Outbreak among healthy newborns due to a new variant of USA300-related meticillin-resistant Staphylococcus aureus.

BACKGROUND: The prevalence of community-associated meticillin-resistant Staphylococcus aureus (CA-MRSA) is increasing throughout the world and is an important cause of skin and soft tissue infection (SSTI) in children and neonates. AIM: To describe the successful control of an outbreak caused by a new strain of CA-MRSA in a newborn nursery. METHODS: The investigation of the outbreak in July 2012 is reported with the control measures taken. Molecular typing of the MRSA isolates was performed. FINDINGS: An outbreak of SSTI caused by CA-MRSA occurred in a newborn nursery. Six neonates were infected in a one-month period [infection rate: 8.5% (6/71)]. A new variant of CA-MRSA was responsible, which was characterized as USA300-related, Panton-Valentine Leucocidin (PVL) positive, arginine catabolic mobile element (ACME) negative, sequence type 8 (ST8), staphylococcal cassette chromosome mec (SCCmec) type IVa, agr type I and spa type t008. The outbreak among term neonates followed a rapid transmission pattern and was successfully controlled by implementing various outbreak control measures, including universal chlorhexidine bathing. CONCLUSION: This is the first report of a hospital outbreak caused by a USA300-related CA-MRSA clone in Korea. Early recognition and reinforcement of infection control measures are important in decreasing transmission of CA-MRSA in a hospital setting.

Effects of propofol on the expression of matric metalloproteinases in rat cardiac fibroblasts after hypoxia and reoxygenation.

BACKGROUND: Propofol is known to protect the myocardium against ischaemia/reperfusion (I/R) injury through its antioxidant and anti-inflammatory properties. Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) are involved in cell migration and invasion, and mediate tissue remodelling during I/R injury. They are regulated by various mechanisms including oxidative stress and AKT and ERK pathways. We investigated whether propofol affected the expression of MMPs and subsequent cell migration and invasion and the signalling pathways involved in primary rat cardiac fibroblasts undergoing hypoxia and reoxygenation. METHODS: The phosphorylation of ERK and AKT signalling pathways was examined by western blot analysis in rat primary cardiac fibroblasts after hypoxia and reoxygenation. mRNA expression of MMP and TIMPS was analysed by real-time PCR, and proteolytic activities of MMP-2 and -9 were assessed. The effects of propofol on migration, invasion, wound healing, and cell proliferation activity were evaluated after reoxygenation. RESULTS: Propofol induced AKT and ERK1/2 activation. Subsequent activation of MMPs resulted in increased cell migration, invasion, and wound-healing activity under hypoxia-reoxygenation, which was decreased by LY294002 (AKT inhibitor) and U0126 (ERK inhibitor) in rat cardiac fibroblasts. However, propofol had no effect on proliferation or viability of cardiac fibroblasts after hypoxia-reoxygenation. CONCLUSIONS: Propofol affected the expression of MMPs and TIMPs and subsequently induced cell migration and invasive ability, through activation of the ERK and AKT signalling pathway in hypoxia-reoxygenated rat cardiac fibroblasts.

New technologies for reproductive medicine: laparoscopy, endoscopy, robotic surgery and gynecology. A review of the literature.

Computer-enhanced telesurgery, called robotic-assisted surgery, is the latest innovation in the minimal invasive surgery field. In gynecology, this machine has been applied in several applications, in the fields of benign gynecology, reproductive medicine, urogynecology, and oncology. The purpose of this paper was to review the published scientific literature regarding robotics and its application to gynecology thus far and summarize findings of this computer enhanced laparoscopic technique. Relevant sources were identified by a Pubmed/Medline search looking at databases from January 1950 to July 2009. A total of 29 papers in benign gynecology were identified, and a total of 44 articles were analyzed involving gynecologic oncology. The estimated blood loss, number of lymph nodes extracted, operating time, length of hospital stay and complications were noted among all the studies. The data shows comparable results between robotic and laparoscopic surgery in terms of estimated blood loss, operative time, length of hospital stay, and complications for gynecologic cancer. Overall, there were more wound complications in the laparotomy approach compared to laparoscopy and robotic assisted laparoscopy. There were more lymphocysts, lymphoceles, and lymphedema in the robotic assisted laparoscopic group compared to the laparoscopy and laparotomy groups in cervical cancer patients. Infectious and lung-related morbidity, postoperative ileus, and bleeding/clot formation was more commonly reported in the laparotomy group compared the other two cohorts in endometrial cancer patients. Computer enhanced technology may enable more surgeons to convert their laparotomies to laparoscopic surgery with its associated benefits. It appears that in the hands of experienced laparoscopic surgeons, final outcomes are the same when using or not using the robot. There is good evidence that robotic surgery facilitates laparoscopic surgery, with equivalent if not better operative time and comparable surgical outcomes, shorter hospital stays, and fewer major complications than those surgeries utilizing the laparotomy approach.

Titrated propofol induction vs. continuous infusion in children undergoing magnetic resonance imaging.

BACKGROUND: Propofol is the popular intravenous (i.v.) anaesthetic for paediatric sedation because of its rapid onset and recovery. We compared the efficacy and safety of a single dose and conventional infusion of propofol for sedation in children who underwent magnetic resonance imaging (MRI). METHODS: This was a double-blind, randomized-controlled study. One hundred and sixty children were assigned to group I (single dose) or II (infusion). Sedation was induced with i.v. propofol 2 mg/kg, and supplemental doses of propofol 0.5 mg/kg were administered until adequate sedation was achieved. After the induction of sedation, we treated patients with a continuous infusion of normal saline at a rate of 0.3 ml/kg/h in group I and the same volume of propofol in group II. In case of inadequate sedation, additional propofol 0.5 mg/kg was administered and the infusion rate was increased by 0.05 ml/kg/h. Induction time, sedation time, recovery time, additional sedation and adverse events were recorded. RESULTS: Recovery time was significantly shorter in group I compared with group II [0 (0-3) vs. 1 (0-3), respectively, P<0.001]. Group I (single dose) had significantly more patients with recovery time 0 compared with group II (infusion) (65/80 vs. 36/80, respectively, P<0.001). Induction and sedation times were not significantly different between groups. There was no significant difference in the frequency of additional sedation and adverse events between groups. CONCLUSION: A single dose of propofol without a continuous infusion can provide appropriate sedation in children undergoing MRI for <30 min.

Remifentanil protects myocardium through activation of anti-apoptotic pathways of survival in ischemia-reperfused rat heart.

Remifentanil is a commonly used opioid in anesthesia with cardioprotective effect in ischemia-reperfused (I/R) heart. We evaluated the influence of remifentanil on myocardial infarct size and expressions of proteins involved in apoptosis in I/R rat heart following various time protocols of remifentanil administration. Artificially ventilated anesthetized Sprague-Dawley rats were subjected to a 30 min of left anterior descending coronary artery occlusion followed by 2 h of reperfusion. Rats were randomly assigned to one of five groups; Sham, I/R only, remifentanil preconditioning, postconditioning and continuous infusion group. Myocardial infarct size, the phosphorylation of ERK1/2, Bcl2, Bax and cytochrome c and the expression of genes influencing Ca2+ homeostasis were assessed. In remifentanil-administered rat hearts, regardless of the timing and duration of administration, infarct size was consistently reduced compared to I/R only rats. Remifentanil improved expression of ERK1/2 and anti-apoptotic protein Bcl2, and expression of sarcoplasmic reticulum genes which were significantly reduced in the I/R rats only. Remifentanil reduced expression of pro-apoptotic protein, Bax and cytochrome c. These suggested that remifentanil produced cardioprotective effect by preserving the expression of proteins involved in anti-apoptotic pathways, and the expression of sarcoplasmic reticulum genes in I/R rat heart, regardless of the timing of administration.

Comparison of intrathecal fentanyl and sufentanil in low-dose dilute bupivacaine spinal anaesthesia for transurethral prostatectomy.

BACKGROUND: The administration of low-dose bupivacaine can limit the distribution of spinal block to reduce adverse haemodynamic effects. Intrathecal opioids can enhance analgesia in combination with subtherapeutic doses of local anaesthetics. We aimed at comparing the efficacy of intrathecal fentanyl and sufentanil with low-dose diluted bupivacaine for transurethral prostatectomy (TURP) in elderly patients. METHODS: Seventy patients undergoing TURP were randomly allocated into two groups. Group F (n=35) received fentanyl 25 microg+bupivacaine 0.5% (0.8 ml)+normal saline 0.3 ml and Group S (n=35) received sufentanil 5 microg+bupivacaine 0.5% (0.8 ml)+normal saline 0.7 ml--in total, bupivacaine 0.25% (1.6 ml) intrathecally. Onset and duration of the sensory block, the degree of the motor block, side-effects, and the perioperative analgesic requirements were assessed. RESULTS: The median peak level of the sensory block was significantly higher in Group S than in Group F (P=0.049). Group S required fewer perioperative analgesics than Group F (P=0.008). The time to the first analgesic request was longer in Group S (P=0.025). There were no differences between the groups for the onset and recovery time of the sensory block, degree of the motor block, quality of anaesthesia, or adverse effects. CONCLUSIONS: Low-dose diluted bupivacaine with fentanyl 25 microg or sufentanil 5 microg can provide adequate anaesthesia without haemodynamic instability for TURP in elderly patients. However, sufentanil was superior to fentanyl in the quality of the spinal block produced.

The addition of fentanyl to 1.5 mg/ml ropivacaine has no advantage for paediatric epidural analgesia.

BACKGROUND: Epidural opioids are frequently combined with local anaesthetics for an additive antinociceptive effect. We investigated the efficacy of epidural fentanyl to 1.25 or 1.5 mg/ml ropivacaine for post-operative epidural analgesia in children. METHODS: One hundred and eight children undergoing hypospadias repair were randomized to receive 1.25 mg/ml ropivacaine (R1.25 group), 1.25 mg/ml ropivacaine with 0.2 mcg/kg/h of fentanyl (R1.25F group), 1.5 mg/ml ropivacaine (R1.5 group) or 1.5 mg/ml ropivacaine with 0.2 mcg/kg/h of fentanyl (R1.5F group) for post-operative epidural analgesia. The epidural catheter was threaded caudally through the L4-5 interspace. The face, legs, activity, cry, consolability (FLACC) score was assessed at every hour and at FLACC score >4, an epidural bolus of 0.5 ml/kg of ropivacaine 1.5 mg/ml was given as the rescue analgesia. The incidence of side effects such as hypoxia, sedation, pruritus, nausea and/or vomiting was recorded. RESULTS: The need for rescue analgesia was higher in the R1.25 group compared with that in the other three groups (all P<0.05). The incidence of side effects was higher in the R1.5F group compared with that in the R1.25 and R1.5 groups (both P=0.010). CONCLUSION: The addition of 0.2 mcg/kg/h fentanyl to 1.5 mg/ml ropivacaine increased the incidence of side effects without improvement of analgesia in infants and children undergoing hypospadias repair. The use of plain 1.25 mg/ml ropivacaine increased the need for rescue analgesia and this could be compensated by addition of fentanyl.

Effect of low-dose ketamine on inflammatory response in off-pump coronary artery bypass graft surgery.

BACKGROUND: Off-pump coronary artery bypass graft surgery (OPCAB) is still associated with a marked systemic inflammatory response. The aim of this study was to investigate whether pre-emptive, low dose of ketamine, which has been reported to have anti-inflammatory activity in on-pump coronary artery bypass surgery, could reduce inflammatory response in low-risk patients undergoing OPCAB. METHODS: In this prospective randomized-controlled trial, 50 patients with stable angina and preserved myocardial function undergoing OPCAB were randomly assigned to receive either 0.5 mg kg(-1) of ketamine (Ketamine group, n=25) or normal saline (Control group, n=25) during induction of anaesthesia. Inflammatory markers including C-reactive protein (CRP), interleukin (IL)-6, tumour necrosis factor-alpha (TNF-alpha), and cardiac enzymes were measured previous to induction (T1), 4 h after surgery (T2), and the first and second days after the surgery (T3 and T4). RESULTS: There were no significant intergroup differences in the serum concentrations of the CRP, IL-6, and TNF-alpha and cardiac enzymes. Pro-inflammatory markers and cardiac enzymes, except TNF-alpha, were all increased after the surgery compared with baseline values in both groups. CONCLUSIONS: Low-dose ketamine administered during anaesthesia induction did not exert any evident anti-inflammatory effect in terms of reducing the serum concentrations of pro-inflammatory markers in low-risk patients undergoing OPCAB.

Epidural sufentanil provides better analgesia from 24 h after surgery compared with epidural fentanyl in children.

BACKGROUND: Studies comparing epidural fentanyl and sufentanil in adults reported a similar analgesic effect with variable side effects. We hypothesized that epidural fentanyl and sufentanil will have a similar analgesic effect in children undergoing urological surgery. METHODS: Sixty-four children undergoing urological surgery were randomized into two groups: fentanyl in ropivacaine (fentanyl group, n=32) and sufentanil in ropivacaine (sufentanil group, n=32). After anaesthesia, an epidural catheter was inserted at the L2-3, L3-4 or L4-5 interspace. For post-operative pain relief, a solution consisting of fentanyl 0.1 mcg/kg/ml or sufentanil 0.015 mcg/kg/ml in 1.5 mg/ml ropivacaine was infused at a rate of 2 ml/h. To assess post-operative pain, the faces pain scale and the face, legs, activity, cry, consolability score were recorded at 1, 6, 24, 48 and 72 h after surgery. The incidence of adverse effects such as hypoxia, sedation, pruritus, nausea and/or vomiting was also evaluated. RESULTS: Pain scores demonstrated no significant difference between the groups. The need for rescue analgesia during 24-72 h was higher in the fentanyl group than in the sufentanil group (6/32 vs. 0/32, P=0.012). The incidence of pruritus was higher in the sufentanil group compared with that in the fentanyl group (5/32 vs. 0/32). CONCLUSIONS: Epidural sufentanil provides better analgesia from 24 h after surgery compared with epidural fentanyl in infants and children undergoing urological surgery. The incidence of pruritus in the sufentanil group was higher than that in the fentanyl group.

Caudal midazolam does not affect sevoflurane requirements and recovery in pediatric day-case hernioplasty.

BACKGROUND: This prospective, randomized, double-blind study aimed to determine whether caudal midazolam combined with ropivacaine affects anesthetic requirements, recovery profiles, and post-operative analgesia compared with ropivacaine alone in pediatric day-case hernioplasty. METHODS: Sixty boys (2-5 years old) received caudal injections of 0.2% ropivacaine 1 ml/kg and epinephrine 1 : 200,000 with (RM group) or without (R group) 50 microg/kg of midazolam under sevoflurane anesthesia. The sevoflurane requirement was determined by adjusting to a bispectral index score=50. RESULTS: Concentrations of end-tidal sevoflurane (ETsevo%) after induction were similar in both groups. After caudal block, ETsevo% before and after surgical stimuli did not show significant intra- or intergroup differences. Recovery characteristics, including post-operative sedations, were similar in both groups. Post-operative pain scores were significantly lower in the RM group than the R group. CONCLUSIONS: Caudal midazolam (50 microg/kg) added to 2% ropivacaine did not influence sevoflurane requirement or recovery but improved post-operative analgesia compared with ropivacaine alone in pediatric day-case hernioplasty.

Determination of the optimal angle for needle insertion during caudal block in children using ultrasound imaging.

Using ultrasound imaging, the optimal angle for needle insertion during caudal epidural injection in children was estimated. After general anaesthesia, ultrasonography was performed at the sacral hiatus in 130 children aged 2-84 months positioned in the lateral position. The median [range] values for the intercornual, caudal space depth and the distance from skin to the posterior sacral bony surface were 17.0 [9.6-24] mm, 3.5 [1-8] mm and 21.0 [10-39] mm, respectively. The optimal angle showed no significant correlation with age, weight, height or body surface area. The median [range] calculated optimal angle for the needle was 21.0 [10-38] degrees. We conclude that the needle should be inserted at about 20 degrees to the skin to avoid puncture of the bone and potential intra-osseous injection.

The time course of biological and immunochemical allergy states induced by anisakis simplex larvae in rats.

Oral infection by Anisakis simplex third stage larvae (L3) frequently gives rise to an allergic response. To comprehend the allergic and immune responses induced by L3, we investigated the kinetics of specific antibody isotype expression and the time course of biological and immunochemical allergy states using sera prepared from rats orally infected with L3 twice, with an interval of 9 weeks between infections. Biological and immunochemical allergy states were analysed by RBL-2H3 exocytosis and by indirect ELISA for IgE, respectively. The peak IgM at reinfection (RI) was comparable or similar to that at primary infection (PI) both in levels analysed by indirect ELISA and in antigen recognition analysed by Western blot. IgG1 and IgG2a levels were higher and showed accelerated kinetics after RI vs. after PI. However, the level of IgG2b was substantially lower than that of IgG2a. Peak immunochemical and biological allergy states for RI were higher and were reached faster than those for PI. The peak biological allergy state was observed at 1 week postreinfection and this occurred sooner than that for the peak immunochemical allergy state found at 2 weeks postreinfection. Our analysis of the relationship between specific IgE avidity and biological allergy state did not show any meaningful correlation. These results suggest that the allergic response induced by L3 oral infection is predominantly caused by reinfection and that this is accompanied by an elevated IgM level, which further suggests that the biological allergy state might not be related to specific IgE avidity.

Enhanced cytotoxicity of doxorubicin encapsulated in liposomes with reconstituted Sendai F-proteins.

Sendai F-virosomes, a novel type of liposome with reconstituted Sendai F-proteins, have been tested as a delivery system for various bioactive materials. However, encapsulation limitations and difficulties in controlling their constituents were drawbacks for further application to therapeutic purposes. We have tried to control virosomal constituents and have enhanced drug encapsulation efficiency into the virosomes. In vitro cytotoxicity of doxorubicin encapsulated in the F-virosomes were compared with free doxorubicin and doxorubicin in conventional liposomes. The F-virosomes were spontaneously prepared by detergent dialysis, a reconstitution process of Sendai F-proteins into liposomes. The reconstitution density of F-proteins affected the vesicle size of virosomes prepared by detergent dialysis; the larger amount of F-proteins made a smaller size of virosomes. There was little variation of size with time at physiological conditions, whilst the vesicle size of virosomes increased at acidic storage conditions (pH 5.5). Doxorubicin encapsulated in the F-virosomes exhibited a lower IC50 against B16BL6 mouse melanoma cells and Chang human hepatocarcinoma cells than that in conventional liposomes. The F-virosomes also exhibited higher cellular uptake than conventional liposomes. Addition of dioleoylphophatidylethanolamine, a fusogenic phospholipid, into the F-virosome further increased the cellular uptake as well as in vitro cytotoxicity. These types of virosome formulations can be clinically applicable as versatile vesicles for the efficient delivery of various therapeutic drugs, including genetic materials.

Correcting the bias of clerkship timing on academic performance.

OBJECTIVES: To document the time-of-year bias in National Board of Medical Examiners subject examination (NBME) scores in a third-year pediatrics clerkship and to develop a grading method that neutralizes the bias. DESIGN: Interventional modeling of final grades. SETTING: University-based medical school. SUBJECTS AND METHODS: During each of the past 3 academic years, we conducted six 2-month pediatric clerkships for third-year students. To counter the time-of-year bias, NBME scores, clinical evaluations, and departmental examination scores for the current rotation were pooled with those from the rotations from the same time of year during the previous 2 years. Final grades for the current rotation were determined by cutoff points derived from that entire 3-year pool. We analyzed this approach by testing the time-of-year effects on NBME scores, clinical evaluations, and final grades while maintaining step 1 of the US Medical Licensing Examination as a preclinical baseline control. RESULTS: The scores for step 1 of the US Medical Licensing Examination did not differ significantly by time of year. Clinical evaluations and NBME scores showed significant upward trends as the academic year progressed. By contrast, according to design, final grades showed no significant time-of-year trend. CONCLUSIONS: Our results support previous reports of significant improvements in NBME scores across the academic year. Our method of computing final grades corrects for this time-of-year bias by judging students only in relation to those who took the rotation at the same time of year. It is our belief that the prevalence and significance of the time-of-year trend warrants such an adjustment in grading to help minimize the academic disadvantage faced by students early in their clinical training.