Ampicillin/sulbactam versus cefazolin plus aminoglycosides for antimicrobial prophylaxis in management of Gustilo type IIIA open fractures: A retrospective cohort study.

BACKGROUND: The antibiotic regimens for prophylaxis in the management of open fractures remain controversial. Although the use of aminoglycosides is widely accepted for treatment of Gustilo type III open fractures, aminoglycosides are often avoided in patients with risk factors. This study aimed to compare efficacy and safety of two regimens, cephazolin plus aminoglycoside (amikacin or gentamicin) and ampicillin/sulbactam (ABPC/SBT), in patients with Gustilo type IIIA open fractures. METHODS: A total of 95 Gustilo type IIIA fractures in 90 patients were retrospectively reviewed in this study. The cohort was categorized into two groups that were treated in accordance with the institutional prescribed regimen in different periods: (1) cefazolin plus aminoglycoside (January 1, 2014-September 30, 2017) and (2) ABPC/SBT monotherapy (October 1, 2017-September 30, 2020). Cefazolin was used at 1-2 g every 8 h, aminoglycoside (amikacin or gentamicin) was used daily depending on body weight, and ABPC/SBT was used at 3 g every 8 h The antibiotic administration was continued within 3 days or until successful soft tissue coverage was achieved. The infection rate and the incidence of acute kidney injury (AKI) in both groups were assessed. RESULTS: ABPC/SBT was used in 34 patients (36 fractures), and 56 patients (59 fractures) received cefazolin plus aminoglycoside for antibiotic prophylaxis. Infection developed in 2 of 36 fractures in ABPC/SBT group and 4 of 59 fractures in the cefazolin plus aminoglycoside group (p > 0.99). The average serum creatinine levels on admission, baseline, and peak during the hospital stay were not significantly different between the two groups. One case of AKI was identified in each group, indicating that incidence rate of AKI was not significantly different between the two groups. CONCLUSION: We demonstrated the non-inferiority of ABPC/SBT therapy over cefazolin plus aminoglycoside regimen for type IIIA open fractures. The ABPC/SBT regimen may be an alternative option for managing Gustilo type IIIA open fractures. Further prospective studies with larger samples are needed to verify these results.

[Determination of Endograft Size in Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury:Report of a Case].

Although the efficacy of thoracic endovascular aortic repair( TEVAR) for blunt thoracic aortic injury (BTAI) has been reported, the determination of the proper endograft size for TEVAR in BTAI cases is yet to be established. The management of BTAI by TEVAR may not be effective if a wrong endograft size is selected, possibly leading to fatal outcomes. In this case report, a hemodynamically unstable patient with BTAI was saved by TEVAR, and the preoperative and postoperative changes in the aortic diameter were compared. In TEVAR for BTAI, the effects of hemodynamic instability should be considered and the appropriate device size should be determined based on blood pressure, pulse, and inferior vena cava diameter.

[Clinical Features and Treatment Strategy of Vertebral Artery Injury Associated with Cervical Spine Trauma].

OBJECTIVE: Vertebral artery injury(VAI)associated with cervical spine trauma has the potential to cause catastrophic vertebrobasilar stroke. However, there are no well-defined treatment recommendations for VAI. The purpose of this study was to identify an effective treatment strategy for VAI following cervical spine trauma. METHODS: Ninety-seven patients with blunt cervical spine trauma were treated at Hyogo Prefectural Kakogawa Medical Center between January 2013 and September 2017. Of these patients, 49 underwent computed tomographic angiography or magnetic resonance angiography for evaluation of the vertebral artery. Eighteen patients(36.7%)had a diagnosis of VAI. We retrospectively analyzed the clinical features, treatment, and outcomes in these 18 patients. RESULTS: Seven patients(38.9%)had bilateral VAI, 16(88.9%)had cervical dislocation, and 2(11.1%)had transverse process fractures extending into the transverse foramen. Surgical reduction was performed in 14 patients. Five patients with either bilateral or unilateral occlusion underwent parent artery occlusion before reduction. There were no complications after this procedure. Two patients with bilateral VAI had a stroke before treatment. There were no infarctions in the distribution of the vertebrobasilar artery after intervention. The perioperative stroke rate was relatively good, and almost all Glasgow Outcome Scale scores were related to the degree of spinal cord injury. CONCLUSIONS: Aggressive screening for VAI is important in patients with cervical spine trauma in order to ensure adequate treatment. Although the treatment strategy described here could yield good results, it may require modification according to the needs of the individual patient.

Glucose Variability Based on Continuous Glucose Monitoring Assessment Is Associated with Postoperative Complications after Cardiovascular Surgery.

PURPOSE: This purpose of this prospective study was to use a continuous glucose monitoring (CGM) system to evaluate the suitability of our institution's glucose management protocol after cardiovascular surgery and to clarify the impact of glycemic variability on postoperative complications. METHODS: In all, 76 patients who underwent elective cardiovascular surgery and were monitored perioperatively using a CGM system were evaluated. Postoperative glucose management consisted of continuous intravenous insulin infusion (CIII) in the intensive care unit, and subcutaneous insulin injections (SQII) after oral food intake started. CIII and subcutaneous injections were initiated when blood glucose level exceeded 150 mg/dL. CGM data were used to analyze perioperative glycemic variability and association with postoperative complications. RESULTS: Target glucose levels (71-180 mg/dL) were achieved during 97.1 ± 5.5% and 86.4 ± 19.0% of the continuous insulin infusion and subcutaneous injection periods, respectively. Major postoperative complications were surgical site infections, found in 6.6% of total patients, and atrial fibrillation, found in 44% of patients with off-pump coronary artery bypass grafting. High glycemic variability during SQII was associated with increased risk for both complications. CONCLUSION: Data analysis revealed that our glucose management protocol during CIII was adequate. However, the management protocol during SQII required improvement.

[Endovascular Repair for Acute Phase of Retrograde Type A Aortic Dissection with an Entry in the Descending Aorta].

OBJECTIVE: Endovascular repair for retrograde type A aortic dissection with an entry in the descending aorta (RAAD) is challenging. We present early and mid- term results of endovascular repair for acute phase of RAAD by using commercially-available device. METHODS: From April 2012 to June 2014, 10 consecutive patients with acute phase of RAAD underwent endovascular repair in our hospital. Of them, 9 patients had emergency surgery within 24 hours after the onset. The other one patient had urgent surgery 3 days after the onset. In all patients, the entry tear was covered with TAG or conformable TAG. RESULTS: Technical success was achieved in all patients. No in-hospital mortality was experienced. In all patients, follow-up computed tomography images showed significant remodeling in the ascending aorta 3 months after surgery. During a median follow-up period of 19.5 months, no patients died and no re-intervention occurred. CONCLUSIONS: In patients with acute phase of RAAD, endovascular repair with commercially-available device can be safely performed and it provides sufficient remodeling in the ascending aorta early after surgery. This technique is an alternative to open repair in these patients.

Functional characterization of the mouse melanocortin 3 receptor gene promoter.

Melanocortin receptor 3 (MC3R) is expressed in the hypothalamus and pituitary in humans and rodents, and is involved in the control of feeding, energy metabolism, and pituitary function. In the mouse pituitary, MC3R is detected in mammotrophs. This study aimed to clarify the regulatory mechanism for Mc3r expression in the mouse pituitary. The promoter activities of reporter constructs for the MC3R gene 5'-flanking region up to -4000 bp (transcription initiation site designated as +1) were analyzed. The promoter activity significantly increased in the -86/+109 construct, but decreased in the -38/+109 construct, indicating that the minimal promoter required for basal expression of Mc3r is located in the -86/+109 region. Putative binding sites for transcription factors AP-1 and ATF4 were found in the 5'-flanking region of Mc3r. Site-directed mutation or deletion of these sites affected the promoter activities. In gel-shift assays with a nuclear extract of mouse anterior pituitary cells, band-shifts were detected for both sites after the addition of the nuclear extract, and were decreased in the presence of excess unlabeled probe competitors. These results indicated that both sites were involved in the regulation of Mc3r expression in anterior pituitary cells. Estradiol-17ß treatment increased the Mc3r promoter activity, indicating that the gene is regulated by estradiol-17ß. In conclusion, we have demonstrated the minimum promoter region required for Mc3r expression, and identified two binding sites for AP-1 and ATF4 and in the 5' upstream-flanking region of Mc3r that are essential for Mc3r expression.

[Adult endocardial blood cyst; report of a case].

We report herein a rare case of endocardial blood cyst (EBC) in an adult patient. A 63-year-old asymptomatic woman underwent echocardiography, which incidentally detected a cardiac tumor in the right atrium. On echocardiography, the tumor was revealed to be a 30-mm round mass with thin, hyperechogenic walls and heterogeneously hypoechogenic contents. The lesion was attached to the septum. On computed tomography, the tumor appeared partly calcified and showed poor contrast-enhancement. On magnetic resonance imaging, the lesion appeared isointense or slightly hyperintense in T1 and T2-weighted sequences. Myxoma was strongly suspected based on these preoperative imaging findings. The tumor was successfully excised under cardiopulmonary bypass. Gross examination confirmed that the cyst was filled with blood. The cystic walls comprised thin-layered fibrous tissue lined with endocardial cells. No tumor cells were found. The diagnosis of EBC was confirmed based on histopathological examination, and the postoperative course was uneventful.

Aspartic protease from Aspergillus (Eurotium) repens strain MK82 is involved in the hydrolysis and decolourisation of dried bonito (Katsuobushi).

BACKGROUND: Katsuobushi is a dried, smoked and fermented bonito used in Japanese cuisine. During the fermentation process with several Aspergillus species, the colour of Katsuobushi gradually changes from a dark reddish-brown derived from haem proteins to pale pink. The change in colour gives Katsuobushi a higher ranking and price. This study aimed to elucidate the mechanism of decolourisation of Katsuobushi. RESULTS: A decolourising factor from the culture supernatant of Aspergillus (Eurotium) repens strain MK82 was purified to homogeneity. The purification was monitored by measuring the decolourising activity using equine myoglobin and bovine haemoglobin as substrates. It was found that the decolourising factor had protease activity towards myoglobin and haemoglobin. Complete inhibition of the enzyme by the inhibitor pepstatin A and the internal amino acid sequence classified the protein as an aspartic protease. The enzyme limitedly hydrolysed myoglobin between 1-Met and 2-Gly, 43-Lys and 44-Phe, and 70-Leu and 71-Thr. The purified enzyme decolourised blood of Katsuwonus pelamis (bonito) and a slice of dried bonito. CONCLUSION: It is proposed that aspartic protease plays a role in the decolourisation of Katsuobushi by the hydrolysis of haem proteins that allows the released haem to aggregate in the dried bonito.

Optimization of thromboelastography-guided platelet transfusion in cardiovascular surgery.

OBJECTIVES: Platelet dysfunction is a major cause of bleeding complications in patients undergoing cardiovascular surgery under cardiopulmonary bypass (CPB). Thromboelastography (TEG) can be used to assess post-CPB coagulopathy, but its utility in guiding platelet transfusion (PT) after CPB is unclear. This study assessed the utility of a TEG-guided PT protocol in patients undergoing cardiovascular surgery under CPB. METHODS: The platelet count and TEG maximum amplitude (MA) was measured in 100 patients undergoing valvular or thoracic aortic surgery under CPB. PTs were guided by an empiric protocol in 50 patients (group C) and by a TEG-guided protocol (MA <35 mm, platelet count <7 × 10(4)/mm(3)) in the other 50 patients (group T). RESULTS: PT was utilized significantly less in group T (11 patients; 22%) than in group C (24 patients; 48%) (P < 0.01). The difference in PT utilization was particularly marked in patients undergoing aortic arch aneurysm repair (20% in group T vs. 100% in group C; P < 0.01), yet there was no difference in bleeding complications between these two groups. CONCLUSIONS: Use of a TEG-guided transfusion protocol dramatically reduced PT after CPB, particularly in patients undergoing aortic arch aneurysm repair.

Takotsubo cardiomyopathy associated with hypoglycemia: inverted takotsubo contractile pattern.

Classic takotsubo cardiomyopathy (TCM) is characterized by transient dysfunction of the apical portion of the left ventricle with hyperkinesis of the other parts of the heart wall. Recently, wall motion abnormalities in parts other than in the apical portion of the heart have been reported. Inverted TCM is one form of these anomalies. In this form, the basal segments rather than the apical part of the heart are akinetic/dyskinetic, and the apex is hyperdynamic. Emotional or physical stress is known to trigger TCM, leading some authors to call TCM stress-induced cardiomyopathy (SC). Hypoglycemia is regarded as one of the physical stresses that cause TCM/SC. We present a case of inverted TCM/SC with hypoglycemia. In this case, a 60-year-old woman was brought to our hospital with loss of consciousness caused by hypoglycemia. Initially, the echocardiography revealed an inverted takotsubo contractile pattern. The patient was stabilized with continuous intravenous fluids and a glucose injection, whereas the echocardiography on day 4 showed an almost normal contractile pattern. Among the case reports regarding hypoglycemia as a preceding stressor of TCM/SC, a case of inverted TCM/SC with hypoglycemia is rare. Hypoglycemia is a relatively common case in emergency department; however wall motion abnormalities are not usually expected in hypoglycemic patients. Thus, undiagnosed self-limited TCM/SC cases are possible among hypoglycemic patients. TCM/SC is reported to be a cause of torsade de pointes, which can be fatal. This might warrant an echocardiogram for hypoglycemic patients so as not to overlook TCM/SC in the emergency department.

Organic solvent-tolerant elastase efficiently hydrolyzes insoluble, cross-linked, protein fiber of eggshell membranes.

Eggshell membrane is a mechanically stable and insoluble cross-linked fibrous protein. Pseudomonas aeruginosa strain ME-4 synthesizes a metalloprotease that degrades the eggshell membrane. We cloned the encoding gene in Escherichia coli. The recombinant protease, over-expressed in E. coli, was inactive but addition of acetone to crude cell extracts restored the activity and removed many E. coli proteins. We purified the active, acetone-treated protease to homogeneity in a single chromatography step with 57% recovery. The recombinant protease partially hydrolyzed eggshell membrane and produced more soluble peptides and proteins than commercial elastase, α-chymotrypsin, and collagenase. The soluble peptides produced from hydrolyzed eggshell membrane inhibited angiotensin-I-converting enzyme activity. The degradation of eggshell membrane by the recombinant elastase could be applied to the production of soluble bioactive peptides.

Characterization of YIPF3 and YIPF4, cis-Golgi Localizing Yip domain family proteins.

The Yip1 domain family (YIPF) proteins are homologues of yeast Yip1p and Yif1p, which are proposed to function in ER to Golgi transport. Here, we report the characterization of YIPF3 and YIPF4, homologues of human Yif1p and Yip1p, respectively. Immunofluorescence and immuno-electron microscopy showed that both YIPF3 and YIPF4 are clearly concentrated in the cis-Golgi. While YIPF4 was detected as a single mobility form consistent with its predicted molecular weight, three different mobility forms of YIPF3 were detected by western blotting. Biochemical and immunofluorescence experiments strongly indicated that YIPF3 is synthesized in the ER as a N-glycosylated form (40 kDa), is then O-glycosylated in the Golgi apparatus to become a lower mobility form (46 kDa) and finally becomes a higher mobility form cleaved at its C-terminal luminal domain (36 kDa). YIPF3 and YIPF4 form a complex in the Golgi apparatus, and this was suggested to be important for their proper localization and function. The knockdown of YIPF3 or YIPF4 in HeLa cells induced fragmentation of the Golgi apparatus, suggesting their involvement in the maintenance of the Golgi structure.

Molecular cloning and sequence analysis of two distinct halotolerant extracellular proteases from Bacillus subtilis FP-133.

We cloned the genes encoding the two distinct extracellular halotolerant proteases of Bacillus subtilis FP-133 Expro-I and Expro-II, which were classified as alkaline serine and neutral proteases respectively. Three-dimensional modeling suggested that acidic and polar amino acid residues located on the surface stabilize protein structure in the presence of relatively high NaCl concentrations.

Fe-superoxide dismutase and 2-hydroxy-1,4-benzoquinone reductase preclude the auto-oxidation step in 4-aminophenol metabolism by Burkholderia sp. strain AK-5.

Burkholderia sp. strain AK-5 converts 4-aminophenol to maleylacetic acid via 1,2,4-trihydroxybenzene, which is unstable in vitro and non-enzymatically auto-oxidized to 2-hydroxy-1,4-benzoquinone. Crude extract of strain AK-5 retarded the auto-oxidation and reduced the substrate analogue, 2,6-dimethoxy-1,4-benzoquinone, in the presence of NADH. The two enzymes responsible were purified to homogeneity. The deduced amino acid sequence of the enzyme that inhibited the auto-oxidation showed a high level of identity to sequences of iron-containing superoxide dismutases (Fe-SODs) and contained a conserved metal-ion-binding site; the purified enzyme showed superoxide dismutase activity and contained 1 mol of Fe per mol of enzyme, identifying it as Fe-SOD. Among three type SODs tested, Fe-SOD purified here inhibited the auto-oxidation most efficiently. The other purified enzyme showed a broad substrate specificity toward benzoquinones, including 2-hydroxy-1,4-benzoquinone, converting them to the corresponding 1,4-benzenediols; the enzyme was identified as 2-hydroxy-1,4-benzoquinone reductase. The deduced amino acid sequence did not show a high level of identity to that of benzoquinone reductases from bacteria and fungi that degrade chlorinated phenols or nitrophenols. The indirect role of Fe-SOD in 1,2,4-trihydroxybenzene metabolism is probably to scavenge and detoxify reactive species that promote the auto-oxidation of 1,2,4-trihydroxybenzene in vivo. The direct role of benzoquinone reductase would be to convert the auto-oxidation product back to 1,2,4-trihydroxybenzene. These two enzymes together with 1,2,4-trihydroxybenzene 1,2-dioxygenase convert 1,2,4-trihydroxybenzene to maleylacetic acid.

A papillary fibroelastoma of the aortic valve that presented with repeated chest pain.

A 70-year-old woman without any previous history of heart disease was referred to our hospital for repeated chest discomfort. She had experienced temporary hemiparesis because of a cerebral infarction of unknown etiology. Clinical evaluations were all within normal limits except for echocardiography. There was a mobile tumor in her ascending aorta, about 15 mm in diameter, adhering to a part of the right coronary cusp on its aortic side. Urgent surgery was performed. The tumor was attached to the edge of the right coronary cusp and excised with a part of the right coronary cusp, which was then repaired. Histological examination revealed the tumor to be a papillary fibroelastoma. The chest discomfort responsible for admission disappeared after the operation. In patients with events that may be embolic in nature and are not explained by other cardiovascular or neurological diseases, a cardiac source of emboli should be considered.

Successful surgical treatment of tricuspid valve endocarditis associated with vertebral osteomyelitis.

Right-sided endocarditis is relatively rare and can occasionally be complicated by vertebral osteomyelitis (VO). We describe successful treatment, including valve repair for tricuspid endocarditis associated with VO. A 77-year-old man presented with back pain and high fever. Magnetic resonance imaging demonstrated VO. Despite 2 months of intravenous antibiotics, the infectious signs persisted and both legs became edematous. Enterococcus faecalis was isolated from blood cultures, and echocardiography showed severe tricuspid regurgitation with large vegetations attached to the anterior leaflet (AL). A series of echocardiographic assessments revealed that the antibiotic therapy did not affect the tricuspid lesions. In surgery, the infection was extended to some chordae and over half of the AL was resected. The AL was repaired with autologous pericardium and artificial chordae. Antibiotic therapy was continued for 2 months after surgery, and the infections did not reoccur. Follow-up echocardiography showed mild regurgitation of the tricuspid valve. The patient remains free from endocarditis at 2 years after surgery.

[Efficacy of vacuum-assisted closure therapy for various non-healing wounds after cardiovascular and thoracic surgery].

Vacuum-assisted closure (VAC) therapy is an efficacious modality for treating chronic and difficult wounds. We present 3 cases that responded well to VAC therapy after cardiovascular and thoracic surgery: 1 methicillin-resistant Staphylococcus aureus (MRSA) wound infection after Stony's incision, 1 inguinal lymphorrhea, and 1 empyema after a traffic accident The duration of VAC therapy was 9, 18, and 90 days, respectively, and all 3 wounds healed completely. Familiar equipment and supplies available on the hospital ward were used, and patients were able to leave their beds. In this report, the efficacy of VAC therapy, the problems encountered, and the steps that could be taken to address them are discussed.