Anterior Choroidal Artery Infarction Evaluated with 123I-Imp Single-Photon Emission Computed Tomography and 7 Tesla Magnetic Resonance Imaging.

Anterior choroidal artery (AchA) infarction remains a challenging diagnosis although it was first described almost 100 years prior. N-isopropyl-p-[123I]-iodoamphetamine single-photon emission computed tomography (123I-IMP SPECT) and 7 Tesla magnetic resonance angiography (7T-MRA) are not routinely performed in cases of AchA infarction. Therefore, the application of 123I-IMP SPECT and 7T-MRA for AchA infarction has not been reported previously. A 67-year-old man presented with disturbed consciousness, gaze preference to the left, aphasia, right homonymous hemianopia, and right hemiparesis. Brain magnetic resonance imaging revealed infarction of the left posterior limb of the internal capsule. Left middle cerebral artery was clearly seen on MRA. However, 123I-IMP SPECT on day 13 showed cortical hypoperfusion which indicated thalamus involvement with neural deactivation. Additionally, 7T-MRA on day 15 revealed an intact left AchA suggesting reperfusion. The neurological deficits improved gradually after treatment and rehabilitation. This case demonstrates AchA infarction with cortical hypoperfusion associated with thalamus involvement, which was clarified by performing 123I-IMP SPECT and 7T-MRA. Perfusion analysis and evaluation of detailed vascular anatomy in stroke can be expected to elucidate pathological conditions.

Genetic identification and antimicrobial susceptibility of clinically isolated anaerobic bacteria: A prospective multicenter surveillance study in Japan.

This prospective multicenter surveillance study was designed to provide antimicrobial susceptibility profiles of clinical anaerobic bacteria with genetic species identification in Japan. In 2014, a total of 526 non-duplicate clinical anaerobic isolates were collected from 11 acute-care hospitals in the Kyoto and Shiga regions of Japan. Genetic identification was performed using 16S rRNA sequencing. Minimum inhibitory concentrations were determined in the central laboratory and were interpreted using the CLSI criteria. Genetic analysis provided species-level identification for 496 isolates (83 species in 40 genera) and genus-level identification for 21 isolates (13 genera). Among these 517 isolates, the most frequent anaerobes were Bacteroides spp. (n = 207), Prevotella spp. (n = 43), Clostridium spp. (n = 40), and Peptoniphilus spp. (n = 40). B. fragilis was the most common species (n = 107) and showed 91.6%-97.2% susceptibility to ß-lactam/ß-lactamase inhibitor combinations (BLBLIs; ampicillin-sulbactam, amoxicillin-clavulanate, and piperacillin-tazobactam) and carbapenems (imipenem and meropenem) as well as 100% susceptibility to metronidazole. Gram-negative anaerobes were highly susceptible to metronidazole (99.0%) followed by BLBLIs and carbapenems (>90% each). BLBLIs or carbapenems also retained activity against Gram-positive anaerobes (99.5%-100%) except Clostridioides difficile. All isolates were susceptible to combinations of metronidazole with BLBLIs or carbapenems. Thus, BLBLIs or carbapenems are first choices for empirical therapy of anaerobic infections in Japan, and these antimicrobials in combination with metronidazole should be reserved for very severe infections and targeted therapy.

Genetic, phenotypic and matrix-assisted laser desorption ionization time-of-flight mass spectrometry-based identification of anaerobic bacteria and determination of their antimicrobial susceptibility at a University Hospital in Japan.

The accuracies of matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS) and the phenotypic method using VITEK 2 were compared to the accuracy of 16S rRNA sequence analysis for the identification of 170 clinically isolated anaerobes. The antimicrobial susceptibility of the isolates was also evaluated. Genetic analysis identified 21 Gram-positive species in 14 genera and 29 Gram-negative species in 11 genera. The most frequently isolated genera were Prevotella spp. (n = 46), Bacteroides spp. (n = 25) and Clostridium spp. (n = 25). MALDI-TOF MS correctly identified more isolates compared with VITEK 2 at the species (80 vs. 58%, respectively; p < 0.01) and genus (85 vs. 71%, respectively; p < 0.01) levels. More than 90% of the isolates of the three major genera identified (Prevotella, Bacteroides, and Clostridium species other than Clostridium difficile) were susceptible to beta-lactam/beta-lactamase inhibitor combinations, carbapenems, metronidazole and chloramphenicol. MALDI-TOF MS provided better identification results than VITEK2. Commonly used anti-anaerobic agents indicated that the isolates of the three most frequently identified anaerobic genera exhibited good antimicrobial susceptibility.

[Risk factors and clinical charasteristics of Stenotrophomonas maltophilia bacteremia: a comparison with bacteremia due to other glucose-non fermenters].

Stenotrophomonas maltophilia (SM) is an important nosocomial pathogen. Due to its intrinsic resistance to various therapeutic drugs, the optimal antimicrobial therapy is often delayed. From January 2005 to September 2012, we retrospectively compared drug susceptibilities, clinical backgrounds, and outcome of SM bacteremic patients (SM group) with these of other non fermentative gram negative bacilli bacteremic patients (non-SM group), at a tertiary-care hospital in Kyoto, Japan. Among the SM group, risk factors of 30-day mortality were evaluated. The SM group and non-SM group included 54 and 237 cases, respectively. Among the non-SM group, bacteremic patients due to Pseudomonas aeruginosa, Acinetobacter species, and other non-fermentative gram negative bacilli included 156, 68, and 13 patients, respectively. SM isolates were susceptible to trimethoprim-sulfamethoxazole and minocycline (82.0% and 100%, respectively). Non-SM isolates were susceptible to meropenem (88.6%), ceftazidime (88.6%), cefepime (85.2%), and amikacin (97.0%). Both SM and non-SM isolates were susceptible to levofloxacin (87.5% and 82.0%, respectively). The use of carbapenems, antipseudomonal cephalosporins, and isolation of SM within 30 days represented an independent risk factor for SM bacteremia. The 30 day mortality rate among the SM group was significantly higher compared with the non-SM group (35% vs 18%, odds ratio: 2.2, 95% CI: 1.2-4.3 p = 0.012). Among the SM group, an independent factor which was associated with 30-day mortality was the SOFA score. SM bacteremia showed a worse outcome compared with bacteremia due to non-SM. For the patients who present risk factors for SM bacteremia, empirical antimicrobial therapy including trimethoprim-sulfamethoxazole, minocycline or levofloxacin should be considered.

Pyogenic sacroiliitis caused by Salmonella schwarzengrund in a young healthy woman: a case report and literature review.

BACKGROUND: Salmonella species are a leading cause of diarrheal diseases worldwide. Recent epidemiological studies have shown that Salmonella schwarzengrund (S. schwarzengrund) is highly prevalent in various regions. Herein, we report that S. schwarzengrund caused sacroiliac joint (SIJ) infection with septic shock in a young woman, although she was immunocompetent. CASE PRESENTATION: A 20-year-old woman presented with left hip pain, accompanied by vasopressor-requiring hypotension. Her imaging examinations showed fluid collection in her SIJ and a small abscess in the left iliac muscle. Later, the blood and aspiration fluid culture and genetic analysis revealed the presence of S. schwarzengrund. We diagnosed sacroiliac joint (SIJ) infection with septic shock caused by S. schwarzengrund. Her condition improved after performing several interventional radiology (IVR) procedures for SIJ abscesses and providing appropriate antibiotic treatment. Finally, she was discharged without any sequelae. Screening tests and genetic analysis about her immunodeficiency did not indicate a congenital disorder. CONCLUSION: These clinical courses indicate that S. schwarzengrund could cause the fatal SIJ infection irrespective of the host immunocompetence. Considering the recent increase in the diagnostic rate of S. schwarzengrund, this case emphasized the need to be more cautious about Salmonella species infection.

Successful Resection of Rapidly Growing Cavitary Infarction After Pulmonary Emboli.

Pulmonary cavitation rarely occurs after pulmonary infarction. Compared with bland infarction, infectious cavitary infarction has a higher mortality rate and requires an aggressive surgical approach to improve the outcome. We herein report a cavitary infarction with Pseudomonas infection that rapidly and destructively grew after the development of bilateral pulmonary emboli despite administration of anticoagulation therapy with antibiotics. The pulmonary infarction was successfully resected by right upper lobectomy.

Risk factors and outcomes of Stenotrophomonas maltophilia bacteraemia: a comparison with bacteraemia caused by Pseudomonas aeruginosa and Acinetobacter species.

Stenotrophomonas maltophilia (SM) is an important nosocomial pathogen that exhibits intrinsic resistance to various antimicrobial agents. However, the risk factors for SM bacteraemia have not been sufficiently evaluated. From January 2005 to September 2012, we retrospectively compared the clinical backgrounds and outcomes of SM bacteraemic patients (SM group) with those of bacteraemic patients due to Pseudomonas aeruginosa (PA group) or Acinetobacter species (AC group). DNA genotyping of the SM isolates using the Diversilab system was performed to investigate the genetic relationships among the isolates. The SM, PA, and AC groups included 54, 167, and 69 patients, respectively. Nine of 17 patients in the SM group receiving trimethoprim-sulfamethoxazole prophylaxis developed SM bacteraemia. Independent risk factors for SM bacteraemia were the use of carbapenems and antipseudomonal cephalosporins and SM isolation within 30 days prior to the onset of bacteraemia. Earlier SM isolation was observed in 32 of 48 patients (66.7%) with SM bacteraemia who underwent clinical microbiological examinations. Of these 32 patients, 15 patients (46.9%) had the same focus of bacteraemia as was found in the previous isolation site. The 30-day all-cause mortality rate among the SM group (33.3%) was higher than that of the PA group (21.5%, p = 0.080) and the AC group (17.3%, p = 0.041). The independent factor that was associated with 30-day mortality was the SOFA score. DNA genotyping of SM isolates and epidemiological data suggested that no outbreak had occurred. SM bacteraemia was associated with high mortality and should be considered in patients with recent use of broad-spectrum antibiotics or in patients with recent isolation of the organism.

Differentiation of vanA-positive Enterococcus faecium from vanA-negative E. faecium by matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry.

Vancomycin-resistant enterococci are important nosocomial pathogens that require rapid and accurate detection for infection control. Matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF/MS) has begun to be used in many clinical laboratories because it is a rapid, simple and inexpensive method for identifying micro-organisms. In this study, the performance of MALDI-TOF/MS to differentiate vanA-positive Enterococcus faecium (VPEF) from vanA-negative E. faecium (VNEF) was evaluated. A total of 61 VPEF isolates collected during regional surveillance in Kyoto (Japan) and 71 VNEF isolates collected from bacteraemia patients were analysed using MALDI-TOF/MS with three ClinProTools models. All of the isolates were correctly identified as E. faecium using the MALDI Biotyper system. To discriminate between VPEF and VNEF, all three ClinProTools models yielded >90% recognition capability (basic sensitivity) and cross-validation (reliability of the models); the genetic algorithm model exhibited the highest performance (99.18% and 92.40%, respectively). The high detection performance of MALDI-TOF/MS for VPEF offers the potential for routine laboratory use.

Complete rupture of the anterolateral papillary muscle complicated with acute myocardial infarction due to diagonal branch occlusion.

It is well known that post-infarction papillary muscle rupture of the anterolateral papillary muscle is less frequent than that of the posteromedial papillary muscle. This is thought to be due to a difference in blood supply (single vs dual) of the papillary muscles. Recently, we had two cases in which occlusion of the diagonal branch of the left anterior descending artery was found to be the culprit lesion of acute myocardial infarction leading to complete rupture of the anterolateral papillary muscle. Herein, we report on these two rare successful surgical cases with some review of the literature.

Predictors of success of the modified maze procedure using radiofrequency device.

The modified maze procedure using radiofrequency devices has become an increasingly common surgical option for patients with atrial fibrillation. Several lesion sets have been proposed and tested, but it remains unclear which yields the best results. We studied 61 patients who underwent the modified maze procedure using radiofrequency devices from March 2005. The pulmonary veins were isolated separately on both sides, and a connecting lesion was made inferiorly in the early series of 30 patients (group 1). In 31 patients (group 2) treated from May 2007, we added a superior connecting lesion between both pulmonary veins (completing a box lesion), and also performed coronary sinus ablation from the epicardial side, using a monopolar device. At 6 months postoperatively, maintenance of sinus rhythm with and without antiarrhythmic medications was 70% and 63%, respectively in group 1, and 94% and 90% in group 2 (both p<0.05). Multivariate analysis indicated that the box lesion with coronary sinus ablation was an independent predictor of the maintenance of sinus rhythm at 6 months. These 2 lesions should not be eliminated from the modified maze procedure.

Treatment of prosthetic valve endocarditis complicated by destruction of the aortic annulus.

PURPOSE: It has been reported that surgical treatment for prosthetic valve endocarditis complicated by destruction of the aortic annulus is associated with high mortality and morbidity. The aim of this study was to evaluate the efficacy of our surgical strategy for this situation. METHODS: Between October 2003 and April 2009, eight patients (mean age 68.6 years) with prosthetic valve endocarditis complicated by destruction of the aortic annulus were surgically treated at our hospital. We use a relatively simple procedure consisting of a patch plasty of the abscess cavity in addition to complete removal of the infected tissue of the abscess cavity followed by standard aortic valve replacement. All patients had active endocarditis and were in New York Heart Association functional class III or IV. Preoperative echocardiography revealed that four patients had moderate or severe aortic regurgitation, and two had mitral valve endocarditis as well. RESULTS: There were no operative deaths (≤30 days). Cardiac complications included paroxysmal atrial fibrillation in three patients and transient atrioventricular block in one. One patient died of multiple organ failure 66 days after the surgery. The overall in-hospital mortality was 12.5%. Patients were followed-up for 6-49 months (mean 31 months). There was no recurrent prosthetic valve endocarditis. One patient required reoperation (mitral annuloplasty and redo aortic valve replacement). There were two late deaths: lung cancer in one and multiple organ failure related to pneumonia after the aforementioned redo operation in the other. CONCLUSION: Our simple procedure for complicated prosthetic valve endocarditis yielded excellent early and midterm outcomes.

Two-staged treatment strategy in patients with severe carotid or cerebrovascular diseases undergoing coronary artery bypass grafting.

PURPOSE: There is no clear consensus on how to treat patients undergoing coronary artery bypass grafting (CABG) who have severe concomitant carotidcerebral artery stenosis. The aim of this study was to evaluate our surgical results in patients with severe carotid and/or cerebrovascular disease undergoing CABG. METHODS: Between October 2003 and April 2009, a total of 47 such patients were treated at our institution with the following strategies: (1) protective carotid artery stenting for severe carotid stenosis performed either before (n = 20) or after (n = 5) CABG or (2) a superficial temporal artery-middle cerebral artery anastomosis procedure followed by CABG if indicated (n = 4). Off-pump CABG was performed in 75% of the patients. RESULTS: There were no major perioperative strokes or in-hospital deaths; however, three patients had transient ischemic attacks and two had minor strokes during the early post-CABG period. All of the patients with postoperative cerebrovascular events had had unilateral carotid artery occlusion. There were no late deaths during the follow-up period (up to 6 years, with a mean of 27 months). However, major adverse cardiocerebrovascular events (MACCE) occurred in seven patients (14.9%). The rates of freedom from MACCE at 1 and 3 years were 92% and 74%, respectively. CONCLUSION: It appears that our two-staged approach is safe and may reduce the risk of postoperative cerebrovascular events.