules studied (ICAM-1, LFA-3, VLA-1, CD11a, CD11b, and CD11c) were detected on the cell surface. Polymerase chain reaction amplification of mRNA from the tumor demonstrated 10 V alpha and three V beta T-cell receptor subfamilies, indicating that this tumor was a low-grade well-differentiated helper type of peripheral T-cell lymphoma of the central nervous system. In addition, the tumor was derived from multiple T-cell lineages.

Elevation of circulating monitor peptide/pancreatic secretory trypsin inhibitor-I (PSTI-61) after turpentine-induced inflammation in rats: hepatocytes produce it as an acute phase reactant

Monitor peptide (MP) is a trypsin-sensitive cholecystokinin (CCK)-releasing peptide purified from rat pancreatic juice on the basis of its stimulatory activity toward pancreatic enzyme secretion and has been reported to exhibit cell growth-stimulating activity. Pancreatic secretory trypsin inhibitor (PSTI) prevents premature activation of trypsinogen in the pancreatic duct. There are two PSTIs (PSTI-61 and -56) purified from rat pancreatic juice on the basis of trypsin inhibitory activity as reported previously. Fushiki et al. (1989, FASEB J. 3, 121) showed that MP is structurally the same peptide as PSTI-61. We measured the serial changes of circulating MP/PSTI-61 in rat and those in the level of PSTI-61 mRNA in the rat liver to investigate another novel role of this peptide in the turpentine-induced acute inflammation model. The elevation of serum MP/PSTI-61 as well as the alpha 2-globulin fraction, which is known to include several acute phase reactants such as alpha 2-macroglobulin and haptoglobin, was observed after induction of the turpentine inflammation. The serum alpha 2-globulin fraction had increased approximately 3-fold over the initial level at 48 hr after the injection. In contrast, serum MP/PSTI-61 had increased approximately 17-fold over the initial level at 48 hr after the injection. The elevation of circulating MP/PSTI-61 was significantly related with that of the alpha 2-globulin fraction (r = 0.91, P < 0.01). Immunoreactive MP/PSTI-61 was detected in the liver after induction of the inflammation (152.5 +/- 16.5 ng/g wet weight), but in the normal rat liver there was no immunoreactive MP/PSTI-61.(ABSTRACT TRUNCATED AT 250 WORDS)

Protective effect of recombinant neutrophil elastase inhibitor (R-020) on sepsis-induced organ injury in rat

Severe inflammatory responses after major surgeries, trauma, and infection develop multiple organ dysfunction. In the mechanisms of the pathogenesis of these responses, activated neutrophils are thought to be important in terms of their ability to produce various kinds of proteinases, which can degrade various proteins constructing human tissues. Among their proteinases, neutrophil elastase is the strongest serine proteinase secreted from activated neutrophils. Thus, we examined in this study the inhibitory effect and therapeutic efficacy of newly produced recombinant human Kunitz-type proteinase inhibitor (R-020), which coded the second domain of human urinary trypsin inhibitor. R-020 was effective in significantly improving the survival rate after induction of the rat lethal peritonitis model (cecal ligation and puncture-induced septic shock model). We suggest that various serine proteinases are implicated in the pathogenesis of neutrophil-related multiple organ failure and that recombinant human Kunitz-type proteinase inhibitor might be effective in the treatment of these kinds of organ dysfunction.

Effect of granulocyte-macrophage colony-stimulating factor on sepsis-induced organ injury in rats

The administration of granulocyte-macrophage colony-stimulating factor (GM-CSF) to patients with severe active infections has been questioned because activation of neutrophils may cause tissue injury. To identify the effect of GM-CSF administration on severe sepsis, we examined the survival rate and pathologic changes in vital organs using the rat lethal sepsis model. Rats received 20 micrograms of recombinant murine GM-CSF (rmGM-CSF) 3 hours after the onset of peritonitis induced by cecal ligation and puncture. After 48 hours, the survival rate did not improve, and earlier deaths than in the control group were observed. In addition, the inhibition of early leuko-sequestration in the peritoneal cavity was seen in animals treated with GM-CSF. These results suggested that the administration of rmGM-CSF after the onset of sepsis was not beneficial; thus, we concluded that care should be taken in the clinical use of GM-CSF in severe infection.

Overexpression of pancreatic secretory trypsin inhibitor in pancreatic cancer. Evaluation of its biological function as a growth factor

Four clones of pancreatic secretory trypsin inhibitor (PSTI)-overexpressing cells (TF-PANC clones 1, 6, 8, and 36) were established to evaluate the physiological function of PSTI secreted by cancer cells, by means of introducing a PSTI-expression vector (pRSV-PSTI) into the human pancreatic adenocarcinoma cell line (PANC-1). No obvious changes were observed in the histological features of these transplanted tumors in nude mice, in the growth of TF-PANC and PANC-1, or that of 3T3 fibroblasts when cocultured with them. Addition of recombinant human PSTI to the cultured media resulted in no increase in proliferation of fibroblasts (3T3 and WI-38) or of four pancreatic cancer cell lines (PANC-1, CAPAN-I, MIAPaCa-2, and Hs766T). These results suggest that the estimation of tumor-bearing PSTI as a paracrine or autocrine growth factor in recent studies should be given careful consideration.

Therapeutic efficacy of granulocyte colony stimulating factor against rat cecal ligation and puncture model

To identify the therapeutic efficacy of granulocyte colony stimulating factor (G-CSF) in severe sepsis, we examined its effect on the mortality and pathological changes in vital organs using the rat lethal sepsis model. Rats were given 15 micrograms of recombinant human (rh)G-CSF after the onset of peritonitis brought about by cecal ligation and puncture. The mortality rate after 72 h was significantly decreased by administration of 15 micrograms of rhG-CSF (p < 0.001). In addition, the administration of rhG-CSF induced an improvement in liver and renal functions. It also produced marked pathological improvement in the lungs. These results strongly indicated that administration of rhG-CSF, even after the onset of sepsis, was effective in decreasing the mortality from peritonitis-induced multiple organ failure, and this finding was clearly useful in the clinical treatment of such sepsis-induced critical illness.

Effect of taurocholate on CCK release and pancreatic secretion produced by two CCK-releasing peptides in conscious rats

The role of luminal bile salts (taurocholate) in regulation of rat pancreatic secretion was examined by studies on the effects of luminal stimulants on the pancreas during infusion of various concentrations of taurocholate into the duodenum of conscious rats. Rats with external bile and pancreatic fistulae were used. For 24 h before the experiment, pancreatic juice was excluded from the intestine but bile was continuously returned to the duodenum. From the beginning of the experiment, 8-200 mM of taurocholate was infused at a rate of 1 ml/h instead of returning the bile. Pancreatic juice was collected for a 2-h period and then 2 micrograms of pancreatic secretory trypsin inhibitor-61 (PSTI-61) (= monitor peptide) or partially purified putative CCK-releasing peptide from rat intestine (intestinal CCK-RP) was injected into the duodenum (1 ml/min). Continuous infusion of taurocholate maintained a constant rate of pancreatic secretion, except at a concentration of 8 mM, which resulted in a slight increase in pancreatic secretion. Both PSTI-61 and intestinal CCK-RP significantly increased pancreatic secretions during infusion of 20 or 40 mM taurocholate, but had no significant effect during infusion of 80 or 200 mM taurocholate. Therefore, higher concentrations of taurocholate in the intestine prevented the stimulatory effects of luminal stimulants, probably by preventing the latter from reaching CCK cells.

Serum interleukin 6, C-reactive protein and pancreatic secretory trypsin inhibitor (PSTI) as acute phase reactants after major thoraco-abdominal surgery

We measured serum immunoreactive interleukin 6 (IL-6) levels in patients after major thoraco-abdominal surgery and compared them with changes in serum C-reactive protein (CRP) and pancreatic secretory trypsin inhibitor (PSTI) levels. Serum IL-6 levels were elevated earlier than serum CRP or PSTI. There were significant relationships between the peak levels of serum IL-6 and the operation time (p less than 0.05) or the volume of blood loss during surgery (p less than 0.05), showing that serum IL-6 can be a useful laboratory test for the evaluation of tissue injuries due to surgical intervention. Though there was a significant relationship between the peak levels of IL-6 and CRP (p less than 0.01), there was no relationship between the peak levels of IL-6 and PSTI.

Response to IL-6 stimulation of human hepatoblastoma cells: production of pancreatic secretory trypsin inhibitor

LPS-stimulated macrophage conditioned medium and IL-6 markedly stimulated the secretion of PSTI by cultured hepatoblastoma cells. The mechanism underlying the cellular response of IL-6-induced secretion of PSTI was investigated. Among the agents affecting the signal transduction pathways, forskolin significantly induced PSTI secretion whereas PMA or A23187 did not, suggesting that IL-6 induced PSTI secretion is mediated by cAMP dependent protein kinase A.

Serum immunoreactive pancreatic phospholipase A2 in patients with various malignant tumors

The high incidence (40.6%) of elevated serum pancreatic phospholipase A2 (PLA2) was demonstrated in patients with various malignancies. Serum PLA2 was significantly increased in cancer patients compared with healthy sex- and age-matched blood donors (358.4 +/- 168.0 vs. 241.7 +/- 69.0 ng/dl; p less than 0.01). No correlation was observed between serum PLA2 and carcinoembryonic antigen (CEA) in these patients. Although patients with advanced and distantly metastatic cancer of the liver, gallbladder and pancreas showed higher PLA2 levels in serum than those with early cancer, patients with other cancers showed no correlation between serum PLA2 and clinical stage. A combined assay of PLA2 and CEA increased the sensitivity of detection of cancers to 60.8%.

On the cDNA's for two types of rat pancreatic secretory trypsin inhibitor

Two types of cDNA, which code for the two types of rat pancreatic secretory trypsin inhibitors (PSTIs), were cloned and sequenced. Both predicted amino acid sequences consisting of 79 amino acids, with the secretion signal peptide consisting of 18 and 23 amino acids for PSTI-I and PSTI-II, respectively. The nucleotide sequences were 91% homologous between the two cDNAs, but 68% and 65% homologous, respectively, when compared with human PSTI cDNA. Northern blot analyses showed that PSTI-I is expressed in the pancreas, whereas PSTI-II is expressed in the pancreas and the liver using the same promoter. Southern blot analyses suggested that both PSTI-I and PSTI-II genes are single copy genes per haploid genome. Duplication of rat PSTI gene seems to have occurred recently, after the divergence of humans and rats.

Rat epidermal growth factors: purification and tissue content

Rat epidermal growth factor (rEGF) was isolated from the submaxillary gland of male rat by reversed phase high performance liquid chromatography and ion exchange chromatography. The binding of purified rEGF to human carcinoma cells (A-431) and its tritiated thymidine uptake on rat epidermal fibroblast cells (FR) were almost the same as those of purified commercially available mouse EGF (mEGF). Antisera to rEGF was raised in rabbits and a radioimmunoassay (RIA) system was established. The assay range of the RIA was about 1.0 to 100 ng/ml. The within assay coefficients of variation were 5 to 10%, while the between assay coefficients of variation were 5 to 13%. The tissue content of rEGF of male rats (10 weeks old) was examined. As a result, the submaxillary gland was found to contain a very high concentration of rEGF (214 micrograms/g wet tissue) as predicted, and digestive tissues, stomach, intestine and duodenum contained 2.49, 3.57, 9.44 ng/g wet tissue, respectively. The amounts in prostate and seminal vesicle were relatively high, being 65.6 and 2,268 ng/g wet tissue, respectively. The amount in the submaxillary gland increased markedly after 7 weeks of age. These results suggest that EGF is an important factor in gonadal function.

Differences in stimulatory effects between rat pancreatic secretory trypsin inhibitor-61 and -56 on rat pancreas

Two types of pancreatic secretory trypsin inhibitors (PSTIs) were recently purified from rat pancreatic juice. One consisted of 61 (PSTI-61) and the other of 56 (PSTI-56) amino acid residues. PSTI-61 has been reported to elicit cholecystokinin (CCK) release when injected into the duodenum. Since no information has been available about the action of PSTI-56 on CCK release, the two PSTIs were compared for their stimulatory effect on CCK release and pancreatic exocrine secretions in conscious rats after intraduodenal administration. Rats were prepared with bile and pancreatic fistulae and with two duodenal cannulae. Pancreatic juice was excluded from the duodenum for 48 h prior to the experiment because rat PSTIs were trypsin sensitive. PSTI-61 significantly stimulated pancreatic secretions and increased plasma CCK concentrations from 3.6 to 6.5 pM, whereas PSTI-56 had no effect on either CCK release or pancreatic secretions. It is suggested that the action as a regulator for CCK release and pancreatic secretions is possessed only by PSTI-61, but not by PSTI-56.

Elevation of serum pancreatic secretory trypsin inhibitor following serious injury

Twenty-six of 31 seriously injured patients (84%) showed a marked elevation of serum pancreatic secretory trypsin inhibitor (PSTI) to more than twice the initial level within the first 2 weeks after admission. Serum PSTI rose from the second or third post-traumatic day and reached the maximum at day 5.8 on average. In uneventful cases, it returned to the level on admission within 2 weeks. The maximum serum PSTI in these patients was significantly correlated with the severity of the injury as judged at the time of admission, indicating that the elevation of serum PSTI in these patients was related to the extent of initial damage. In contrast, serum PSTI in patients with serious complications remained at high level even at 2 weeks after trauma, and it was not correlated with the initial severity of the injury.

Purification, characterization and amino-acid sequencing of two pancreatic secretory trypsin inhibitors in rat pancreatic juice

We purified two pancreatic secretory trypsin inhibitors (PSTI-I and PSTI-II) from rat pancreatic juice. PSTI-I consisted of 61 and PSTI-II of 56 amino-acid residues. Their amino-acid sequences were similar (40 out of 56 amino acid residues of PSTI-II being identical with those of PSTI-I), but PSTI-I and PSTI-II appeared to be translation products of different genes. There was no difference in inhibitory properties between PSTI-I and PSTI-II.

Release of pancreatic secretory trypsin inhibitor from human hepatoblastoma cells on stimulation with cytokines

To determine whether or not human pancreatic secretory trypsin inhibitor (PSTI) is an acute phase reactant released from hepatocytes, we investigated the effects of various cytokines on the release of PSTI from cultured human hepatoblastoma cells. PSTI was synthesized in human hepatoblastoma cells and released on stimulation with various cytokines: interleukin-1, tumor necrosis factor and interferon-beta.