Influence of microscopic surface asperities on the wear of ultra-high molecular weight polyethylene in a knee prosthesis

The wear of ultra-high molecular weight polyethylene (UHMWPE) in knee and hip prostheses is one of the major factors restricting the longevity of these implants. A number of microscopic scratches caused by various factors were observed on the metallic femoral components of the retrieved knee prostheses with an anatomical design. It appears that microscopic surface asperities caused by this surface damage contribute to increasing and/or accelerating the wear of the UHMWPE tibial insert. In this study, in the first step, microscopic observations and surface roughness measurements of several retrieved metallic femoral components were performed in order to produce simplified two-dimensional (2D) finite-element method (FEM) models of a microscopic surface asperity using roughness parameters. Next, a three-dimensional (3D) microscopic surface profile measurement of the damaged surface of a retrieved metallic femoral component and the reproduction of the femoral component surface were performed in order to produce 3D FEM models of a microscopic surface asperity based on actual measurement data. 2D and 3D elastoplastic contact analyses between a metallic microscopic surface asperity and UHMWPE were also performed in order to investigate the mechanical state and microscopic wear of UHMWPE caused by a metallic microscopic surface asperity. The analytical findings of this study suggest that the aspect ratio, shape ratio, and indentation depth of the microscopic surface asperity have significant influence on increasing and/or accelerating the wear of UHMWPE. Higher aspect ratios, shape ratios, and indentation depths cause higher contact stresses and plastic strains in UHMWPE.

Elasto-plastic contact analysis of an ultra-high molecular weight polyethylene tibial component based on geometrical measurement from a retrieved knee prosthesis

The wear phenomenon of ultra-high molecular weight polyethylene (UHMWPE) in knee and hip prostheses is one of the major restriction factors on the longevity of these implants. Especially in retrieved knee prostheses with anatomical design, the predominant types of wear on UHMWPE tibial components are delamination and pitting. These fatigue wear patterns of UHMWPE are believed to result from repeated plastic deformation owing to high contact stresses. In this study, the elasto-plastic contact analysis of the UHWMPE tibial insert, based on geometrical measurement for retrieved knee prosthesis, was performed using the finite element method (FEM) to investigate the plastic deformation behaviour in the UHMWPE tibial component. The results suggest that the maximum plastic strain below the surface is closely related to subsurface crack initiation and delamination of the retrieved UHMWPE tibial component. The worn surface whose macroscopic geometrical congruity had been improved due to wear after joint replacement showed lower contact stress at macroscopic level.

Destruxins, cyclodepsipeptides, block the formation of actin rings and prominent clear zones and ruffled borders in osteoclasts

Bone-resorbing osteoclasts exhibit polarized morphological structures such as actin rings, clear zones, and ruffled borders. To gain insight into the mechanism of bone-resorbing activity of osteoclast and to discover new types of anti-resorptive agents, we have screened for natural compounds that inhibit the bone-resorbing activity of osteoclast-like multinucleated cells (OCLs). Destruxin B (DestB) and E (DestE), cyclodepsipeptides, were found to inhibit pit formation without affecting osteoclast differentiation and survival. Destruxins reversibly induced morphological changes in OCLs in a dose-dependent manner (DestB, 0.2-1 microM; DestE, 0.01-0.05 microM) and inhibited pit formation. Destruxin-induced morphological changes were accompanied by disruption of the actin rings in OCLs. The formation of actin rings in OCLs after adhesion was also inhibited by destruxins. Electron microscopical analysis revealed that destruxin-treated OCLs on dentine slices have no prominent clear zones and ruffled borders. The effective concentrations of destruxins on the morphological changes were almost the same as those that inhibited bone resorption in organ culture system. These results suggest that the anti-resorptive effects of destruxins result from induction of a disorder of the morphological structures in polarized OCLs.

Invasive pulmonary aspergillosis resulting in respiratory failure during neutrophil recovery from postchemotherapy neutropenia in three patients with acute leukaemia

Respiratory failure is a severe complication of invasive pulmonary aspergillosis (IPA). Its pathogenesis is not well understood. We herein describe three cases of subacute respiratory failure that occurred during the recovery phase of neutropenia following induction chemotherapy for acute leukaemia with IPA. In each case, severe neutropenia (19-85 days), high-grade fever, severe anaemia, the use of granulocyte-colony-stimulating factor and increasing infusion volume were noted. As the neutrophil count was recovering, the shadows on the chest X-ray expanded with progressing hypoxia. We should pay attention to the respiratory failure during the recovery phase of neutropenia in patients with IPA.

Porcine enamel matrix derivative enhances trabecular bone regeneration during wound healing of injured rat femur

To elucidate the effects of enamel matrix derivative (EMD: Emdogain) on bone regeneration in rat femurs after drill-hole injury, defects in bone were filled with either EMD or its carrier, PGA, as control. On postoperative days 4 to 28, dissected femurs were examined by means of various morphological approaches. In both experimental groups, formation of trabecular bone, which was immunostained for bone sialoproteins (BSP), had occurred in the medullary cavities at cylindrical bone defects on Day 7 postoperatively. Cuboidal osteoblasts were clearly observed on these newly-formed BSP-positive bone trabeculae. On Days 7 and 14, many multinucleated giant cells, which strongly expressed cathepsin K, had appeared on these bone trabeculae, indicating active bone remodeling. In these bone trabeculae, Ca and P weight % and Ca/P ratio were similar to those of cortical bone, and there was no significant difference between the PGA- and EMD-applied groups. Bone volume fraction of newly-formed bone trabeculae on Day 7 postoperatively was significantly higher in the EMD-applied group than in the PGA-applied controls. Because of active bone remodeling and the marked decrease of bone volume, on Days 14 and 28 postoperatively, however, there was no longer a significant difference in trabecular bone volume fraction between the experimental groups. Our results suggest that EMD possesses an osteo-promotive effect on bone and medullary regeneration during wound healing of injured long bones.

[A case of Chlamydia pneumonia and systemic lupus erythematosus (SLE) pleurisy]

A 40-year-old female was admitted with right chest pain. SLE was absent from her past history, although she complained of polyarthralgia in winter. Atypical pneumonia/pleuritis was suspected by chest X-ray film, showing a nodular shadow in the right lower field and moderate pleural effusion. Chlamydia pneumonia was diagnosed by elevated anti-C. psittsci antibody, while characteristics of pleural fluid revealed serositis accompanied by SLE because of the high titered anti-DNA antibody and the low titered complement. She was cured by clarithromycin and subsequent administration of prednisolone and cyclophosphamide.

Paralytic ileus due to strongyloidiasis: case report and review of the literature

We report a rare case of a patient with ileus due to Strongyloides infection that occurred four times within a six-month period. The ileus was improved by treatment with ivermectin and there has not been a recurrence of the symptoms within the last two years.

Adaptive multimode lubrication in natural synovial joints and artificial joints

To examine the lubrication mechanisms in both natural synovial joints and artificial joints with artificial cartilages, pendulum tests of pig shoulder joints and simulator tests of sliding pairs of a stainless steel spherical component and natural articular cartilage or artificial cartilage have been conducted. Firstly, it was shown in pendulum tests of pig shoulder joints that both concentration of hyaluronic acid or viscosity and adsorbed film formation of proteins and phospholipids exerted a significant effect on frictional behaviour in swinging motion immediately after a loading of 100 N. Under a high load of 1 kN, low friction was observed under wide-ranging viscosity conditions, since a high load similar to body weight probably enhanced the squeeze film effect due to improved congruity. Next, frictional behaviour of sliding pairs in knee joint models, consisting of a stainless steel spherical surface and either specimens of pig tibial cartilage or polyvinylalcohol (PVA) hydrogel, was examined during walking in simulator tests. In these tests, the influences of lubricant viscosity and addition of protein on frictional behaviour were evaluated. For both compliant materials, the appropriate addition of gamma-globulin to sodium hyaluronate (HA) solution maintained low friction and protected rubbing surfaces under thin film conditions. These phenomena are discussed from the viewpoint of adaptive multimode lubrication.

[Clinical analysis on 127 cases of fungemia in Fukuoka University Hospital between 1984 and 1994]

A clinical analysis on 127 cases out of 140 cases presenting with fungemia at Fukuoka University Hospital between 1984 and 1994 was done. The number of the positive blood cultures during the same period was 1188 and the rate of fungemia was 11.8%. The rates generally increased in recent years, 9.0% (1984-1986), 10.2% (1987-1989) and 13.6% (1990-1994), but decreased after 1992. C. albicans has shown a tendency to decrease while C. parapsilosis and C. glabrata have increased in recent years thus suggesting the effect of the prevalence of intravenous hyperalimentation (IVH) and azole antifungal agents. Only 3.9% of the fungemia were preceded by bacteremia. In addition to the known risk factors for fungemia such as IVH (89.0%) and the antibacterial agents, H2-receptor antagonists were used in 58.3% of the cases. 14 cases of the fungemia were observed during the prophylactic use of antifungal drugs. Therefore, fungemia should always be kept in mind regarding the differential diagnosis for bacteremia when an indwelling venous catheter is used. The prompt extubation of the catheter in addition to the adjustment of the dosage of antifungal drugs in response to the status of the host defense system are thus considered to be important in the treatment of fungemia.

[Infective endocarditis--a review of 21 cases in last 10 years]

Twenty one cases of infective endocarditis in last 10 years were re-evaluated by Duke's criteria. Fourteen strains of Streptococcus viridans, 4 of Enterococcus faecalis, 1 of Haemophilus parainfluenzae were isolated from blood culture. As to the minimum inhibitory concentration (MIC) of 8 strains of Streptococci, imipenem revealed the lowest MIC value, following penicillin G, ceftriaxon not equal to ampicillin, vancomycin and gentamicin. One strain of them was penicillin-resistant (0.8 micrograms/ml). Serum inhibitory test (SIT) and serum bactericidal test (SBT) were undergone for 6 cases. The assay was efficient to determine penicillin-tolerance of causative bacterium. Vegetations were observed in 18 cases of 21 by the echo-cardiography, especially transesophageal echocardiography had better diagnostic sensitivity compared to transthoracic echocardiography. However, it took 12 weeks from the first febrile episode to achieve definite diagnosis. One of reasons to take such a long time to reach diagnosis was that major causative organism was S. sanguis, whose inflammatory reaction to the host was said to be strikingly weak.

[A case of tuberculous pyothorax after an interval of four years of finishing with the first treatment for pulmonary tuberculosis]

We reported a case of tuberculous pyothorax which developed at four years after finishing with the first treatment for pulmonary tuberculosis. A 50-year-old female was admitted to our hospital with right chest pain. Tuberculous pyothorax was diagnosed by means of polymerase chain reaction (PCR method) of pleural effusion and of histological findings of the pleural section. She was cured by operation, pleural drainage and anti-tuberculous drugs. The bone scincigram of 99mTc revealed accumulation in the right 9th rib, tuberculous empyema might have been a secondary development from osteomyelitis.

Analysis of the expression of CagA and VacA and the vacuolating activity in 167 isolates from patients with either peptic ulcers or non-ulcer dyspepsia

OBJECTIVES

The goals of this study were: 1) to examine the prevalence of cytotoxin-associated protein (CagA), vacuolating cytotoxin (VacA), and the vacuolating cytotoxin activity (VCA) in vitro of infecting Helicobacter pylori isolates and 2) to clarify the relation between the expression of these virulence factors and the occurrence of peptic ulceration.

METHODS

One hundred sixty-seven clinical isolates of H. pylori from patients with peptic ulcer disease (gastric ulcer, 62 cases; duodenal ulcer, 48 cases) and nonulcer dyspepsia (57 cases) were studied regarding their genetic and phenotypic properties.

RESULTS

Type 1 bacteria, which had both CagA and VCA, and type 2 bacteria, which did not express either CagA or VCA, represented 62.9% and 7.8%, respectively; the remaining 29.4% had an intermediate phenotype, expressing either CagA independent of the presence of VCA (CagA+VCA-) or vice versa (CagA-VCA+). CagA+VCA- and CagA-VCA+ bacteria represented 17.4 % and 12.0%, respectively, both of which were more numerous than the type 2 category. The proportion of the CagA-positive isolates was significantly higher in both the duodenal ulcer (97.9%) and gastric ulcer (83.9%) patients than in the non-ulcer dyspepsia patients (61.4%) (p < 0.01). On the other hand, the proportion of VacA/VCA-positive isolates was not significantly different between peptic ulcer disease and non-ulcer dyspepsia.

CONCLUSIONS

The currently used classification of this bacterium based on the concomitant expression of CagA and VacA/VCA into the two major types is not adequate. The CagA-positive phenotype thus may be important as a virulence marker for peptic ulcer disease independent of the presence of VacA/VCA.

[Immunodeficiency and carcinogenesis in patients with chronic active Epstein-Barr virus infection]

Three adult patients with chronic active Epstein-Barr virus infection (CAEBV) had high anti-EBV-VCA antibody, positive anti-EA, low anti-EBNA and were associated with systemic lymphadenopathies and immunosuppression. The case 1 and 2 had elevated serum immunoglobulin levels, and recurrent infections, and case 3 showed pancytopenia. These 3 cases developed both EBV and latent membrane protein (LMP) positive malignant histiocytosis, EBV positive but LMP negative plasmacytoma, and EBV negative acute myelogeneous leukemia, respectively. It was suggested that CAEBV belonged to high risk groups for the development of malignant neoplasms. Since HLA of the case 1 and his father was identical, we conducted a in vitro cytotoxicity test using EBV transformed autologous B lymphocytes, K562 cells, and Raji cells to clarify the association of immunosuppression and HLA. The case 1 showed a low level of specific cytotoxicity to autologous EBV transformed B cells, while his parents were negative for the specific cytotoxicity. The patient and his parents developed inducible cytotoxicity to all targets after in vitro incubation of peripheral mononuclear cells with recombinant interleukin 2 (rIL-2) for 7 days. The patient and his mother showed lower enhancement of cytotoxicity, while HLA identical father could induce good cytotoxic activity to all targets as well as normal controls, indicating that a low IL-2 induced cytotoxic activity observed in CAEBV was independent of HLA associated immunoregulation at least in the case 1. Further studies are required to clarify the exact mechanisms responsible for the development of CAEBV.

[Comparison between monotherapy with imipenem/cilastatin sodium (IPM/CS) and combinations of IPM/CS and other drugs for treating bacterial infections in patients with hematopoietic disorders]

One hundred and nine patients with infections concurrent with hematopoietic disorders were treated with imipenem/cilastatin sodium (IPM/CS) either alone (IPM/CS monotherapy) or in combination with other antimicrobial drugs (IPM/CS combination therapy). The following results were obtained. 1. One hundred and nine patients were allocated at random to two groups: 53 patients to IPM/CS monotherapy and 56 patients to IPM/CS combination therapy. Fourteen patients (6 and 8 in the 2 groups, respectively) were excluded from the clinical evaluation. There were not significant differences between the two groups with respect to the background. 2. The efficacy rates of the 2 treatments against bacterial infections were as follows: in the IPM/CS monotherapy group, 62.5% in 8 patients with sepsis, 75.0% in 23 patients with fever of undetermined origin (FUO), 50.0% in 10 patients with pneumonia, and 68.3% in the 47 patients, and in the IPM/CS combination group, 85.7% in 7 patients with sepsis, 63.6% in 24 patients with FUO, 50.5% in 8 patients with pneumonia, and 67.4% in the 48 patients. The differences between the two groups were not significant. 3. Among the drugs used in combination with IPM/CS, antibiotics other than penicillins, cephalosporins, and aminoglycosides were used in 12 patients and a high efficacy rate of 91.7% was obtained. 4. Bacteriologically, 19 and 17 strains were isolated from the IPM/CS monotherapy and combination therapy groups respectively, and the eradication rates were 100% and 88.9% respectively. 5. Side effects were noted in 2 patients in the IPM/CS monotherapy group and 7 in the combination therapy group, but all of these resolved after discontinuation or completion of the treatment. The efficacies against severe bacterial infections in the presence of hematopoietic disorders were not different between IPM/CS alone and IPM/CS in combination with other antibiotics. Adverse reactions were uncommon with the monotherapy.

Chronic Prototheca meningitis

A case of chronic meningitis caused by the achloric alga Prototheca wickerhamii is described, which has persisted for more than 6 years despite treatment with various antifungal agents. For the last year no treatment has been given, but the patient has no complaints.

The purification of a GroEL-like stress protein from aerobically adapted Campylobacter jejuni

From plate cultures of Campylobacter jejuni grown in room air a particulate protein of 62 kDa was isolated by ion-exchange chromatography. The protein had a square shape from the side view but when viewed from the top it had a star-shaped structure. The molecular size of the whole particle determined by gel filtration was 850 kDa which suggested the presence of 14 subunits of 62 kDa in each particle. The N-terminal 37 amino residues showed more than 80% homology with the sequence of these heat shock protein (HSP) 60 homologs of Chlamydia trachomatis, Helicobacter pylori, and Escherichia coli (GroEL). This protein is immunologically cross-reactive with the antiserum for the 60-kDa HSP of Yersinia enterocolitica. Production of the 62-kDa protein increased under heat stress and growth in an aerobic atmospheric environment. From these observations we concluded that the 62-kDa protein is a Campylobacter stress protein (Cj62) which belongs to the HSP 60 family.

[Clinical efficacy of sulbactam/cefoperazone for the treatment of geriatric patients with respiratory tract infections]

We performed clinical studies on sulbactam/cefoperazone (SBT/CPZ) for the treatment of geriatric patients with respiratory tract infections. Seven patients with pneumonia, 7 with acute bronchitis, 6 with chronic respiratory tract infections were treated with SBT/CPZ. The patients were administered with a daily dose of 2.0 g or 4.0 g for 4-14 days. The clinical responses were excellent in 3, good in 13, fair in 3, and poor in 1 patients. The efficacy rate was 80.0%. No side effects were observed in any patients, but elevations of GOT, GPT were observed in two cases. Causative organisms were E. coli (2 strains), P. aeruginosa (2), MSSA (1), MRSA (1), S. pneumoniae (1), H. influenzae (1), K. oxytoca (1), and E. aerogenes (1). The bacteriological effect rate was 60%. One strain of MRSA and one of two strains of P. aeruginosa persisted in 2 patients.

[A comparative study of imipenem/cilastatin sodium BID vs QID in the treatment of infections associated with hematopoietic disorders]

Using the envelope method, we allocated 125 patients with infections accompanied by hematopoietic disorders into two groups treated with imipenem/cilastatin sodium (IPM/CS) at a daily dose of 1 g/1 g b.i.d. (group BID) or 0.5 g/0.5 g q.i.d. (group QID), and obtained the following results. 1. In group BID, ANLL was observed in 25 patients; ALL in 6; and NHL in 12. In group QID, ANLL was observed in 27 patients; ALL in 7; and NHL in 13. 2. In group BID, efficacy rates were 54.5% (6/11) in sepsis, 63.0% (17/27) in fever of undetermined origin and 50.0% (4/8) in pneumonia, thus the overall efficacy was 61.8% (34/55). In group QID, efficacy rates were 66.7% (4/6) in sepsis, 76.0% (19/25) in fever of undetermined origin and 35.7% (5/14) in pneumonia, thus the over all was 61.1% (33/54). No significant difference in response rates were observed between the two groups. 3. Bacteriologically, 22 bacterial strains were isolated in group BID and 21 21 strains, in group QID. The eradication rates after treatment with IPM/CS was 100% in group BID and 66.7% in group QID. 4. Side effects were observed in 8 patients in group BID and 3 in group QID. Laboratory examination revealed abnormal values in 9 patients in group BID and 6 in group QID. However, all of the side effects disappeared after the suspension or discontinuation of IPM/CS. The efficacies of IPM/CS therapy for severe infections in patients with hematopoietic disease were similar between 1 g/1 g b.i.d. and 0.5 g/0.5 g q.i.d. groups.

Granulocyte colony-stimulating factor does not enhance phagocytosis or microbicidal activity of human mature polymorphonuclear neutrophils in vitro

The direct effects of human granulocyte colony-stimulating factor (hG-CSF) on mature polymorphonuclear neutrophils (PMNs) in vitro were studied with regard to chemotaxis, superoxide production, and phagocytosis and microbicidal activity against the following viable microorganisms: Staphylococcus aureus, serum-resistant Pseudomonas aeruginosa, and Candida albicans. Recombinant hG-CSF (rhG-CSF) acted as a chemoattractant for human PMNs in a dose-dependent manner. The chemotactic response of PMNs to N-formyl-methionyl-leucyl-phenylalanine (FMLP) was not enhanced by rhG-CSF at any of the concentrations used. rhG-CSF did not induce the generation of superoxide by itself. However, rhG-CSF was able to prime human PMNs and to enhance O2- release stimulated by FMLP in a dose-dependent manner. rhg-CSF did not enhance phagocytosis or killing of the three species of microorganisms by normal PMNs. With PMNs obtained from patients who had hematological disorders or solid tumors, no enhancement of the microbicidal activity was observed in most cases. Microbial killing mediated by PMNs depended on the ratio of PMNs to target organisms. We concluded from these facts that the most important effect of rhG-CSF was to increase the number of the peripheral PMNs and not to enhance the functions of mature PMNs.

Characterisation of the external surfaces of Pseudomonas aeruginosa isolated from human blood and respiratory tract

The surface structures of the cell envelopes of 16 clinical isolates of Pseudomonas aeruginosa were examined by electronmicroscopy with the new fixation technique of freeze-substitution. Two types of structures were observed among the organisms. In one group of strains, mostly isolated from blood, a dense fibrous layer c. 30 nm thick was found around the outer-membrane surface, whereas no such structure was observed in the other group of isolates, most of which were from sputum. Lipopolysaccharides extracted from the isolates with a dense fibrous layer were found by SDS-PAGE to have long O-polysaccharide chains, whereas strains without such a layer mostly had lipopolysaccharides that lacked high mol. wt. O-polysaccharide chains.

Purification of Pneumocystis carinii trophozoites and identification of their circulating antigens

We have developed a new method to isolate Pneumocystis carinii trophozoites from experimental rat bronchoalveolar lavage specimens by using a Percoll discontinuous gradient and have identified the circulating antigens in experimental rat P. carinii pneumonia. The antigenic components of the trophozoites were compared with those of cysts by immunoblotting. A major immunoreactive band of 90,000 Da and some others of lower molecular mass were found in trophozoites. On the other hand, bands of 110,000, 50,000, and 45,000 Da were observed in cysts. The band of 50,000 Da was not identified when antitrophozoite rabbit serum preabsorbed with P. carinii-infected rat serum was used for immunoblotting. These results suggest that the molecule of 50,000 Da is the major circulating antigen in P. carinii-infected rats.

Clinical features of patients suffering from Streptococcus milleri infections--a retrospective analysis

We examined the clinical records of patients from whom S. milleri was isolated at Kyushu University Hospital from January 1987 through December 1988. Sixty-one patients were treated in 64 episodes with drainage or antibiotics. Oral and nasopharyngeal infections were observed in 27 cases, intrathoracic infections in 13, urogenital infections in 8, intraabdominal infections in 6 and skin and subcutaneous infections in 6. Except for acute bronchitis and urogenital infections, all of them were suppurative. As to underlying diseases, 21 patients had malignancies and 6 had diabetes mellitus. Leukocytopenia was not observed in any of the patients. S. milleri can be eradicated by treatment but it is sometimes replaced by other organisms. However, considering its tendency to cause suppurative infections, its pathogenic significance should be taken into account and patients should undergo surgical drainage combined with antibiotic therapy.

The effect of humoral and cell-mediated immunity in resistance to systemic Serratia infection

Protection against experimental Serratia marcescens infection in mice was enhanced by prior injection of formalin-killed or viable bacteria of the same strain. From the first to the fourth week after vaccination, specific immunity was involved in the host defence against systemic serratia infection. The transfer of antiserum specific for S. marcescens increased bacterial clearance from the liver, but did not increase the survival of the mice. Bacterial clearance from the liver was also increased by the transfer of spleen cells from immunised mice, but, again, survival was not increased. However, the transfer of both antiserum and spleen cells from vaccinated mice increased both bacterial clearance from the liver and survival (p less than 0.01). These results suggest an additive effect of humoral immunity and T-cell-mediated immunity in protection against systemic serratia infection.

[Therapeutic evaluation of imipenem/cilastatin sodium for bacterial infections in patients with hematological diseases]

1. To evaluate the efficacy and tolerance of imipenem/cilastatin sodium (IPM/CS) in severe infections associated with hematopoietic disorders, IPM/CS was administered to a total of 105 patients. 2. Out of 96 patients evaluable for efficacy, clinical responses were excellent in 23 patients, good in 30, fair in 15, poor in 19 and unknown in 9, and the overall response rate was 60.9%. 3. The most common underlying hematopoietic disease was acute non-lymphocytic leukemia and the most common infections were sepsis and suspected sepsis. 4. Daily dose, severity of infection and neutrophil count had effects on the clinical response. 5. The overall eradication rate of bacteria was 83.7%. 6. Side effects were observed in 10 patients (9.5%) and abnormal laboratory test results in 12 (11.4%). From the above findings, we have concluded that IPM/CS is very useful for the treatment of severe infections in compromised patients with hematopoietic diseases.

[A case of remarkable effect of clindamycin in nasal septum abscess caused by Streptococcus milleri]

We encountered a 14-year-old male patient with a destructive abscess of nasal septum, caused by Streptococcus milleri. He was successfully treated with Clindamycin in combination with surgical intervention. We emphasized the significance of Streptococcus milleri as a causative agent for abscess formation, and clindamycin should be considered as a first choice of antibiotics against Streptococcus milleri infection.

[Ofloxacin in the treatment of infection caused by Salmonella paratyphi A]

We reported a case of salmonellosis treated with ofloxacin (OFLX) which showed excellent clinical and bacteriological effect in a 22 year-old Japanese male with Salmonellosis paratyphi A. He had stayed in India from Sept. 6, 1990 to Oct. 13, 1990. On Oct. 25, 1990, he complained of a high fever and headache. On Oct. 29, he was admitted to our hospital and was diagnosed as Salmonellosis paratyphi A by the blood culture. He was treated with 2.0 g/day of chloramphenicol (CP) for 7 days, but the clinical efficacy was not sufficient. Therefore, we added 900 mg/day of OFLX for 10 days. He was treated successfully with them, the temperature became on the 2nd day. No side effect and no changes of laboratory data were observed and no recurrence was observed clinically and bacteriologically for three months after his discharge.

Accumulation of phosphate-containing granules in the nucleoid area of Pseudomonas aeruginosa

Many electron-dense granules were found in the nucleoid area of Pseudomonas aeruginosa strain K by electron microscopy with the technique of the freeze-substitution method. These granules contained phosphorus and calcium as determined by X-ray microanalysis. The size and the numbers of the granules decreased when the bacteria was cultured in the medium from which phosphate-containing compounds were depleted. From these observations we concluded that the granule was a phosphate-containing granule and possibly a polyphosphate granule. The excellent preservation of the fine structures by the freeze-substitution technique enables us to show very small polyphosphate granules in the nucleoid area of the bacterial cells which cannot be revealed by the conventional chemical fixation method. As we could not see the granules in other bacteria cultured in nutrient medium such as Serratia, Escherichia, Bacillus and Vibrios, the accumulation of the phosphate granules in Ps. aeruginosa might be a unique character of this bacteria and might be related to the growing capability of this bacteria in extremely low nutrient supply.

[A case of Plasmodium vivax malaria with findings of DIC]

We reported a rare case of Plasmodium vivax malaria who showed findings of disseminated intravascular coagulation (DIC). A 50-year-old Japanese male was sent to our hospital with the diagnosis of Plasmodium vivax malaria on the 26th of April, 1990. He had stayed in the Solomon Islands from Oct. 1987 to Dec. 1989, and had febrile episodes during his stay in the island. On April 18, 1990, he complained of a high fever with chills, and showed the same episodes on the 20th, 22th and was diagnosed as malaria. He was treated successfully with the sulfadoxine 500 mg and pyrimethamine 25mg (Fansidar), following the normal temperature on the 4th day and disappearance of malarial parasites in the peripheral blood smear on the 6th day. Interestingly, he had thrombocytopenia and a high titer serum level of fibrin degradation product (FDP) supporting the questionable diagnosis of DIC. Even on the 12th day after improved thrombocytopenia by treatment with Gabexate (FOY), the serum level of FDP, D-dimer and thrombin-nati-thrombin (TAT)III complex still remained at high titer levels. One month later he was readmitted for a relapse of Plasmodium vivax malaria, when he showed thrombocytopenia but the serum level of FDP, D-dimer, TAT III complex and PM.alpha 2 PI complex were normal levels. We concluded that the thrombocytopenia and the high titer of FDP at his first admission was a manifestation of DIC.

Treatment of complicated urinary tract infections with ofloxacin following an aminoglycoside

In order to reduce the dosage of aminoglycoside in the treatment of patients with complicated urinary tract infections (UTI) in outpatient clinics and to improve cost benefits, we tried both ofloxacin (OFX) treatment and a combination treatment with OFX and a single dose of aminoglycoside (isepamicin). Both groups showed the same cure rate on day 5, but the bacteriuria elimination rate on day 1 was slightly higher in the isepamicin-OFX group. The recurrence rate on days 7-14 did not differ between the groups. This aminoglycoside-OFX treatment did not show significantly higher effectiveness against complicated UTI but resulted in earlier elimination of bacteriuria. These results suggest that this combination therapy may be cost effective in treating complicated UTI, because of the shorter treatment period required.

[Clinical studies on the utility of ofloxacin for lower respiratory infections]

One hundred and thirteen patients who were treated at the Kyushu University Hospital and other related hospitals were randomly assigned to 2 groups to compare the effect of twice daily administration of 200 mg each and that of 300 mg each of ofloxacin (OFLX). The patients included 41 cases with pneumonia, 18 with acute bronchitis, 33 with chronic bronchitis, 15 with bronchiectasis with infection, 3 with diffused panbronchiolitis, and 3 with other secondary infectious diseases. Fifty-five cases were administered 400 mg OFLX a day and 58 cases received 600 mg. The number of severe cases in the 600 mg group was greater than that in the 400 mg group. The ratios of general amelioration of clinical symptoms were 92.6% in the 400 mg group and 82.1% in the 600 mg group. Thus, the ratio of the 400 mg group was better than that of the 600 mg group. However, the ratio of significant amelioration in the 600 mg group was 35.7% which was better than that in the 400 mg group, 27.8%. For bacteriological effects the rate of disappearance and decrease in number of bacteria was 92% in the 400 mg group and was significantly better than that of the 600 mg group, 70%. The incidence of side effects in the 600 mg group was 22.4% and this was high in contrast to that in the 400 mg group, 3.6%. Most of the side effects in the 600 mg group involved symptoms of the central nervous system such as sleeplessness. No significant differences were observed in incidences of abnormalities of laboratory tests at 1.8% and 1.7%, respectively. Safety in the 400 mg group were 96.4% which was significantly higher in number than those in the 600 mg group, 77.6%. Efficacy rates of twice daily administrations each with 200 mg and 300 mg OFLX for lower respiratory infections were 94.4 and 79.3%, respectively. In conclusion, the daily dose of 400 mg was the most effective.

[An autopsied case of infective endocarditis with cardiac tamponade due to myocardial rupture]

Since it is very rare that cardiac tamponade due to myocardial rupture caused by infective endocarditis, occurs we are reporting this case. A 62 year old man, who had underlying diseases of pneumoconiosis and hypertensive heart disease, visited Chikuho Rosai Hospital complaining of chest oppression and general fatigue on Feb. 7, 1987. He was diagnosed as having ischemic heart disease by electrocardiogram. Two days later, he suddenly had chills and a fever, and the laboratory data showed leukocytosis and a positive C-reactive protein (CRP). The echo cardiogram showed mitral regurgitation (MR) and aortic regurgitation (AR), but neither vegetation nor pericardial effusion was observed. On Feb. 16, he was admitted with shock, and he died the next day. The blood cultures grew gram-positive cocci, respectively. From the clinical symptoms, chest roentgenogram and electrocardiogram, we suspected a cardiac tamponade. On autopsy findings, though coronary arteries were intact, the aortic valves had severe valvular adhesions, calcifications and hypertrophies. The rupture hole was observed in the left ventricles, which was just under the aortic valve through the pericardiac space. It seemed that he died of a cardiac tamponade due to the outflow of blood from this hole. On histopathologic findings of the cardiac wall, gram-positive cocci and many of neutrophils were observed.

[Clinical studies on mycosis especially deep-seated candidiasis in blood disorder patients]

Deep-seated mycosis is prominently increasing as a terminal infection in compromised hosts with malignant blood disorders or malignant tumors. Moreover, localized candidal abscess of visual organs has recently been reported in several laboratories. We investigated the occurrence of deep-seated mycosis in 105 autopsied cases with blood disorders in our clinic from 1980 to 1987. Forty-four of those cases had died of various infections, and 80% of them were fungal infections. More than half of the fungal infections were aspergillosis. Deep-seated candidiasis was recognized in 10 cases, 6 of which were systemic candidiasis, the average duration of neutropenia below 500/mm3 was 19.7 days that of lymphopenia was 36.5 days. Two cases were complicated with GI-tract ulcer, and involved with hepatic candidiasis. On the other hand, in the 4 cases of localized candidial abscess, the duration of neutropenia was 58.5 days and that of lymphopenia was 28.8 days. These four cases were complicated with GI-tract ulcer. Histologically, Candida spp. were recognized at the bottom of the ulcer and invasion by inflammatory cells or tumor cells was found in the portal vein. We surmised that GI-tract ulceration is a very important complication of hepatic candidiasis or liver abscess, and the occurrence of localized candidiasis seems to depend on the duration and severity of neutropenia.

Effects of vaccination against systemic Serratia infection

Host defense against Serratia marcescens in experimental infection in mice was enhanced by vaccination with formalin-killed bacteria of the same strain. The enhancement appeared within 24 hr after vaccination, reached a peak seven days later and lasted four weeks. The enhanced resistance to Serratia infection was also observed in the early phase (within seven days) after vaccination with killed Escherichia coli or other Gram-negative strains, but the efficacy on Day 7 was inferior to that with killed S. marcescens. Phagocytic activities of both circulating neutrophils and peritoneal macrophages were measured by the chemiluminescence (CL) response, and the activity of tissue macrophages was evaluated by the carbon clearance test. The activities were significantly elevated in the early phase, that is, within two or three days for neutrophils, seven days for peritoneal macrophages and at least 14 days for tissue macrophages, after vaccination with killed Gram-negative bacteria. These results suggest that the enhancement of host defense in the early phase is dependent on phagocytic functions that are non-specifically activated by dead bacteria. In the late phase after vaccination, specific immunity might have been involved in the defense mechanism. However, transfer of high titer specific antiserum, in itself, did not render mice resistant to Serratia infection.

Protective effect of recombinant murine granulocyte-macrophage colony-stimulating factor against Pseudomonas aeruginosa infection in leukocytopenic mice

The effects of recombinant murine granulocyte-macrophage colony-stimulating factor (rmGM-CSF) against Pseudomonas aeruginosa infection in ICR mice were investigated. Mice were treated with cyclophosphamide (CPA) and were then injected intraperitoneally with rmGM-CSF three times daily, beginning on the day after CPA treatment, for 7 days. The number of peripheral blood leukocytes in both CPA- and rmGM-CSF-treated mice and control CPA-treated mice reached a nadir on day 4, when P. aeruginosa was injected intraperitoneally. The administration of rmGM-CSF significantly increased the proportion of survivors among mice infected with a lethal dose of P. aeruginosa. This effect was further analyzed by monitoring sequential changes in leukocyte count and bacterial growth in various organs. The number of bacteria in the peritoneal cavities, peripheral blood samples, and livers of GM-CSF-treated mice decreased to an undetectable level after a transient increase, and the number was significantly lower than that in control mice. In GM-CSF-treated mice, the neutrophil levels in peripheral blood started to increase 5 days after CPA administration and were consistently higher than those in controls. Furthermore, the neutrophils in GM-CSF-treated mice were more mature morphologically. Thus, the prophylactic effect of rmGM-CSF against P. aeruginosa infection may result from a rapid recovery of myelopoiesis and a partial enhancement of mature neutrophil function.

Purulent pericarditis caused by Streptococcus milleri

Streptococcus milleri was isolated in pure culture from the pericardial fluid of a 42-year-old man with pulmonary tuberculosis. Pericardiectomy had to be done to cure the pericarditis.

[Laboratory and clinical study of intravenous miconazole]

Laboratory and clinical study was carried out on miconazole (MCZ), a new synthetic imidazole. The antifungal activity of MCZ was studied and expressed as MICs for clinical isolates. The drug proved to have the highest activity against Cryptococcus neoformans, with MICs of no more than 0.16 micrograms/ml for all isolates of this species. MICs of Torulopsis glabrata were 0.08-5 micrograms/ml for all isolates and those of Candida albicans and Candida tropicalis were 5-20 micrograms/ml for more than 90% of the isolates. Most of other strains were less than 10 micrograms/ml. When 3 healthy adult men were administered each with 200 mg of MCZ by intravenous drip infusion for 1.25 hours, the mean serum MCZ concentration was 1.39 micrograms/ml at the end of the infusion, then decreased rapidly to 0.49 microgram/ml in following 30 minutes, and then decreased gradually to 0.17 microgram/ml 6 hours later. The mean cumulative urinary excretion rate of the drug was as low as 3.0% at this stage. A total of 25 patients with ages of 30-78 years, comprising 17 men and 8 women, were treated with 200-1,800 mg of MCZ daily for 3-93 days. The clinical effectiveness was ascertained in 19 cases among the patients; 9 cases with candidiasis, 3 with cryptococcosis and 7 with aspergillosis. Clinical responses were excellent in 2, good in 9 and poor in 8 cases, and its efficacy rates was 58%. The efficacy rate of the combination therapy with other antifungal agents was 60% in comparison with 57% of MCZ alone. Adverse reactions to the drug such as nausea, vomiting and anorexia were observed in 3 cases (12%). Abnormal changes in laboratory parameters were also observed: 3 patients with elevations of GOT and GPT, and another with eosinophilia.