Clinical Outcomes of S-1 Monotherapy and Modified FOLFIRINOX Therapy after Gemcitabine plus Nab-paclitaxel Therapy in Unresectable Pancreatic Cancer

Objective S-1 and modified FOLFIRINOX (mFFX) were often used as the second-line chemotherapies after failure of gemcitabine plus nab-paclitaxel (GnP) in unresectable pancreatic cancer (UPC) until nanoliposomal irinotecan plus 5-fluorouracil/leucovorin therapy was approved as an alternative in Japan in 2020. However, the clinical outcomes of S-1 and mFFX after GnP have scarcely been reported. Therefore, we retrospectively studied them. Methods We extracted the clinical data of 86 patients with UPC who received second-line chemotherapy after GnP between 2015 and 2020. Among the patients who had a good organ functions and no massive ascites, 41 patients treated with S-1 and 21 treated with mFFX were enrolled. Results Compared to S-1, mFFX tended to be used for younger patients with a good general condition (median age, 63 vs. 71 years, p<0.01; and performance status 0, 67% vs. 37%, p<0.05). The median progression-free and overall survival were similar between the S-1 (3.7 and 7.2 months, respectively) and mFFX (3.3 and 7.4 months, respectively) groups. The response rate in patients with measurable lesions was 4% (n=1/23) in the S-1 group and 17% (n=2/12) in the mFFX group. The incidence of grade 3 or 4 adverse events was 20% in the S-1 group and 57% (neutrophil count decreased in 43%) in the mFFX group (p<0.01). Conclusion S-1 and mFFX were both acceptable second-line chemotherapies after GnP therapy for UPC, although attention should be paid to myelosuppression during mFFX treatment. Further studies involving nanoliposomal irinotecan plus 5-fluorouracil/leucovorin therapy are necessary to facilitate the selection of the optimal regimen for each patient.

Apoptosis-associated speck-like protein containing a CARD regulates the growth of pancreatic ductal adenocarcinoma

Apoptosis-associated speck-like protein containing a caspase recruitment domain (ASC) is a key adaptor protein of inflammasomes and a proapoptotic molecule; however, its roles in signal transduction in pancreatic ductal adenocarcinoma (PDAC) cells remain unknown. Here, we clarified the role and mechanisms of action of ASC in PDAC using clinical evidence and in vitro data. ASC expression in PDAC tissues was analyzed using public tumor datasets and immunohistochemistry results of patients who underwent surgery, and PDAC prognosis was investigated using the Kaplan-Meier Plotter. ASC expression in PDAC cells was downregulated using small-interfering RNA, and gene expression was assessed by RNA sequencing. Review of the Oncomine database and immunostaining of surgically removed tissues revealed elevated ASC expression in PDAC tumors relative to non-tumor tissue, indicating poor prognosis. We observed high ASC expression in multiple PDAC cells, with ASC silencing subsequently inhibiting PDAC cell growth and altering the expression of cell cycle-related genes. Specifically, ASC silencing reduced cyclin D1 levels and stopped the cell cycle at the G1 phase but did not modulate the expression of any apoptosis-related molecules. These results show that ASC inhibited tumor progression via cell cycle modulation in PDAC cells and could be a potential therapeutic target.

Simple prognostic markers for optimal treatment of patients with unresectable pancreatic cancer

Most patients with pancreatic cancer are ineligible for curative resection at diagnosis, resulting in poor prognosis. This study aimed to evaluate the prognostic factors in patients with unresectable pancreatic cancer.We retrospectively collected clinical data from 196 patients with unresectable pancreatic cancer who received palliative chemotherapy (N = 153) or palliative care alone (N = 43) from January 2011 to December 2013. Patients' background data and overall survival were analyzed using the Cox proportional hazard regression model.In patients receiving palliative chemotherapy (gemcitabine-based regimen, 88.2%) and palliative care alone, the median (range) ages were 68 (43-91) and 78 (53-90) years, and metastatic diseases were present in 80% (N = 123) and 86% (N = 37), respectively. Multivariate analysis in the palliative chemotherapy patients showed that liver metastasis (hazard ratio [HR] 2.25, 95% confidence interval [CI] 1.58-3.20, P < .001), neutrophil-to-lymphocyte ratio (>4.5 vs ≤4.5; HR 3.45, 95% CI 2.22-5.36, P < .001), and cancer antigen 19-9 (CA19-9) (≥900 vs <900 U/mL; HR 1.45, 95% CI 1.02-2.05, P = .036) were independent prognostic factors. In those receiving palliative care alone, lung (HR 3.27, 95% Cl 1.46-7.35, p = 0.004) and peritoneum (HR 2.50, 95% CI 1.20-5.18, P = .014) metastases and the C-reactive protein-to-albumin ratio (≥1.3 vs <1.3; HR 3.33, 95% Cl 1.51-7.35, P = .003) were independent prognostic factors. Furthermore, patients with multiple factors had worse prognosis in both groups. Median survival time of palliative chemotherapy patients with risk factors 0, 1, 2, and 3 were 13.1 (95% CI 8.0-16.9), 9.4 (95% CI 7.9-10.1), 6.6 (95% CI 4.9-7.8), and 2.5 (95% CI 1.7-4.0) months, respectively. Similarly, median survival time was 5.7 (95% CI 1.3 -8.0), 2.1 (95% CI 1.5-3.9), and 1.3 (95% CI 0.6-1.7) months, respectively, for palliative care alone patients with risk factor 0, 1, and 2 to 3.Prognostic markers for pancreatic cancer were neutrophil-to-lymphocyte ratio, liver metastasis, and CA19-9 in patients undergoing palliative chemotherapy and C-reactive protein-to-albumin ratio and lung/peritoneum metastases in patients undergoing palliative care alone. These simple markers should be considered when explaining the prognosis and therapeutic options to patients.

Pancreas stiffness in liver cirrhosis is an indicator of insulin secretion caused by portal hypertension and pancreatic congestion

AIM

Portal hypertension induces pancreatic congestion and impaired insulin secretion in patients with liver cirrhosis (LC). However, its mechanism is unclear, with no established noninvasive imaging method for the evaluation of its pathogeneses. The present study focused on pancreas stiffness, as assessed by shear wave elastography (SWE), and examined its association with portal hypertension and insulin secretion.

METHODS

Shear wave elastography and contrast-enhanced ultrasonography were utilized to evaluate pancreas stiffness and congestion, respectively. A glucagon challenge test was used for insulin secretion assessment. Furthermore, rat models of carbon tetrachloride (CCl₄ )-induced LC and portal hypertension were used to identify the direct effects of pancreatic congestion. Immunohistochemistry staining of the pancreas was carried out on human autopsy samples.

RESULTS

Pancreas stiffness measured by SWE was higher in patients with LC than in controls and showed significant correlation with pancreatic congestion. The glucagon challenge test indicated a lower value for the change in C-peptide immunoreactivity in the LC group, which was inversely correlated with pancreas stiffness and congestion. Additionally, portal hypertension and insulin secretion dysfunction were confirmed in CCl₄ rat models. Autopsy of human samples revealed congestive and fibrotic changes in the pancreas and the relationship between insulin secretion and their factors in patients with LC.

CONCLUSIONS

In patients with LC, pancreas stiffness measured by SWE could be a potential noninvasive test for evaluating pancreatic congestion and fibrosis due to portal hypertension. Moreover, it was associated with impaired insulin secretion, and could aid in guiding the treatment for hepatogenous diabetes.

Endoscopic stent placement above the sphincter of Oddi for biliary strictures after living donor liver transplantation

Background

Endoscopic balloon dilation and/or plastic stent placement has been a standard method for treating biliary strictures complicated post living donor liver transplantation (LDLT). The strictures may be refractory to endoscopic treatment and require long-term stent placement. However, consensus on the optimal period of the stent indwelling and usefulness of the inside stent does not exist.

Methods

We evaluated the long-term efficacy of stent treatment in patients with biliary stricture post LDLT. In addition, we compared the stent patency between inside stent and conventional outside stent.

Results

A total of 98 ERC sessions (median 6: range 1–14) performed on 16 patients receiving endoscopic treatment for biliary strictures post LDLT with duct-to-duct biliary reconstruction were analyzed. Biliary strictures successfully treated in 14 patients (88%) included 7 patients (44%) showing improvement of biliary strictures with repeated endoscopic stent placement. Stent replacement was carried out every 6 to 12 months for the remainder 7 patients (44%). Biliary stents were placed in 87 sessions (77 inside sessions and 10 outside sessions). Stent migration occurred 13 times (16%) and none of the inside stent sessions and the outside stent sessions, respectively. Median patency of inside stent and outside stent were 222 days (range; 8–1736) and 99 days (range; 7–356), respectively. The stent occlusion was significantly less in inside stent than in outside stent (p < 0.001). Stone formation was observed in 14 (18%) of the inside stent and 3 (30%) of the outside stent. Biliary stones were small and successfully removed endoscopically.

Conclusions

The endoscopic treatment using inside stent was useful in the management of biliary strictures after LDLT.

ABO Blood Type and the Long-term Outcomes of Pancreatic Cancer

Objective The long-term effect of the ABO blood type on the clinical course of patients with pancreatic cancer (PC) is inconclusive. This study aimed to determine whether or not the ABO blood type influences the long-term outcomes of PC in Japanese patients. Methods The medical records of Japanese patients with PC were reviewed. Data, including the age, sex, and outcomes, from the Ehime Pancreato-Cholangiology Study Group were analyzed. Results The mean age of the 406 patients was 71.0±10.5 years, and 220 (54.2%) were men. A total of 44.6%, 20.7%, 22.4%, and 12.3% had blood type A, B, O, and AB, respectively. The median survival time (MST) of patients with A alleles was shorter than that of patients with non-A alleles (p=0.048), especially among those who underwent resection (p=0.031). In contrast, no marked difference in the MST was noted among those who underwent chemotherapy and palliative care. Finally, a multivariate analysis confirmed A alleles as an independent factor associated with the long-term outcome of PC (p<0.05 in 2 different models). Conclusion The ABO blood type influenced the long-term outcomes of Japanese patients with PC, presumably due to its impact on disease onset and tumor behavior.

Early Detection of Pancreatic Cancer in Patients With Chronic Liver Disease Under Hepatocellular Carcinoma Surveillance

OBJECTIVE

To evaluate whether patients with hepatitis B virus (HBV)- and hepatitis C virus (HCV)-related chronic liver disease were diagnosed as having pancreatic cancer (PC) at an early stage during abdominal imaging surveillance for hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

We retrospectively examined 447 patients with PC diagnosed at Ehime University Hospital and affiliated centers (2011-2013). Data were collected regarding HBV and HCV status, likelihood of PC diagnosis, and Union for International Cancer Control (UICC) stage. Intergroup comparisons were performed using the χ² test.

RESULTS

The UICC stage distribution in the HCC surveillance group (n=16) was stage 0 (n=2, 12.5%), stage IA (n=3, 18.8%), stage IB (n=2, 12.5%), stage IIA (n=2, 12.5%), stage IIB (n=2, 12.5%), stage III (n=1, 6.3%), and stage IV (n=4, 25%). The UICC stage distribution in the nonsurveillance group (n=431) was stage 0 (n=4, 0.9%), stage IA (n=28, 6.5%), stage IB (n=27, 6.3%), stage IIA (n=86, 20.0%), stage IIB (n=48, 11.1%), stage III (n=56, 13.0%), and stage IV (n=182, 42.2%). The HCC surveillance group had significantly more patients with stage 0 disease than with stages IA through IV (P=.02). Similar results were observed when including stages IA (P=.007) and IB (P=.004) as early stages but not stage IIA (P=.10). A dilated pancreatic duct led to a PC diagnosis in all 6 patients with stage 0 disease.

CONCLUSION

Patients with HBV- and HCV-related chronic liver disease had an early PC diagnosis during HCC surveillance. Careful evaluation of the pancreas is warranted during HCC surveillance.

Endoscopic ultrasound findings and pathological features of pancreatic carcinoma in situ

Background and study aims Few studies have evaluated detection of pancreatic carcinoma in situ (PCIS). We evaluated findings of endoscopic ultrasound (EUS) and pathological features of PCIS.

Patients and methods We histopathologically studied 16 patients with PCIS following EUS. Diagnostic features evaluated retrospectively included stricture of the main pancreatic duct (MPD) on EUS, presence or absence of hypoechoic areas surrounding the MPD stricture on EUS, the noncancerous part (pancreas of background) on EUS and histopathology, and histological findings adjacent to the area of PCIS.

Results On EUS, stricture of the MPD was found in 15 patients (93.8 %). Hypoechoic areas surrounding the MPD stricture were observed in 9 patients (56.3 %), including three (18.8 %) with a 10- to 11-mm hypoechoic mass. EUS findings of the noncancerous part indicated chronic pancreatitis in six patients (37.5 %), pancreatic fatty infiltration in seven (43.8 %), early chronic pancreatitis in two (12.5 %), and normal pancreas in one (6.3 %). Histological findings of the noncancerous part (proximal to the MPD stricture) indicated chronic pancreatitis in 13 patients (81.3 %) and pancreatic fatty infiltration in five patients (31.3 %). Histopathologically, subepithelial inflammatory cell infiltration and fibrosis were present in all 16 patients with PCIS.

Conclusions PCIS frequently causes localized changes in inflammation and fibrosis around the pancreatic duct. PCIS often accompanies chronic pancreatitis and pancreatic fatty infiltration in the background of the pancreas. EUS offers sufficient resolution to demonstrate pancreatic changes of PCIS.

Evaluation of ozonated water using ASTM E1174 for standardized testing of handwash formulations for healthcare personnel

Removal of bacteria by handwashing with ozonated water was evaluated using the ASTM E1174 standard test method. Thirty healthy volunteers were assigned randomly to three groups: ozonated water, antimicrobial soap and water, and non-antimicrobial soap and water. A 3 log₁₀ cfu reduction was achieved by washing hands with ozonated water or antimicrobial soap and water. However, ozonated water was not significantly superior to non-antimicrobial soap and water. Ozonated water may remove bacteria from the hands to at least a similar extent as that by non-antimicrobial soap and water in the absence of visible dirt or body fluid contamination.

Pertussis outbreak among patients and healthcare workers in a provincial dialysis facility in Japan

BACKGROUND

Sixteen pertussis cases in haemodialysis patients and healthcare workers were detected in a 25-bed outpatient haemodialysis facility in Japan between October 2013 and April 2014.

AIM

To describe an outbreak of pertussis among patients and healthcare workers, and to identify risk factors for pertussis infection.

METHODS

Sputum cultures, loop-mediated isothermal amplification assays performed on nasopharyngeal swabs to detect respiratory pathogens including Bordetella pertussis, and serum anti-pertussis toxin immunoglobulin G measurements were performed for all haemodialysis patients and healthcare workers. A retrospective case-control study was performed to identify the risk factors for pertussis infection in the clinic.

FINDINGS

Only six of the 16 pertussis patients (37.5%) had respiratory symptoms. Recent exposure to an unmasked individual with a cough was associated with pertussis infection (odds ratio 6.25, P<0.05). The outbreak was terminated successfully after enforcing the use of surgical masks among both patients and healthcare workers.

CONCLUSION

This report demonstrates the risk of pertussis transmission in a haemodialysis facility, and underscores the importance of wearing surgical masks to control a pertussis outbreak.

Outbreak of extended-spectrum β-lactamase-producing Escherichia coli transmitted through breast milk sharing in a neonatal intensive care unit

BACKGROUND

Routine surveillance in a neonatal intensive care unit (NICU) showed an increased detection of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (ESBL-E. coli) in August 2012, following nearly a year without detection.

AIM

To describe the investigation and interventions by a hospital infection control team of an outbreak of ESBL-E. coli in a NICU.

METHODS

Six neonates with positive cultures of ESBL-E. coli (five with respiratory colonization, one with a urinary tract infection), control infants who were negative for ESBL-E. coli during the study period, and mothers who donated their breast milk were included. A case-control study was performed to identify possible risk factors for positive ESBL-E. coli cultures and molecular typing of isolated strains by pulsed-field gel electrophoresis.

FINDINGS

The odds ratio for ESBL-E. coli infection after receiving shared unpasteurized breast milk during the study period was 49.17 (95% confidence interval: 6.02-354.68; P < 0.05). The pulsed-field gel electrophoresis pattern showed that all strains were identical, and the same pathogen was detected in freshly expressed milk of a particular donor. After ceasing the breast milk sharing, the outbreak was successfully terminated.

CONCLUSION

This outbreak indicates that contamination of milk packs can result in transmission of a drug-resistant pathogen to newborn infants. Providers of human breast milk need to be aware of the necessity for low-temperature pasteurization and bacterial cultures, which should be conducted before and after freezing, before prescribing to infants.

Diagnostic strategies for early pancreatic cancer

Diagnosis of pancreatic cancer (PC) at an early stage with curative surgery is the approach with the potential to significantly improve long-term patient outcome. Recently, some reports showed that patients with pancreatic tumors smaller than 10 mm showed a favorable prognosis. However, the rate of tumor detection on computed tomography in patients with small pancreatic tumors is low. For the diagnoses of PC with tumors smaller than 10 mm, the rate of tumor detection was higher on endoscopic ultrasonography (EUS) than on computed tomography or other modalities, and histologic diagnosis using EUS-guided fine-needle aspiration was helpful in confirming the diagnosis. For the diagnosis of PC in situ, EUS and magnetic resonance cholangiopancreatography may play important roles in detecting the local irregular stenosis of the pancreatic duct. Endoscopic retrograde pancreatography and sequential cytodiagnosis using pancreatic juice obtained by endoscopic nasopancreatic drainage multiple times was useful in the final diagnosis of PC in situ. At present, improving survival lies in identifying those individuals with high-risk factors or precursor lesions through an effective screening method. For example, these should include ultrasonography, various biological markers, or national familial pancreatic cancer registration. Additionally, the relationship between specialists in PC from medical centers and practicing physicians plays an important role in the early diagnosis of PC.

Safety of polypropylene mesh for incarcerated groin and obturator hernias: a retrospective study of 110 patients

PURPOSE

The purpose of this study was to evaluate the mesh repair for an incarcerated groin hernia.

METHODS

A total of 110 patients who underwent emergency surgery for incarcerated hernias were retrospectively analyzed using a multivariate analysis.

RESULTS

The postoperative complications were associated with bowel resection, odds ratio (OR) 2.984, and 95 % confidence interval (CI) 1.273 to 6.994. The risk factors for bowel resection were femoral hernia, (OR 5.621, 95 % CI 2.243 to 14.082), and late hospitalization (24 h<), (OR 2.935, 95 % CI 1.163-7.406). The hernias were repaired with mesh in ten of the 39 (25.6 %) patients with bowel resection and sixty-four of the 71 (90.1 %) patients without bowel resection. The complication rate of the patients with bowel resection was 53.8 % and was 26.8 % in those without. The ratios of wound infection were 23.1 and 0.0 %, respectively. Wound infections were detected in two (20 %) of the ten patients who underwent bowel resection with mesh repair; however, there were no patients in whom the mesh was withdrawn due to infection.

CONCLUSIONS

No wound infections in patients without bowel resection were detected, and mesh repair could be safely performed. Mesh repair for the patients with bowel resection is not contraindicated, as long as the clean-contamination of the wound was maintained during surgery.

Measurement of short-chain fatty acids in human faeces using high-performance liquid chromatography: specimen stability

BACKGROUND

Short-chain fatty acids such as lactic acid produced by the intestinal bacterial flora have various physiological actions involved in health, and it is important to determine the concentrations of faecal short-chain fatty acids and evaluate their relationship with large intestinal diseases. In this study, we evaluated the highly selective and sensitive simultaneous measurement of both volatile and non-volatile short-chain fatty acid hydrazides using high-performance liquid chromatography (HPLC).

MATERIALS AND METHODS

Faeces treated with ethanol were used as analytic samples. Short-chain fatty acids were measured as fatty acid hydrazides by HPLC.

RESULTS

For 12 types of short-chain fatty acid, the results regarding linearity, recovery tests and reproducibility were favourable. Faeces treated with ethanol could be stored at room temperature.

DISCUSSION

The stability of short-chain fatty acids in faeces at room temperature was statistically analysed. Faeces stored without treatment with ethanol showed increases/decreases in the concentrations of short-chain fatty acids, which may be due to assimilation by intestinal bacteria. However, specimen in 70% ethanol and stored in room temperature exhibited no substantial changes in concentrations of short-chain fatty acids up to seven days.

A randomised phase III trial comparing gemcitabine with surgery-only in patients with resected pancreatic cancer: Japanese Study Group of Adjuvant Therapy for Pancreatic Cancer

BACKGROUND

This multicentre randomised phase III trial was designed to determine whether adjuvant chemotherapy with gemcitabine improves the outcomes of patients with resected pancreatic cancer.

METHODS

Eligibility criteria included macroscopically curative resection of invasive ductal carcinoma of the pancreas and no earlier radiation or chemotherapy. Patients were randomly assigned at a 1 : 1 ratio to either the gemcitabine group or the surgery-only group. Patients assigned to the gemcitabine group received gemcitabine at a dose of 1000 mg m(-2) over 30 min on days 1, 8 and 15, every 4 weeks for 3 cycles.

RESULTS

Between April 2002 and March 2005, 119 patients were enrolled in this study. Among them, 118 were eligible and analysable (58 in the gemcitabine group and 60 in the surgery-only group). Both groups were well balanced in terms of baseline characteristics. Although heamatological toxicity was frequently observed in the gemcitabine group, most toxicities were transient, and grade 3 or 4 non-heamatological toxicity was rare. Patients in the gemcitabine group showed significantly longer disease-free survival (DFS) than those in the surgery-only group (median DFS, 11.4 versus 5.0 months; hazard ratio=0.60 (95% confidence interval (CI): 0.40-0.89); P=0.01), although overall survival did not differ significantly between the gemcitabine and surgery-only groups (median overall survival, 22.3 versus 18.4 months; hazard ratio=0.77 (95% CI: 0.51-1.14); P=0.19).

CONCLUSION

The current results suggest that adjuvant gemcitabine contributes to prolonged DFS in patients undergoing macroscopically curative resection of pancreatic cancer.

Risk of facial splashes in four major surgical specialties in a multicentre study

This study analyses the results of face-shield blood spatter contamination at six medical facilities to determine exposure risk when facial protection is not used. Blood spatter exposure was evaluated on the basis of overall incidence, location of spatter on face shields, surgical specialty, risk for operating room staff, length of surgery and volume of blood loss. Six hundred face shields were evaluated for blood spatter contamination by visual inspection as well as by staining with leucomalachite green. The face shield was divided into three regions: Orbital (O-region), Paraorbital (P-region) and Mask (M-region). Visual examination detected blood spatter contamination in 50.5% (303/600) of the face shields, whereas leucomalachite green staining detected blood contamination in 66.0% (396/600). Blood contamination was 36.6% (220/600) in the O-region, 37.8% (227/600) in the P-region and 57.0% (342/600) in the M-region. Among operating room staff, the incidence of blood spatter was greatest among lead surgeons at 83.5% (167/200), followed by the first assistant at 68.5% (137/200) and the scrub nurse at 46.0% (92/200). By specialty, cardiovascular surgery was at highest risk with an incidence of 75.3% (113/150) followed by neurosurgery at 69.3% (104/150), gastrointestinal at 60.0% (90/150) and orthopaedic surgery at 60.0% (90/150).

Clinical benefit of liver hanging maneuver for right-side major hepatectomy

15171

Background: Liver hanging maneuver is a new technique in anterior approach of major hepatectomy. However, the impact of the maneuver has never been fully investigated in patients with liver tumors. To evaluate the surgical benefits of liver hanging maneuver, we set up a comparative study in right-side major hepatectomy. Methods: From 2000 to 2006, 326 hepatectomy were performed in our institution. Fifty-eight patients with liver tumor (hepatocellularcarcinoma in 36, metastatic liver tumor in 13, and the others in 9) considered for right-side major hepatectomy were prospectively analyzed. Right-side hepatectomy included 26 right hepatectomy, 24 extended right hepatectomy, and 8 tri-segmentectomy. The patients were devided into a group with conventional approach (n = 21), a group with anterior approach without hanging maneuver (n = 19), and a group with approach with liver hanging maneuver (n = 18). In the three groups, age, body mass index, child-pugh classification, type of liver tumor, staging in hepatocellularcarcinoma, tumor size, resected liver weights, intraoperative blood loss, frequency of transfusion and surgical time were analyzed. Results: In conventional approach, anterior approach without hanging maneuver, and approach with liver hanging maneuver, mean age was 55, 59, and 65 years, and mean tumor size was 65, 75, and 108mm, respectively. Patients with liver hanging maneuver were significantly elder (p<0.05) and have larger tumor size (p<0.01). There were no significant differences in body mass index, child-pugh classification, type of liver tumor, staging in hepatocellularcarcinoma, and resected liver weights. Mean intraoperative blood loss was 1771, 805, and 704g, and mean surgical time was 562, 483, and 435minutes, and the frequency of red blood cell transfusion was 33, 21, and 17%, respectively. Patients with liver hanging maneuver had significantly less intraoperative blood loss (P=0.0001) and surgical time (P=0.002). The frequency of red blood cell transfusion in the liver hanging maneuver group was significantly lower than that of the conventional group (p<0.05). Postoperative morbidity rate were 33.3, 15.8, and 16.7%, respectively. Conclusions: Liver hanging maneuver is less invasive and a quite useful method for right-side major hepatectomy.

No significant financial relationships to disclose.

Doubling time of preoperative serum alpha-fetoprotein level can predict recurrence and prognosis after hepatic resection of hepatocellular carcinoma

15118

Background: It is quite important to predict postoperative recurrence or prognosis in the patients with hepatocellular carcinoma (HCC) before surgery. There have been few reports about the value of doubling time of preoperative serum a-fetoprotein (AFP) or protein induced by vitamin K absence (PIVKA-II) levels. Methods: Between January 2000 to December 2005, 160 consecutive HCC patients underwent hepatic resections in our institution. Serum AFP and PIVKA-II level was prospectively measured at least two points before surgery to calculate a doubling time. Clinical factors such as age, gender, BMI, etiology of hepatitis, degree of liver damage, gross tumor type, tumor size, tumor numbers, portal vein tumor thrombosis (PVTT), and AFP-L3 were concurrently investigated. Univariate and multivariate analyses were done to clarify predictive factors of postoperative recurrence and survival. Results: There were no relationship between preoperative levels and doubling time of both tumor markers. In univariate analysis, significant predictors of postoperative recurrence were AFP > 200 ng / ml, PIVKA-II > 200 mAU / ml, AFP-L3 > 10%, non-simple nodular type tumor, tumor size > 3 cm, multiple tumors, PVTT positive, and doubling time of AFP < 40 days. The significant prognostic factors were AFP > 200 ng / ml, HBs antigen positive, non-simple nodular type tumor, multiple tumors, PVTT positive, and doubling time of AFP < 40 days. In multivariate analysis, multiple tumors (odds ratio: 1.48), and doubling time of AFP < 40 days (odds ratio: 2.17) were significant predictors of recurrence. The significant prognostic factors were non-simple nodular type tumor (odds ratio: 6.41), multiple tumors (odds ratio: 7.62), and doubling time of AFP < 40 days (odds ratio: 6.49). Postoperative mean recurrence free survival time of HCC patients with doubling time of AFP < 40 days was only 2.8 months and mean survival time was 34 months. Conclusions: In HCC patients, doubling time of preoperative serum AFP level is useful to predict early recurrence and poor prognosis. Perioperative adjuvant therapy should be considered for such high risk patients.

No significant financial relationships to disclose.

Radio-frequency ablation (RFA) is equivalent in therapeutic effect but safer compared to microwave coagulation therapy (MCT) for hepatocellular carcinoma

15064

Background: Radio-frequency ablation (RFA) and microwave coagulation therapy (MCT) have been developed as a useful locoregional treatment for hepatocellular carcinoma (HCC). It is still unclear which ablation therapy is superior for the patients with HCC, from the viewpoint of not only short term but also long term outcome. Methods: Between January 1991 and December 2005, 430 patients with HCC were treated with ablation therapy (230 RFA and 200 MCT) in our institution. Enroll criteria of this therapy were as follows; 1) unresectable HCCs, 2) each smaller than 3 cm, 3) up to three nodules, 4) without vascular invasion. Either percutaneous (P), endoscopic (E) or open (O) approach was selected individually based on location, size, number, or other factors. Treatment was repeated until complete ablation of HCC. Results: 1. Proportion of Child B or C was 62% and 60%; Stage III or IV was 56% and 58% in the patients with RFA and MCT, respectively. 2. Average tumor size and tumor number was 27mm/2.5 and 26mm/1.9 in the two groups. 3. Approaches were P: 55%, E: 33%, O: 12% in RFA and P: 48%, E: 30%, O: 22% in MCT. 4. Number of treatment was 1.1 in RFA and 1.2 in MCT. 5. Recurrence rate at the therapeutic site was 8% in RFA and 12% in MCT. Especially, endoscopic RFA provided a quite low recurrence rate (3%). 6. Cumulative 5-year survival was 52% versus 45% in the two groups. 7. Complication rate was significantly lower in RFA (5%) compared to MCT (11%). Intraabdominal tumor seeding (1% in MCT) and liver abscess formation (4% in MCT) was never encountered in RFA. Conclusions: Radio-frequency ablation for hepatocellular carcinoma is a safer procedure and can provide a similar favorable long- term prognosis compared to microwave coagulation therapy.

No significant financial relationships to disclose.

A novel multimodality treatment for resectable pancreatic cancer (PC)

4630

Background: Patients with PC often suffer from tumor recurrence despite curative resection, thus indicating that systemic therapy added to local control might be required to further improve the survival. The aim of this phase II trial was to assess the feasibility and tolerance as well as overall survival of a novel multimodality therapy composed of pancreatic resection and intraoperative radiation therapy (IORT) combined with neoadjuvant (NAC) and adjuvant (AC) combination chemotherapy for patients with PC. Methods: Eligibility criteria included: no distant metastases / no tumor extension to the CA or the SMA by imaging, tumor size ≥ 1 cm, ECOG PS ≤ 2, age < 80, and normal organ function. For NAC, 5-FU was administered at a dose of 125 mg/m2 on days 1–5 every week as a continuous pancreatic and hepatic arterial infusion, and gemcitabine was infused intravenously at a dose of 800 mg/m2 for 30 min once weekly for 2 weeks. Pancreatic resection combined with IORT (30 Gy, 12 Mev of electron beam) was performed after a one-week rest following the completion of NAC. AC was performed in the same regimen as NAC after the recovery from surgery. We performed intension to treat analyses. Results: Between 2001 and 2006, 32 pts were enrolled: 32 received NAC, 28 received AC, and 28 received IORT. Of 32 pts given NAC, 13 had grade 3–4 hematological toxicity. All pts underwent surgery, including R0 resection in 26 pts, without delay by NAC- related toxicity. Of 28 pts given AC, 18 had grade 3–4 hematological, and 6 had non-hematological toxicity, although no chemotherapy-related death was observed. The median follow-up period was 20 months (rang 3.9 to 67.4). Overall survivals at 1, 3, and 5 years were 77.0 %, 60.2 %, and 48.1 %, respectively. Median survival was 38.5 months. Conclusions: This new multimodality treatment is feasible and tolerable, and may contribute to the survival benefit of patients with PC.

No significant financial relationships to disclose.

An increased incidence of Enterobacter cloacae in a cardiovascular ward

Routine surveillance in a cardiovascular ward showed that the incidence of Enterobacter cloacae isolated from sputum and oropharyngeal cultures in June 2004 increased to 27.6% (8/29) compared to 5.5% (12/219) from the rest of the hospital during the same period (OR=13.2; 95% CI 2.97-58.7; P<0.05). While an increase in E. cloacae pneumonia was not verified, an investigation was undertaken by the infection control team to prevent an outbreak. The estimate of relative risk for E. cloacae infection was based on a case-control study which measured exposure to intubation, history of a stay in the intensive care unit (ICU) and oral care between patients with E. cloacae and those negative for E. cloacae. An odds ratio of 13.2 suggested cross-contamination via the transoesophageal echocardiography (TOE) probe in the ICU prior to transfer to the cardiovascular ward. Pulsed-field gel electrophoresis and antibiogram patterns were also consistent with this hypothesis. Intervention was undertaken in the form of enforcing the disinfection of TOE probes using a 0.55% phtharal solution and the use of a single-use sheath to protect the probe from recontamination. Following intervention, the incidence rate returned to previous levels. This report illustrates the limitations in the effectiveness of current nosocomial surveillance strategies due to the retrospective nature of analysis. Improved surveillance methods such as data-mining tools specifically applicable to the institution, patient population, region and country are needed to increase the sensitivity of detecting unrecognized outbreaks, including cross-contamination.

Evaluation of the mechanical strength and patency of functional end-to-end anastomoses

BACKGROUND

Although many mechanical devices are being developed for functional end-to-end anastomosis (FETEA), the best choice remains to be determined. The mechanical strength of each device is an important factor associated with anastomotic leakage. In turn, anastomotic patency is related to postoperative stenosis. This study examined the bursting pressure and circumference of several FETEAs.

METHODS

Young domestic pigs were used in this study. In experiment 1, a 10-cm segment of intestine was transected using an EndoGIA 60 blue, EndoGIA 60 green, or GIA 60 blue stapler, and the bursting pressure of each instrument's mechanical staple line was examined. In experiment 2, after FETEA had been created with EndoGIA 60 blue, the bursting sites were examined, and the bursting pressures of buttressed and nonbuttressed FETEA were measured and compared. In experiment 3, the circumference of FETEA was compared between the closed technique and reinforcement.

RESULTS

The bursting pressure of EndoGIA 60 blue was significantly higher than that of the other devices. When an anastomotic crotch was buttressed, the bursting pressure (44 +/- 13 mmHg) was significantly increased over that of the nonbuttressed FETEA (27.5 +/- 5.8 mmHg; p < 0.05). The circumference of FETEA using the wide technique (92.7 +/- 2.3 mm) was larger than that using the offset technique (55.7 +/- 5.8 mm).

CONCLUSIONS

The bursting pressure of the mechanical staple line using the EndoGIA 60 stapler was the strongest. Functional end-to-end anastomosis was stronger when created with buttress of an anastomotic crotch, and larger circumferences were created with the wide technique.

Does incineration turn infectious waste aseptic?

Incineration of infectious waste is considered to be biologically safe. We performed basic experiments to confirm that bacillus spores are killed by incineration in a muffle furnace. Biological samples containing 10(6) spores of Bacillus stearothermophilus were placed in stainless steel Petri dishes and then into hot furnaces. The furnace temperature and duration of incineration were 300 degrees C for 15 min, 300 degrees C for 30 min, 500 degrees C for 15 min, 500 degrees C for 30 min and 1100 degrees C for 3 min. We confirmed that all spores of B. stearothermophilus were killed at each of these settings. The effect of incineration seems to be equivalent to that of sterilization, based on the satisfactory sterilization assurance level of 10(-6).

Evaluation of the Efficacy of Combined Continuous Arterial Infusion and Systemic Chemotherapy for the Treatment of Advanced Pancreatic Carcinoma

PURPOSE

To evaluate the effects of combined continuous transcatheter arterial infusion (CTAI) and systemic chemotherapy in patients with advanced pancreatic carcinoma.

METHODS

CTAI was performed in 17 patients with stage IV pancreatic cancer with (n = 11) or without (n = 6) liver metastasis. The reservoir was transcutaneously implanted with the help of angiography. The inferior pancreatic artery (IPA) was embolized to achieve delivery of the pancreatic blood supply through only the celiac artery. The systemic administration of gemcitabine was combined with the infusion of 5-fluorouracil via the reservoir. Treatment effects were evaluated based on the primary tumor size, liver metastasis, and survival time and factors such as tumor size, tumor location, and stage of pancreatic carcinoma; the embolized arteries were analyzed with respect to treatment effects and prognosis.

RESULTS

A catheter was fixed in the gastroduodenal artery and splenic artery in 10 and 7 patients, respectively. Complete peripancreatic arterial occlusion was successful in 10 patients. CT showed a decrease in tumor size in 6 of 17 (35%) patients and a decrease in liver metastases in 6 of 11 (55%) patients. The survival time ranged from 4 to 18 months (mean +/- SD, 8.8 +/- 1.5 months). Complete embolization of arteries surrounding the pancreas was achieved in 10 patients; they manifested superior treatment effects and prognoses (p < 0.05).

CONCLUSION

In patients with advanced pancreatic cancer, long-term CTAI with systemic chemotherapy appeared to be effective not only against the primary tumor but also against liver metastases. Patients with successfully occluded peripancreatic arteries tended to survive longer.

Evaluation of a fully automated system (RAISUS) for rapid identification and antimicrobial susceptibility testing of Staphylococci

RAISUS is a system for rapid bacterial identification and antimicrobial susceptibility testing. RAISUS and VITEK showed 97.8% and 75.9% agreement in identification of 45 Staphylococcus aureus strains and 58 coagulase-negative staphylococci (CoNS), respectively, and RAISUS and CLSI (formerly NCCLS) methods showed 87.2% and 87.9% agreement in the MICs for S. aureus and CoNS, respectively. RAISUS provided these data within 3.75 h, suggesting its utility for clinical bacteriological laboratories.

Pigment epithelium-derived factor induces pro-survival genes through cyclic AMP-responsive element binding protein and nuclear factor kappa B activation in rat cultured cerebellar granule cells: Implication for its neuroprotective effect

Pigment epithelium-derived factor (PEDF) protects immature cerebellar granule cell neurons (CGCs) against apoptosis induced by K+ and serum deprivation. However, the precise mechanism of this protection remains unknown. We recently reported that the transcription factor nuclear factor kappa B (NF-kappaB) is activated in PEDF-treated CGCs. Although it is well known that NF-kappaB blocks apoptotic cell death through the induction of pro-survival factors, the effects of PEDF on the expression of these factors are not fully understood. In this study, we employed the use of reverse transcriptase-polymerase chain reaction to analyze the gene expression of certain pro-survival genes and found that genes such as c-IAP1, c-IAP2, FLIPs, A1/Bfl-1 and Mn-SOD were induced in PEDF-treated neurons. On the other hand, no induction was observed of the pro-apoptotic Bcl-2 family members Bax and Bid at any time from 3 to 24 h following PEDF addition. Furthermore, phosphorylation of cyclic AMP-responsive element binding protein (CREB) and increment of nuclear cyclic AMP-response element (CRE)-like DNA binding were observed in PEDF-treated CGCs. The anti-apoptotic effect of PEDF was blocked by overexpression of dominant negative CREB or a mutated form of IkappaBalpha. These results suggested that induction of both CRE- and NF-kappaB-dependent genes is required for the observed neuroprotective effects of PEDF on CGCs.

Residual formaldehyde on plastic materials and medical equipment following low-temperature steam and formaldehyde sterilization

We measured the amount of residual formaldehyde on 16 plastic materials and five medical devices following low-temperature steam and formaldehyde (LTSF) sterilization, based on the European Standard EN14180. The amounts of formaldehyde residue on the plastic materials were compared with that on a filter paper of similar dimensions. The amount of residual formaldehyde on polyamide 6, polyurethane, natural rubber and polyacetal was higher (21.9, 15.2, 3.0 and 2.1 times, respectively) than that on the filter paper. The amount of formaldehyde recovered from a breathing circuit, anaesthesia circuit, oxygen tubing, airway tube and tweezers was 260, 240, 594, 56 and 0 microg, respectively, following LTSF sterilization. Our results emphasize the need to verify the main material composing the medical equipment before LTSF sterilization, as the amount of formaldehyde retrieved following sterilization varies according to the material used for construction.

A new method to establish the rational extent of hepatic resection for advanced gallbladder cancer using dye injection through the cystic artery

BACKGROUND

Hepatic resection has been indicated to eliminate cancer at the surgical margin in cases of advanced gallbladder carcinoma, but there is considerable controversy about the reasonable extent of liver resection. A new on-table dye injection technique has been introduced to determine the venous drainage of the gallbladder and ascertain the amount of liver to remove.

METHODS

In four hepatic resections for pT2 gallbladder cancer, indocyanine green solution (25 mg/20 ml) was injected over a period of 30 seconds through the cystic artery. The stained area of the liver surface was completely resected, maintaining a margin of at least 2 cm from the gallbladder.

RESULTS

The entire serosal surface of the gallbladder takes on a light green stain immediately after dye injection, and then the liver surface around the gallbladder gradually becomes stained with a clear demarcation line. The distance between the demarcation line and the gallbladder ranged from 1.0 to 5.0 cm. The extent of the stained area differed from one individual to another. Histopathological examination of resected liver specimens revealed that one of the four resected livers had micrometastasis in the portal area 27 mm from the gallbladder wall and there were no cancer cells at the surgical margins. No recurrence has been seen in any of our 4 patients at 16-26 months after operation.

DISCUSSION

The dye injection method is useful in determining the appropriate extent of hepatic resection for advanced gallbladder cancer, as it is possible to determine the necessary and sufficient amount of liver parenchyma that should be removed according to the perfusion area of the cystic veins in each individual patient.

Evaluation of a low-temperature steam and formaldehyde sterilizer

We evaluated a low-temperature steam and formaldehyde (LTSF) sterilizer based on the draft European Standard prEN 14180. Microbiological tests were conducted on small and full loads using process challenge devices in five programs (P1-P5). With small loads all tests showed no growth of Bacillus stearothermophilus (ATCC7953) spores. However, positive cultures were observed with full-load tests using P5 (sterilization temperature, 50 degrees C). Our data indicated that the load influenced the efficacy of the LTSF sterilizer. Desorption tests were conducted to determine residual formaldehyde in indicator strips. The mean concentrations of formaldehyde in P1-P5 were 31.9, 56.3, 54.9, 82.2 and 180.6 microg, respectively, which are below the limits allowed by the draft Standard. Our results indicate that the LTSF sterilizer is useful for sterilization because of its excellent efficacy, short handling time, and safety.

Antimicrobial activity of everninomicin against clinical isolates of Enterococcus spp., Staphylococcus spp., and Streptococcus spp. tested by Etest

The in-vitro antimicrobial activity of everninomicin, a novel oligosaccharide antibiotic, was tested against clinical isolates of 11 methicillin-susceptible Staphylococcus aureus (MSSA) strains, 11 methicillin-resistant S. aureus (MRSA) strains, 22 Staphylococcus epidermidis strains, 23 Enterococcus faecalis strains, 23 Enterococcus faecium strains, 23 Enterococcus avium strains, 27 Streptococcus pneumoniae strains, 22 Streptococcus pyogenes strains, and 20 Streptococcus agalactiae strains. The minimum inhibitory concentrations (MICs) of everninomicin were determined by Etest and compared with those of vancomycin, teicoplanin, and minocycline. The Etest showed that everninomicin exhibited excellent activity (MIC, <0.016 to 1.5 microg/ml) against the gram-positive cocci tested. The antimicrobial activity of everninomicin against S. aureus and S. epidermidis was stronger than that of vancomycin, teicoplanin, and minocycline, in particular against MRSA, with an MIC50 of 0.38 microg/ml and an MIC90 of 0.5 microg/ml. Against strains of enterococci and streptococci, everninomicin was more active than vancomycin, but as active as teicoplanin.

Relatedness between the coagulase gene 3'-end region and coagulase serotypes among Staphylococcus aureus strains

The 3'-end region of the coagulase gene from 22 strains of Staphylococcus aureus including 10 standard serotype strains was sequenced, and five subgroups with 4-8 tandem repeating units were distinguished among the tested strains. Phylogenetic analysis of the 3'-end region of the coagulase gene indicated that strains belonging to the same serotype were clustered in the same branch. A phylogenetic tree of the deduced amino acid sequences revealed that the C-terminal region might not be responsible for the epitope of the coagulase protein.

Quantitative determination of gelatinase activity among enterococci

Gelatinase, hemolysin and aggregation substance have all been reported to be virulence factors of enterococci. In this study, gelatinase production was investigated in isolates of Enterococcus faecalis (n=93), E. faecium (n=49) and E. avium (n=36) recovered from hospitalized patients. Gelatinase was detected in 45% of E. faecalis isolates, but could not be detected in E. faecium and E. avium. Gelatinase activity was then measured by radial diffusion for the 42 gelatinase-positive E. faecalis isolates. To convert gelatinase activity into proteinase K activity, a standard curve was produced by placing different concentrations of proteinase K into wells in the gelatine plate. Gelatinase activity per E. faecalis colony ranged from 2.6 x 10(-7) to 2.2 x 10(-5) microg/ml, proportionate to the activity of proteinase K. An approximately 84-fold difference in gelatinase concentration was observed between the colony producing the highest amount and that producing the lowest amount. This method may be useful for determining the virulence of given isolates in relation to gelatinase production as it is quick, easy and inexpensive to perform.

Vascular encasement by pancreatic cancer: correlation of CT findings with surgical and pathologic results

PURPOSE

The purpose of this study was to correlate thin-slice high-resolution helical CT findings of arterial and venous involvement in pancreatic cancers with surgical and histopathologic results.

METHOD

Forty-eight patients with pancreatic cancer underwent preoperative thin-slice high-resolution helical CT, followed by surgical dissection of the pancreatic vessels during curative or palliative surgery. Major vessels running within 1 cm from the tumor margin were evaluated. CT appearance was graded on a 0-4 scale (0: none, 1: <24%, 2: 25-49%, 3: 50-74%, 4: 75-100%) by circumferential contiguity of tumor to vessels. Resected specimens were available from 26 patients.

RESULTS

Surgical correlation of CT findings was available in 89 veins and 83 arteries, and both surgical and histologic correlation was available for 42 veins and 29 arteries. At surgical observation, 29 of 35 veins (82.9%) evaluated as CT grade 3 or 4 were found to be involved, whereas only 18 of 30 arteries (60%) evaluated as CT grade 3 or 4 were proved to be involved. On microscopic observation, tumor invasion to the portal venous systems was confirmed in 15 of 42 (35.7%) vessels, and this invasion was depicted as from CT grades 1 to 4. In arteries, tumor invasion was seen in 3 of 29 vessels (10.3%), all of which were graded as 3 or 4 by CT.

CONCLUSION

The grading system of vascular invasion should differ between arteries and veins. Involvement of the venous system exceeding one-half circumference of the vessels (grade 3 or 4) was suggestive of vascular invasion; however, this criterion was not always satisfactory for the evaluation of tumor invasion in the arterial system.

Lymphatic spreading pattern of intrahepatic cholangiocarcinoma

BACKGROUND

There have been very few reports on the pattern of lymphatic spread of intrahepatic cholangiocarcinoma. This pattern was elucidated to help define the rational extent of radical lymph node dissection.

METHODS

Thirty-nine consecutive patients who underwent hepatectomy with radical lymph node dissection were reviewed retrospectively.

RESULTS

Lymph node metastases were detected in 24 of the 39 patients (62%). The metastatic nodes were found in the hepatoduodenal ligament, along the common hepatic artery, around the abdominal aorta, on the posterior surface of the pancreas head, along the left gastric artery, along the superior mesenteric artery, around the celiac artery, along the lesser curvature of the stomach, and around the cardia. The nodal involvements along the left gastric artery, along the lesser curvature, or around the cardia were recognized only in the left peripheral and hilar types of cholangiocarcinoma, while all other sites included both the left or right peripheral type and the hilar type cholangiocarcinoma.

CONCLUSIONS

Intrahepatic cholangiocarcinomas, irrespective of their intrahepatic location, mainly spread to the nodes in the hepatoduodenal ligament, then to the para-aortic nodes, retropancreatic nodes, or common hepatic artery nodes. In addition to these spreading routes, the left peripheral type or hilar type of cholangiocarcinoma tends to spread along the left gastric nodes through the lesser curvature.

Lymphatic spreading pattern of intrahepatic cholangiocarcinoma

BACKGROUND

There have been very few reports on the pattern of lymphatic spread of intrahepatic cholangiocarcinoma. This pattern was elucidated to help define the rational extent of radical lymph node dissection.

METHODS

Thirty-nine consecutive patients who underwent hepatectomy with radical lymph node dissection were reviewed retrospectively.

RESULTS

Lymph node metastases were detected in 24 of the 39 patients (62%). The metastatic nodes were found in the hepatoduodenal ligament, along the common hepatic artery, around the abdominal aorta, on the posterior surface of the pancreas head, along the left gastric artery, along the superior mesenteric artery, around the celiac artery, along the lesser curvature of the stomach, and around the cardia. The nodal involvements along the left gastric artery, along the lesser curvature, or around the cardia were recognized only in the left peripheral and hilar types of cholangiocarcinoma, while all other sites included both the left or right peripheral type and the hilar type cholangiocarcinoma.

CONCLUSIONS

Intrahepatic cholangiocarcinomas, irrespective of their intrahepatic location, mainly spread to the nodes in the hepatoduodenal ligament, then to the para-aortic nodes, retropancreatic nodes, or common hepatic artery nodes. In addition to these spreading routes, the left peripheral type or hilar type of cholangiocarcinoma tends to spread along the left gastric nodes through the lesser curvature.

Characterization of MRSA transmission in an emergency medical center by sequence analysis of the 3'-end region of the coagulase gene

The distribution of methicillin-resistant Staphylococcus aureus (MRSA) isolates at the St. Marianna University affiliated emergency medical center (EMC) was studied by sequence analysis of the 3'-end region of the coagulase gene. We collected a total of 42 MRSA isolates, consisting of 20 strains from the hospital environment, 13 strains from the nostrils or fingers of medical staff, and 9 strains from inpatients in the EMC. We compared our results with those from 27 stock strains of known coagulase serotype and 2 strains reported in the literature. All 69 strains tested have four to six tandem repeats in the 3'-end region of the coagulase gene. Among the 42 MRSA isolates collected, the base sequence of the 3'-end region of the coagulase gene was identical in 28 of them (67%). The number of isolates originating from the hospital environment, medical staff, and patients, respectively, that were identical to this representative strain were 18 (90%), 6 (46%), and 4 (44%). Phylogenetic analysis using the DNA sequences of the tandem repeat region demonstrated that almost all strains from the patients formed a concordant cluster with the representative strain from the hospital ward. We also assessed the value of sequence analysis of the 3'-end region of the coagulase gene as an epidemiological marker. Our results indicate that sequence analysis of the 3'-end region of the coagulase gene of MRSA may be a potent epidemiologic typing system.

Evaluation of the activity of antimicrobial agents against Legionella pneumophila multiplying in a human monocytic cell line, THP-1, and an alveolar epithelial cell line, A549

The intracellular activity of three antimicrobial agents, erythromycin, clarithromycin, and ciprofloxacin, against Legionella pneumophila was examined in the human monocyte-derived cell line, THP-1, and the human alveolar epithelial cell line, A549. L. pneumophila multiplied by three- to four-log in THP-1 and by two- to three-log in A549 after 48-h incubation. The activity of the two macrolides was markedly greater in A549 than in THP-1, while ciprofloxacin exhibited similar activity in both cell lines. The intracellular concentrations of the two macrolides were markedly higher in A549 than in THP-1, while those of ciprofloxacin were almost equal in both types of cell lines. The intracellular activity of antimicrobial agents and the intracellular growth of L. pneumophila vary with different types of host cells.

Evaluation of a human monocytic cell line THP-1 model for assay of the intracellular activities of antimicrobial agents against Legionella pneumophila

We examined the intracellular activities of 11 antimicrobial agents against Legionella pneumophila using a human monocyte-derived cell line, THP-1. Colony counting and microscopic examination of L. pneumophila co-incubated with THP-1 cells (5 x 105 cells/well) were performed. Both extra- and intra-cellular multiplication of L. pneumophila were observed and were dependent on the inoculum of L. pneumophila in the culture; L. pneumophila did not grow in the cell culture medium alone. Light microscopic examination confirmed that extracellular L. pneumophila originated from THP-1 cells disrupted by bacterial multiplication. L. pneumophila multiplied by 3-4 logs after 24 h incubation with THP-1 cells and their number remained stable at 106-107 cfu/mL until 72 h. The results of viability studies using four antimicrobial agents-ciprofloxacin, erythromycin, minocycline and rifampicin-demonstrated that our system was suitable for the intracellular activity assay. We used a concept of 'minimum extracellular concentration inhibiting intracellular multiplication' (MIEC) to evaluate the intracellular activity of antimicrobial agents. The MIECs of three beta-lactams were markedly higher than their conventional MICs while those of macrolides, quinolones, rifampicin and minocycline were similar to their MICs. Our results suggest that evaluation of the clinical efficacy of drugs against L. pneumophila should include determination of their intracellular activity against the bacteria, which could be measured using our assay system in THP-1 cells.

Comparative uptake of grepafloxacin and ciprofloxacin by a human monocytic cell line, THP-1

The present study was designed to compare the uptake of grepafloxacin by a human monocytic cell line, THP-1, with that of ciprofloxacin. THP-1 cells were incubated with 20 microg/ml of either drug, and the entry of the drugs into the cells was determined using a velocity gradient centrifugation technique and HPLC assay. Antibiotic uptake by the cells was expressed as the ratio of the intracellular to the extracellular drug concentration (IC/EC). Grepafloxacin entered THP-1 cells readily within 5 min, and at steady-state (37 degrees C; 60 min), the IC/EC ratio of grepafloxacin (11.9 +/- 1.7; n = 13) was about 2.4-fold higher than that of ciprofloxacin (5.0 +/- 1.3; n = 13). The ratios decreased at low incubation temperature (4 degrees C), in paraformaldehyde-treated dead cells, and at low extracellular pH (pH 6.0), but were not influenced by high extracellular pH (pH, 9.0). Characterization of fluoroquinolone uptake suggests that these drugs penetrate the THP-1 membrane by passive diffusion, and also, in part, via an active transport system. We also examined the uptake of the two fluoroquinolones in phorbol 12 myristate 13-acetate (PMA)-stimulated adherent THP-1 cells (THP-1 macrophages). The IC/EC ratios for both fluoroquinolones in the THP-1 macrophages were significantly higher than those in the THP-1 monocytes. Further the uptake of three other fluoroquinolones, levofloxacin, tosufloxacin, and sparfloxacin, by THP-1 monocytes was examined in comparative studies. The IC/EC ratio of grepafloxacin was comparable to that of sparfloxacin and significantly higher than that of the other fluoroquinolones. Our results indicate that grepafloxacin exhibits better intracellular accumulation than ciprofloxacin and other fluoroquinolones in human monocytic and macrophage-like cells.

Removal and inactivation of hepatitis B virus from contaminated pooled plasma in a large-scale manufacturing process for factor VIII and human serum albumin

BACKGROUND AND OBJECTIVES

The Japanese Red Cross Society recalled one lot of monoclonal-antibody-purified factor VIII (F VIII) and two lots of human serum albumin (HSA) 5 months after preparation of the final products, because of a procedural error that led to contamination by a unit of plasma positive for hepatitis B surface antigen (HBsAg). We evaluated the effectiveness of virus inactivation/removal in a large-scale process for manufacturing F VIII and HSA.

MATERIALS AND METHODS

HBV DNA in the retained samples in process was measured by the polymerase chain reaction (PCR). The kinetics of virus inactivation by solvent-detergent (S/D) treatment was examined using model viruses. We also did a look-back survey of the patients who received corresponding products.

RESULTS

Contaminated hepatitis B virus (HBV) DNA became undetectable beyond fraction S IV-I in the albumin process and immunoaffinity chromatography in the F VIII process, respectively. The model viruses were inactivated within 5 s by S/D treatment. There is no evidence that patients were infected by HBV after transfusion of these products.

CONCLUSION

We conclude that virus inactivation/removal was effectively achieved in a large-scale manufacturing process for F VIII and HSA.

Intraductal papillary tumors of the pancreas. Histopathologic correlation of MR cholangiopancreatography findings

PURPOSE

To evaluate MR cholangiopancreatography (MRCP) findings of intraductal papillary tumors of the pancreas and correlate them with histopathology.

MATERIAL AND METHODS

Seventeen patients with intraductal papillary tumor of the pancreas underwent MRCP before surgery. MRCP findings were correlated to histopathology with regard to the presence of septa and excrescent nodules in the cystic lesion, communication between the cystic lesion and the main pancreatic duct (MPD), degree of dilatation of MPD, and dilatation of the common bile duct (CBD).

RESULTS

MRCP demonstrated septa in 17 cases (100%), excrescent nodules in 8 cases (47.1%), communication between the intraductal papillary tumor and the MPD in 14 cases (82.3%), dilatation of MPD over 50% in 6 cases (35.3%), and dilatation of CBD in 3 cases (17.6%). These findings showed excellent correlation with histopathology. The septum on MRCP corresponded with a layer of connective tissue with pancreatic duct epithelium. Excrescent nodules in the carcinomas consisted not only of malignant cells, but also of dysplasia and adenoma. Excrescent nodules in adenomas were consistent not only with minimal papillary growth of adenoma, but also with proliferation of fibrosis, and hematoma and organized fibrin with minimal fibrosis. Pancreatic tissue was affected by chronic pancreatitis in all cases. Cases with dilatation of CBD on MRCP were due to microscopic invasion by the carcinoma.

CONCLUSION

MRCP appearances of intraductal papillary tumors are well correlated with the findings at histopathology.

Value of extended resection and intraoperative radiotherapy for resectable pancreatic cancer

Since 1984 intraoperative radiotherapy (IORT) combined with extended resection for pancreatic cancer has been performed in our clinic to prevent local recurrence. Following extended resection, a dose of 30 Gy of 9- to 12-MeV electrons is administered to the operative field, including the paraaortic area from the diaphragm above to the inferior mesenteric artery below. The 5-year survival rate was 15.3% in all 37 cases, 20.2% in patients who had macroscopic tumor clearance, and 16.9% in patients with stage IVa tumor according to the Japanese classification. In autopsies of 10 patients who underwent combined therapy, four had local recurrence enclosed by thick, firm connective tissue. There was no local control recurrence in two patients who underwent noncurative resection. Enhanced local control induced by the combined therapy, however, has only a limited impact on overall survival because of the systemic spread of disease, especially hepatic metastases. At present, as we have no effective treatment for hepatic metastases, it is important to perform an extended resection with IORT on carefully selected patients. The combined therapy may offer the best approach to control local recurrence when dealing with advanced, but not highly advanced, cancer as defined by the stage of tumor. Therefore a combination of IORT and extended resection can have an impact on the results of surgical treatment for pancreatic cancer when anticancer treatment of hepatic metastases is established.