Impact of a surgical safety checklist on surgical site infections, antimicrobial resistance, antimicrobial consumption, costs and mortality.

BACKGROUND: In 2010, following the recommendations of the World Health Organization (WHO), our hospital implemented a surgical safety programme centred around a surgical safety checklist. AIM: The aim of this study was to compare indicators of surgical site infection, antimicrobial consumption, antimicrobial resistance, costs and in-hospital mortality before (January 2006 to July 2010) and after (August 2010 to December 2014) implementation of the programme. METHODS: A case-control study was carried out matching patients with surgical site infection (SSI) to surgical patients without infection to examine the impact of the intervention. FINDINGS: Use of the surgical checklist was associated with a significant reduction in SSI. When comparing the two time periods, we also identified a reduction in infections due to micro-organisms in the ESKAPE group (from 90.7% to 73.9%, P<0.001), a reduction of SSI in patients with contaminated, infected and potentially contaminated wounds, and for those in whom perioperative antimicrobial prophylaxis was discontinued in less than 48 hours. Overall, there was a reduction in antimicrobial resistance, though there was increased resistance to carbapenems for, to glycopeptides for Enterococcus faecium, and to clindamycin for Staphylococcus aureus. We also detected increased antimicrobial consumption of second- and third-generation cephalosporins and clindamycin. We observed a reduction in hospital deaths from 6.4% to 3.2% (P=0.001), but we did not observe any reduction in costs. CONCLUSIONS: Implementation of a surgical checklist was an independent predictor of SSI reduction, and was also associated with a decrease in antimicrobial resistance and reduced in-hospital mortality.

G protein-mediated neuronal DNA fragmentation induced by familial Alzheimer's disease-associated mutants of APP.

Missense mutations in the 695-amino acid form of the amyloid precursor protein (APP695) cosegregate with disease phenotype in families with dominantly inherited Alzheimer's disease. These mutations convert valine at position 642 to isoleucine, phenylalanine, or glycine. Expression of these mutant proteins, but not of normal APP695, was shown to induce nucleosomal DNA fragmentation in neuronal cells. Induction of DNA fragmentation required the cytoplasmic domain of the mutants and appeared to be mediated by heterotrimeric guanosine triphosphate-binding proteins (G proteins).

Differentiation of erythroid progenitor (CFU-E) cells from mouse fetal liver cells and murine erythroleukemia (TSA8) cells without proliferation.

Erythropoietin (epo) appears to play a significant role in influencing the proliferation and differentiation of erythroid progenitor (CFU-E) cells. To determine the mechanism of action of epo, the effect of drugs on the in vitro colony formation of CFU-E cells induced from a novel murine erythroleukemia cell line, TSA8, was examined. While cytosine arabinoside inhibited colony formation and terminal differentiation of the CFU-E cells responding to epo, herbimycin, which is a drug that inhibits src-related phosphorylation, inhibited colony formation only. The same effect of herbimycin was observed with normal CFU-E cells from mouse fetal liver cells. These results suggest that epo induces two signals, one for proliferation and the other for differentiation, and that the two signals are not linked in erythroid progenitor cells.

Stent-supported angioplasty of a residual coronary artery dissection following replacement of the ascending aorta for acute type A aortic dissection. A report of a successful case.

A 54-year-old-man suddenly experienced severe back pain while eating. On admission to our hospital, contrast-enhanced computed tomography revealed an acute type A aortic dissection, and emergency surgical repair was performed the same day. Through median sternotomy, graft replacement of the ascending aorta, including removal of the site of the intimal tear, was carried out under deep hypothermia and retrograde cerebral perfusion. Although the postoperative course was satisfactory, the patient suddenly complained of sever chest pain on postoperative day 23; the ECG trace showed anomalous alterations. Emergency coronary angiography revealed the presence of a wide coronary artery dissection from the entry of the left anterior descending aorta (LAD) to the re-entry of the left circumflex artery (LCX). Multiple stents were implanted in the LAD and LCX. After stenting, the chest symptoms remitted and the ECG trace was normal. The patient was discharged from our hospital on postoperative day 42.

Characterization and expression of human HepG2/erythrocyte glucose-transporter gene.

The human HepG2/erythrocyte glucose-transporter gene, including the promoter region, has been isolated and characterized. The gene, which is approximately 35,000 base pairs, is interrupted by nine intervening sequences or introns. The sequence of the HepG2 glucose-transporter protein predicted from the gene sequence differs from that determined from the published cDNA sequence in having Leu rather than Phe at position 152. In addition, there are several other nucleotide differences between the gene and cDNA sequences in both the coding region and 3'-untranslated region that do not alter the amino acid sequence of the protein. The sequence of the promoter and the site of transcription initiation have also been determined. The promoter region includes a TATA motif and two binding sites for the transcription factor Spl as well as a sequence that is found in the promoter region of several phorbol ester-inducible genes.

Expression of GLUT1 and GLUT2 glucose transporter isoforms in rat islets of Langerhans and their regulation by glucose.

Previous studies revealed that rat islets express the GLUT2-liver facilitative glucose transporter isoform, a glucose carrier with a low affinity for glucose but a high capacity for glucose transport. These studies indicated the presence of a second glucose transporter in rat islets; however, they did not indicate to which of the five known facilitative glucose transporters it corresponded. In this study, we isolated RNA from rat islets of Langerhans and confirmed the presence of GLUT2 mRNA. In addition, we present data indicating that the second isoform expressed in islets is the GLUT1-erythrocyte isoform. The effect of culturing islets in 5.5, 8.3, or 11.1 mM glucose on the levels of GLUT1 and GLUT2 mRNA also was examined. The levels of GLUT1 and GLUT2 mRNA were two- and threefold higher, respectively, in islets cultured for 24 h in 11.1 mM glucose compared with those incubated in the presence of 5.5 mM glucose. Therefore, the previously observed increase in GLUT2 mRNA levels in the islets of rats made hyperglycemic by chronic infusion of glucose can be mimicked in vitro, implying that glucose regulates GLUT2 mRNA expression.

In vitro synergistic interactions between the cisplatin analogue nedaplatin and the DNA topoisomerase I inhibitor irinotecan and the mechanism of this interaction.

Among the numerous clinical regimens used in combination chemotherapy, synergy is particularly marked in combinations containing cisplatin (CDDP). However, the clinical use of CDDP is sometimes limited due to its nephrotoxicity. Nedaplatin (NDP) is a second-generation platinum complex with reduced nephrotoxicity that may substitute for CDDP or even surpass it for use in combination with other drugs. We investigated the effects of combinations of NDP and other anticancer drugs on the growth of human small cell lung cancer cells (SBC-3) and non-small cell lung cancer cells (PC-14) using a three-dimensional analysis model. Among the combinations tested, the combination of NDP and irinotecan (CPT-11) showed the most marked synergistic interaction, and the synergism has also been observed against PC-14 cells. With regard to treatment schedule, a remarkable synergistic interaction was produced by concurrent exposure to NDP and CPT-11. On the other hand, sequential exposure to the two drugs led only to additivity. To analyze the interaction between the drugs, the effect of NDP on the 7-ethyl-1-hydroxy-CPT (the active form of CPT-11)-induced inhibitory effect on DNA topoisomerase I was examined. The topoisomerase I-inhibitory effect of 7-ethyl-1-hydroxy-CPT was enhanced 10-fold in the presence of NDP at microgram/milliliter concentrations. These biochemical interactions might be responsible for the synergistic interaction between NDP and CPT-11. These results suggest that the combination of NDP with CPT-11 may be clinically useful for the chemotherapy of lung cancer.

Molecular biology of mammalian glucose transporters.

The oxidation of glucose represents a major source of metabolic energy for mammalian cells. However, because the plasma membrane is impermeable to polar molecules such as glucose, the cellular uptake of this important nutrient is accomplished by membrane-associated carrier proteins that bind and transfer it across the lipid bilayer. Two classes of glucose carriers have been described in mammalian cells: the Na(+)-glucose cotransporter and the facilitative glucose transporter. The Na(+)-glucose cotransporter transports glucose against its concentration gradient by coupling its uptake with the uptake of Na+ that is being transported down its concentration gradient. Facilitative glucose carriers accelerate the transport of glucose down its concentration gradient by facilitative diffusion, a form of passive transport. cDNAs have been isolated from human tissues encoding a Na(+)-glucose-cotransporter protein and five functional facilitative glucose-transporter isoforms. The Na(+)-glucose cotransporter is expressed by absorptive epithelial cells of the small intestine and is involved in the dietary uptake of glucose. The same or a related protein may be responsible for the reabsorption of glucose by the kidney. Facilitative glucose carriers are expressed by most if not all cells. The facilitative glucose-transporter isoforms have distinct tissue distributions and biochemical properties and contribute to the precise disposal of glucose under varying physiological conditions. The GLUT1 (erythrocyte) and GLUT3 (brain) facilitative glucose-transporter isoforms may be responsible for basal or constitutive glucose uptake. The GLUT2 (liver) isoform mediates the bidirectional transport of glucose by the hepatocyte and is responsible, at least in part, for the movement of glucose out of absorptive epithelial cells into the circulation in the small intestine and kidney. This isoform may also comprise part of the glucose-sensing mechanism of the insulin-producing beta-cell. The subcellular localization of the GLUT4 (muscle/fat) isoform changes in response to insulin, and this isoform is responsible for most of the insulin-stimulated uptake of glucose that occurs in muscle and adipose tissue. The GLUT5 (small intestine) facilitative glucose-transporter isoform is expressed at highest levels in the small intestine and may be involved in the transcellular transport of glucose by absorptive epithelial cells. The exon-intron organizations of the human GLUT1, GLUT2, and GLUT4 genes have been determined. In addition, the chromosomal locations of the genes encoding the Na(+)-dependent and facilitative glucose carriers have been determined. Restriction-fragment-length polymorphisms have also been identified at several of these loci.(ABSTRACT TRUNCATED AT 400 WORDS)

Short term effects of glucose and arginine on the preproinsulin messenger ribonucleic acid level in the perfused rat pancreas: comparison with insulin secretion.

To investigate the role of glucose and arginine in short term regulation of preproinsulin mRNA (ppImRNA) levels, the rat pancreas was perfused in the presence of glucose and/or arginine, and changes in ppImRNA levels in the pancreas were compared with the amount of insulin released during the perfusion. Perfusion of the pancreas with high glucose and arginine induced a significant increase in ppImRNA levels within 2 h, whereas perfusion with low glucose and arginine or high glucose alone had no significant effect during this period. The insulin release induced by perfusion of high glucose combined with arginine was 2 times greater than that induced by high glucose alone or low glucose with arginine. In conclusion, insulin gene transcription can be evoked during a short period in response to an extremely large secretory demand for insulin.

Sequence of an intestinal cDNA encoding human motilin precursor.

A cDNA clone encoding the human motilin precursor was isolated from an intestinal library using synthetic oligonucleotide probes. The predicted amino acid sequence indicates that the motilin precursor consists of 115 amino acids and includes a 25-residue N-terminal signal peptide followed by the 22-amino-acid motilin sequence and a long, 68-residue C-terminal peptide. The amino acid sequence of human motilin predicted from the cDNA sequence is identical to its porcine counterpart, which has been determined by protein sequencing. Proteolytic processing of promotilin to motilin occurs at the sequence, Lys-Lys, this being the first reported instance of processing occurring at a pair of Lys residues. In other precursors it occurs at Lys-Arg, Arg-Arg, Arg, or very rarely Lys.

Phorbol ester and okadaic acid-resistant cells: the crossroads of signal transduction and drug resistance.

Many factors are involved in the development of drug resistance for anticancer drugs. The drugs should pharmacokinetically attain the appropriate concentration. They should be metabolized to the active forms. Tumor cells should have sensitivity to them. Several molecular and biochemical mechanisms that may explain cellular drug resistance have been identified. The contribution of protein phosphorylation and dephosphorylation for drug resistance is demonstrated in phorbol ester and okadaic-acid-resistant cells. The modulation of drug resistance by substances that affect the signal transduction pathway is an important issue in the development of an effective method for overcoming drug resistance.

Pancreatobiliary and biliary control of fecal beta-glucuronidase activity in the rat.

Bile duct ligation experiments suggest that bile is an important regulator of intestinal beta-glucuronidase, an enzyme thought to be involved in colon carcinogenesis. Exclusion of pancreatobiliary secretions from the rat intestine significantly decreases glucuronidase activity (Roberton et al., Cancer Res., 42 (1982) 5165-5166). However, the separate roles of pancreatic and biliary secretions have not been examined. We ligated the bile ducts of rats at the hepatic duct, allowing pancreatic juice but not bile to enter the intestine, or at the Sphincter of Oddi, excluding pancreatic juice as well as bile. Fecal beta-glucuronidase activity was lowered in both cases, indicating that bile itself, and not pancreatic juice, is a major factor modulating beta-glucuronidase activity.

Mitogen-activated protein kinase antisense oligonucleotide inhibits the growth of human lung cancer cells.

Mitogen-activated protein kinase (MAPK) pathway is proposed to be a therapeutic target for cancer cells. In order to find the potential therapeutic usefulness of MAPK for cancer cells, the effect of EAS1, an antisense oligonucleotide for an MAPK, on cancer-cell-growth were investigated in vitro. EAS1 effectively inhibited the growth of several human lung cancer cell lines such as PC-14 cells upon exposure to 10-0-10-1 microM of EAS1 determined dye-formation (MTT) assay. The ED50 values were comparable to those obtained for the inhibition of MAPK activity, DNA synthesis. EAS1 arrested the PC-14 cells at the G2/M phase of cell cycle followed by apoptosis in a dose-dependent manner. In order to determine the factors which influence the cellular sensitivity against MAPK inhibition, the effect of EAS1 on H-ras-transformed murine fibroblast cells were compared with that on parental cells. The NIH3T3 cells transformed by the H-ras gene (PT22-3) showed higher sensitivity against the effects of EAS1. Because MAPK activity was activated by H-ras gene transfection in PT22-3, the status of the MAPK cascade in cells was the determining factor for the efficacy of EAS1. In addition, cell permeabilization by digitonin enhanced the growth inhibitory effect of EAS1. Penetration of the cell membrane by EAS1 is also crucial for the growth inhibitory effect of EAS1. In conclusion, MAPK is an important target for cancer treatment and MAPK antisense oligonucleotide is a potentially significant antitumor oligonucleotide.

Internal mammary artery grafting in patients with smaller body structure.

The results of internal mammary artery grafting in 50 patients with a body surface area less than 1.6 m2 were compared with those in 54 patients with a larger body surface area. Age (58.8 +/- 8.2 versus 54.9 +/- 10.3 years old) and prevalence of female gender (28% versus 4%) were significantly different between the group of patients with a small body surface area and the group with a large body surface area, respectively. However, the prevalence of unstable angina, previous myocardial infarction, extent of coronary artery disease, and preoperative ejection fraction was not significantly different between the two groups. The mean number of distal anastomoses was 3.0 and 2.8, and the mean duration of aortic occlusion was 65.6 +/- 23.0 minutes and 59.5 +/- 21.7 minutes in the small and large body surface area groups, respectively (not significant). The mean free flow rate of the internal mammary artery was 65.6 +/- 16.8 ml/min in the small body surface area group and 78.0 +/- 21.6 ml/min in the large body surface area group (p less than 0.05). The diameters of the anterior descending and the circumflex arteries were significantly smaller in the small body surface area group. Two patients (4%) died within 30 days of operation and one patient died later in the small body surface area group, whereas no death was noted in the large body surface area group (not significant). No significant differences were found in the incidence of aortic balloon pumping, perioperative myocardial infarction, and serious postoperative complications between the two groups. Symptomatic relief was equally good in both groups (92% and 96%). The patency rate of the internal mammary artery was 95% (42/44) in the small body surface area group and 100% (48/48) in the large body surface area group within 1 year, mean 2.3 +/- 2.4 months. In conclusion, internal mammary artery grafting can be performed safely and effectively even in patients with small body structure. Though the blood flow of the internal mammary artery and the size of the coronary arteries were smaller in patients with small body structure, excellent patency of the internal mammary artery graft and satisfactory symptomatic relief can be expected.

Mechanism of the radiosensitization induced by vinorelbine in human non-small cell lung cancer cells.

Vinorelbine (Navelbine, KW-2307), a semisynthetic vinca alkaloid, is a potent inhibitor of mitotic microtubule polymerization. The aims of this study were to demonstrate radiosensitization produced by vinorelbine in human non-small cell lung cancer (NSCLC) PC-9 cells and to elucidate the cellular mechanism of radiosensitization. A clonogenic assay demonstrated that PC-9 cells were sensitized to radiation by vinorelbine with a maximal sensitizer enhancement ratio at a 10% cell survival level of 1.35 after 24-h exposure to vinorelbine at 20 nM. After 24-h exposure to vinorelbine at 20 nM, the approximately 67% of the cells that had accumulated in the G2/M-phase were cultured in the absence of vinorelbine and then irradiated at a dose of 8 Gy. Flow cytometric analyses showed prolonged G2/M accumulation concomitant with continuous polyploidization, and induction of apoptosis was observed in the cells subjected to the combination of vinorelbine-pretreatment and radiation. Polyploidization and induction of apoptosis were confirmed by morphological examination and a DNA fragmentation assay, respectively. We concluded that vinorelbine at a minimally toxic concentration moderately sensitizes human NSCLC cells to radiation by causing accumulation of cells in the G2/M-phase of the cell cycle. Prolonged G2/M accumulation concomitant with continuous polyploidization and increased susceptibility to induction of apoptosis may be associated with the cellular mechanism of radiosensitization produced by vinorelbine.

Characteristic features of insulin secretion in the streptozotocin-induced NIDDM rat model.

Male Wistar neonatal rats at age 1.5 days (Streptozotocin [STZ] group 1) and 5 days (STZ group 2) received a subcutaneous injection of 90 mg/kg STZ. After 10 weeks, the rats were subjected to an oral glucose tolerance test (OGTT) (2 g/kg) in a conscious state. The pancreas perfusion experiments were conducted 2 weeks after the OGTT. There was no statistical difference in insulin response between the STZ group 1 and the control group. On the contrary, in the STZ group 2, the plasma glucose response to OGTT showed a typical diabetic pattern, and the plasma insulin response was markedly blunted. In the isolated perfused rat pancreas, the infusion of glucose evoked a biphasic insulin secretion, but the peak insulin levels induced by 16.7 mmol/L glucose in the STZ group 1 were significantly lower than in the controls. We further investigated characteristics of insulin secretion in response to different secretagogues in these animal models using isolated islets. The insulin content of the islets of the STZ group 1 were about one half that of the control group. Insulin secretion in the STZ group 1 was impaired in response to glucose stimulation, but remained normal in response to arginine and forskolin. These results suggest that insulin secretion of non-insulin-dependent diabetes mellitus (NIDDM) rat model is selectively impaired in response to glucose stimulation, possibly due to a disorder of signaling mechanism other than adenylate cyclase.

Comparative effect of somatostatin-14 and somatostatin-28 on glucagon-induced glycogenolysis from the perfused rat liver.

The effect of somatostatin (SS)-14 and SS-28 on glycogenolysis was studied, using a rat liver perfusion technique. Livers from nonfasted rats were perfused with 5.5 mmol/L glucose or perfusate without the glucose addition. Glucagon-induced glucose output was lower in the presence of 5.5 mmol/L glucose than in glucose free perfusate at every concentration of glucagon. Under glucose free conditions, SS-14 given at five minutes prior to the glucagon addition reduced the glucagon-induced glucose output dose-dependently. SS-14 given 15 minutes after glucagon addition also inhibited glucagon-induced glucose output significantly. However, various concentrations of SS-28 failed to affect glucose output. On the other hand, in the presence of 5.5 mmol/L glucose, neither SS-14 nor SS-28 affected glucagon-induced glucose output. It is suggested, therefore, that glycogenolysis induced by glucagon from the liver is reduced by SS-14, but not by SS-28, only under glucose free conditions.

Primary cultures of neuronal and non-neuronal rat brain cells secrete similar proportions of amyloid beta peptides ending at A beta40 and A beta42.

To determine the types of brain cells responsible for the production of amyloid beta peptides (A beta), as well as their carboxyl-terminal properties, we studied the secretion of A beta in rat neuronal, astrocytic, microglial and meningeal primary cell cultures. All four types of cells produced A beta, among which neurons secreted approximately 4 times more A beta than other cell types. The percentage of A beta42 ending at position 42 as a fraction of total A beta was similar between different cell types, ranging from 10 to 15%. These results suggest that neurons might be the most potent source for A beta production in the brain, although other non-neuronal type cells could also contribute to this process.

Skin test study of Bancroftian filariasis in Kuroshima Island, Okinawa: a 13-year longitudinal study during a control campaign.

A longitudinal study was performed in an island, endemic for Bancroftian filariasis, by blood survey and skin test from the beginning of a filariasis control campaign in 1967 through 1980. The initial microfilarial rate of 13.2% was successfully reduced to almost 0 by 1970, by the selective administration of diethylcarbamazine to microfilaria positives. The age distribution of skin-test positivity changed year by year, especially in the younger age groups. A marked reduction was seen in the positive rate in the 0- to 9- and 10- to 19-year-old age groups. The change of skin reactivity for all islanders was evaluated, and revealed a gradual decrease in the wheal-size over the observation period.

Coronary artery bypass grafting by utilizing in situ right gastroepiploic artery: basic study and clinical application.

The right gastroepiploic artery (GEA) was studied angiographically and histologically to determine its suitability for coronary artery bypass grafting. One hundred celiac angiograms demonstrated that the right GEA has the appropriate size (diameter less than 1.5 mm, 4%; 1.5 to 2 mm, 29%; more than 2 mm, 67%) and length (less than half of the greater curvature, 5%; more than half of the greater curvature, 95%; more than two-thirds of the greater curvature, 34%) for use as an in situ graft. A stenotic lesion of a GEA was observed in only 1 angiogram. Histological examination of a right GEA from 5 patients who had undergone gastrectomy demonstrated no evidence of arteriosclerosis. Encouraged by these results, we performed a coronary artery bypass reoperation utilizing an in situ right GEA graft in 2 women. Postoperative angiograms showed good patency of those grafts. The patients recovered well and were free from angina.