Epidemiological analysis of a large enterohaemorrhagic Escherichia coli O111 outbreak in Japan associated with haemolytic uraemic syndrome and acute encephalopathy.

A large outbreak of enterohaemorrhagic Escherichia coli (EHEC) O111 and O157 occurred in Japan in April 2011. We conducted an unmatched case-control study and trace-back investigation to determine the source of EHEC O111 infection and risk factors for severe complications. Pulsed-field gel electrophoresis was performed to help define cases. A total of 86 individuals met the case definition. Of these, 40% experienced haemolytic uraemic syndrome (HUS), 24% acute encephalopathy, and 6% died. Illness was significantly associated with eating the raw beef dish yukhoe (odds ratio 19·64, 95% confidence interval 7·03-54·83), the likely food vehicle. EHEC O111 and its closely related stx-negative variants were found in the beef. HUS occurred most frequently in individuals aged 5-9 years, and this age group was significantly associated with acute encephalopathy. The prevalence of HUS and acute encephalopathy was higher than in previous non-O157-related outbreaks, indicating a high risk of severe complications.

Vascular dysfunction detected by a simplified venous occlusion test in NIDDM patients.

OBJECTIVE: To elucidate the relationship between angiopathies and vascular function evaluated by a simplified venous occlusion test in patients with NIDDM. RESEARCH DESIGN AND METHODS: The serum concentration of FDP was measured before and 5 min after venous occlusion in 23 NIDDM patients, 11 patients with cerebrovascular accident, and 10 age-matched healthy control subjects. RESULTS: The increment of serum FDP level after venous occlusion was significantly less in patients with NIDDM (60.6 +/- 33.5 to 81.5 +/- 49.6 ng/ml) and in those with cerebrovascular accident (101.4 +/- 51.5 to 116.2 +/- 47.2 ng/ml) than in control subjects (79.9 +/- 41.0 to 148.8 +/- 65.4 ng/ml). The increment of serum FDP after venous occlusion in NIDDM patients with macroangiopathy was significantly lower than that in those without macroangiopathy. CONCLUSION: The responsiveness of fibrinolytic activity to venous occlusion was significantly less in NIDDM patients with macroangiopathy, as in patients with cerebrovascular accident, compared with that in healthy control subjects.

Direct and vagally mediated chronotropic effects of morphine studied by selective perfusion of the sinus node of awake dogs.

Two milliliters of a morphine sulfate solution (1 mg/ml) perfused selectively into the sinus node artery of five trained unanesthetized dogs caused an immediate brief sinus tachycardia followed by a delayed but prolonged sinus bradycardia. Beta-receptor blockade was achieved by selective perfusion of propranolol hydrochloride solution (10 mug/ml) into the sinus node artery and did not prevent the initial sinus tachycardia. Selective perfusion of the sinus node with atropine sulfate solution (1 mug/ml), however, did prevent morphine from causing further sinus rate increase. The immediate positive chronotropic action of morphine was thus attributable to a peripherally located vagolytic action. The exact opposite was true with regard to the delayed bradycardia; it was due to a centrally mediated generalized increase in vagal tone regularly elicited by morphine.

Chronotropic and dromotropic effects of histamine on the canine heart.

The actions of 2-methylhistamine (H1 agonists), 4-methylhistamine (H2 agonist), and histamine were studied by selective perfusion of the sinus node artery and atrioventricular node artery in 75 dogs anesthetized with pentobarbital sodium. 2-Methylhistamine and histamine had variable and inconsistent effects on the sinus rate. 4-Methylhistamine (100 microgram/ml) produced acceleration of the sinus rate from 158 +/- 4 to 173 +/- 5 beats per minute (P less than 0.05) when perfused via the sinus node artery. The effects of the histamine agonists on atrioventricular junctional rhythms were similar to the effects on sinus rhythm. The response of the sinus node to vagal stimulation was attenuated by selective perfusion with histamine; however, the direct negatively chronotropic action of acetylcholine was not affected by histamine. Neither 2-methylhistamine nor 4-methylhistamine affected the response of the sinus node to vagal stimulations. Both 4-methylhistamine and histamine (but not 2-methylhistamine) attenuated (P less than 0.05) the response of the sinus node to stimulation of the right stellate ganglion. The positively chronotropic effects of directly perfused norepinephrine were unaffected by histamine or 4-methylhistamine. These results suggest a neural depressing action of histamine on autonomic efferent fibers. In the atrioventricular junction, both histamine and 2-methylhistamine (but not 4-methylhistamine) had negatively dromotropic effects. Cimetidine (an H2 antagonist) had no significant direct effects on the sinus rate or atrioventricular conduction and failed to prevent the acceleration of the sinus rate produced by local perfusion with 4-methylhistamine.

Asymptomatic cor triatriatum incidentally revealed by computed tomography.

We report a case of asymptomatic cor triatriatum in a 75-year-old man in whom the anomaly was incidentally revealed by computed tomography (CT). To our knowledge, this patient is the oldest case reported and the only such case in which the anomaly was demonstrated by CT.

Paradoxical embolization with Ebstein's anomaly.

A 48-year-old woman with known Ebstein's anomaly had bilateral, lower-extremity arterial emboli after a total abdominal hysterectomy. She underwent embolectomy, placement of a Greenfield caval filter, subsequent tricuspid valve replacement, and closure of an atrial septal defect. Antemortem diagnosis of a paradoxical embolus is rare. To our knowledge, this is the first case associated with this congenital cardiac anomaly in a survivor.

Hemangiopericytoma of the chest wall.

We treated a 79-year-old woman with hemangiopericytoma of the chest wall. This is a very rare entity, with only a total of 12 cases including our case reported in Japan. There is a predominance of women (10 female patients and two male patients) and a predilection for the right side (9 in the right side and 3 in the left side).

Excision of an invasive thymoma: a cure for ulcerative colitis?

Thymoma is often associated with other diseases, including autoimmune diseases and endocrine disorders. Ulcerative colitis is a nonspecific inflammatory disease and is thought to be an immune-mediated disorder; however, coincidence of thymoma and ulcerative colitis is rare. We treated a 51-year-old woman with invasive thymoma and ulcerative colitis. After excision of the invasive thymoma with partial resections of pericardium, left lung, brachiocephalic vein, and left phrenic nerve, the ulcerative colitis was cured.

Bronchial artery aneurysm.

Two patients with giant bronchial artery aneurysm at the origin of the bronchial artery from the descending aorta were successfully treated. Both of them had been given a diagnosis of bronchiectasis and found with hemoptysis. One was a 64-year-old woman treated with transcatheter arterial embolization, and the other was a 64-year-old woman treated with surgical ligation.

Secondary spontaneous pneumothorax.

To assess the clinical manifestations and therapy of secondary spontaneous pneumothorax (SSP), 123 episodes of SSP in 67 patients were retrospectively reviewed and were compared with 254 episodes of primary spontaneous pneumothorax in 130 patients. The major underlying lung diseases associated with SSP were emphysema (22 patients) and tuberculosis (21 patients). The average age of patients with SSP was 66.8 years, and the most common symptom was dyspnea. The average arterial oxygen tension at onset of SSP was 61.1 +/- 12.1 mm Hg (mean +/- standard deviation), which was lower than that of patients with primary spontaneous pneumothorax (p < 0.01). The recurrence rate of open thoracotomy with pleural abrasion was 12.5% (3 of 24 episodes), which was not lower than that of thoracostomy tube drainage with chemical pleurodesis using tetracycline (recurrence rate, 18.8%) (p > 0.5). We concluded that considering the high age of the patients, the presence of underlying lung diseases, and the increased operative risk, thoracostomy tube drainage rather than open thoracotomy was preferred as the first choice of therapy for SSP.

Simplification of a venous occlusion test.

Chronological changes in plasma or serum concentrations of various fibrinolytic parameters, such as tissue-type plasminogen activator, plasminogen activator inhibitor, fibrinopeptide B beta 15-42 and FDP, were examined in 31 healthy volunteers before and after venous occlusion to determine a suitable time of venous stasis and a good parameter for use in a simplified venous occlusion test. After venous stasis for 5 min, a significant increase in the serum concentration of FDP (from 38.3 +/- 21.1 to 100.9 +/- 87.2 ng/ml (n = 24)) was observed, and the increase was parallel with changes in the plasma concentrations of other fibrinolytic parameters. The serum FDP level after 10 min VO was not significantly higher than that after 5 min VO. A significant decrease in ADP-induced platelet aggregation was observed after venous occlusion when measured by the impedance method, but not by the turbidimetric method. Therefore, as a simplified test, the change in the serum concentration of FDP after VO for 5 min was measured. The clinical significance of this simplified test was evaluated in fourteen patients with stenosis of cerebral artery. The mean percentage change in serum FDP concentration after venous stasis in the patients, 34.5 +/- 54.8%, was significantly less than that in normal subjects, 156.5 +/- 90.9%. Similar results were obtained on changes in plasma responses of other fibrinolytic parameters. Measurement of increase in serum FDP concentration after venous occlusion for 5 min should be useful as a screening tests for the hypofibrinolytic or thrombotic state due to vascular dysfunction.

Inhibitory action of gliclazide on platelet functions.

Gliclazide (GC), an oral hypoglycemic agent, inhibits platelet functions, but its effective concentration is reported to be much higher in vitro than in vivo. To determine why, we compared its inhibitory effect measured by impedance aggregometry using citrated whole blood with that measured by turbidometry using platelet-rich plasma. In addition, to see how GC inhibits platelet functions, we examined its effects on arachidonic acid metabolism in platelets in an in vitro system. Impedance aggregometry was found to be more sensitive than turbidometry for detecting the inhibition of platelet aggregation, and revealed significant inhibition at 1 x 10(-4) M GC. GC reduced the amount of prostaglandin I2 (PGI2) needed to inhibit ADP-induced platelet aggregation and the adhesiveness of platelets to a rabbit vessel wall after their preincubation with 1 x 10(-3) M GC for 10 min. GC (1 x 10(-4) -1 x 10(-2) M) had no effect on platelet cyclo-oxygenase activity. GC inhibited thromboxane A2 (TXA2)-induced platelet aggregation, but had no effect on the aggregation triggered by addition of mixtures of arachidonic acid (AA) and inhibitors of key enzymes regulating various steps of AA metabolism in platelets. GC had no significant effect on PGI2-stimulated cyclic AMP (cAMP) production in platelets. These results show that the difference in the effective concentrations of GC reported to modulate platelet functions in vivo and in vitro is partly due to differences in the methods used to evaluate its effect: turbidometry evaluates platelet aggregability, but not other platelet functions modulated by GC in vivo.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopy and the general surgeon.

Laparoscopic cholecystectomy has belatedly awakened the general surgical community to the concept of closed abdominal surgery. Current techniques have largely been developed by our colleagues in gynecology. The unanticipated demand by the public has placed unprecedented pressure on our systems for training, credentialing, developing, supplying, and evaluating changes in surgical technique. The diagnostic value of laparoscopy has been documented by a handful of general surgeons over the past several decades and is likely to become a more widely accepted technique. The potential of future developments in video-controlled operations is immense.

Inhibitory effects of gabexate mesilate (FOY) on experimental DIC.

The inhibitory effects of a newly synthesized protease inhibitor, Gabexate mesilate (FOY), on experimental disseminated intravascular coagulation were studied as compared with those of aprotinin or heparin. Thrombin, tissue thromboplastin, and endotoxin were used as DIC trigger substances. As parameters on DIC, platelet counts, white blood cell counts, neutrophilic leukocyte counts, fibrinogen, fibrin degradation products, platelet retention, platelet aggregation, prothrombin time, partial thromboplastin time were served. The drug efficacy in each parameter were expressed by the score system and analyzed statistically. The results were summarized as follows; (1) In thrombin-induced DIC, FOY was apparently superior to the other drugs (p less than 0.05). (2) In thromboplastin-induced DIC, heparin was slightly more effective than FOY or aprotinin. (3) In endotoxin infusion, there were no significant differences among them. In conclusion, the results of the present study suggest that FOY was more effective than heparin or aprotinin on experimental DIC.

Emergent pneumonectomy for hemoptysis in a patient with previous thoracoplasty.

Hemoptysis is a life-threatening episode of respiratory disease. By means of every possible treatment, hemostasis should be obtained to secure the airway as well as to prevent blood loss. We describe an emergent pneumonectomy for massive hemoptysis from destroyed lung in a patient with previous thoracoplasty. After prolonged ventilation support postoperatively, the patient with compromised lung function recovered well.

Emergent pneumonectomy for hemoptysis in a patient with previous thoracoplasty.

Hemoptysis is a life-threatening episode of respiratory disease. By means of every possible treatment, hemostasis should be obtained to secure the airway as well as to prevent blood loss. We describe an emergency pneumonectomy for massive hemoptysis from destroyed lung in a patient with previous thoracoplasty. After the prolonged ventilation support postoperatively, the patient with compromised lung function recovered well.

A liquid-liquid blood-gas exchange for the treatment of acute respiratory failure. A new blood gas exchange using artificial blood as an oxygen carrier.

A new liquid-liquid blood gas exchange system was investigated using a venovenous low flow extracorporeal circuit. A 2 m2 hollow fiber dialyzer served as the interface of the blood and oxygen carrier (a 38 percent FC-43, perfluorocarbon emulsion in a buffered electrolyte solution), which was continuously recycled through a bubble oxygenator. Experiments were performed on five mongrel dogs under general anesthesia. Upon the arrest of spontaneous ventilation, the dogs' lungs were inflated with 50% oxygen gas under a positive pressure of 10 cmH2O. After 10 min of apnea the dogs' PaO2 decreased to 37 +/- 14 mmHg, and the extracorporeal circulation was started at 10 ml/min/kg b./w. At 15 min the PaO2 had risen to 80 +/- 41 mmHg and at 30 min to 121 +/- 17 mmHg. The oxygen transfer was 8.3 +/- 2.3 ml/min. The extracorporeal circulation was continued 5h, when PaO2 reached 156 +/- 90 mmHg, and PaCO2 148 +/- 43 mmHg, then stopped. Fifteen minutes later, the PaO2 had returned to 32 +/- 10 mmHg. These findings indicate that our blood gas exchange system can supply a sufficient amount of oxygen to the body under apnea with continuous positive airway pressure.

[Enteropathogenicity and enteropathogenic toxin production of Vibrio mimicus].

Enteropathogenicity and enteroreactive-toxins were examined in 66 strains of Vibrio mimicus and the following results were obtained. Frequencies of enteropathogenic strains judged by the result of suckling mouse tests were 11/13 (85%) for clinical isolates and 37/53 (70%) for fish or environmental isolates. Frequencies of preservation of cholera toxin gene and NAG-ST gene were 2 and 15%, respectively, for 48 enteropathogenic strains, and 0 and 6%, respectively, for 18 non-enteropathogenic strains. Frequencies of production of NAG-rTDH, FAF and hemolysin were 4, 63 and 100%, respectively, for 48 enteropathogenic strains, and 6, 50, and 100%, respectively, for 18 non-enteropathogenic strains. No correlation between serovar and enteropathogenicity was observed in the suckling mouse test. Six out of 12 enteropathogenic strains produced hemolysin in ligated rabbit ileal loop, while 1 out of 12 non-enteropathogenic strains did so under the same condition. A significant inhibition of fluid accumulation in the ligated rabbit ileal loop test with viable cells was noted in rabbits immunized with hemolysin of non-O1 V. cholerae. These results suggest that approximately two-thirds of environmental isolates are enteropathogenic and that hemolysin is the most important toxin in the enteropathogenic mechanism of V. mimicus strains.

[Pulmonary thromboembolism after videothoracoscopic excision of a mediastinal tumor; report of a case].

We experienced a case of pulmonary thromboembolism after videothoracoscopic excision of a mediastinal tumor. A 57-year-old woman underwent videothoracoscopic excision of an upper mediastinal tumor, which was pathologically diagnosed as neurilemmoma. On the first postoperative day, she suddenly suffered from fatigue and blood-gas analysis showed hypoxemia. No abnormal shadow was seen on chest X-ray. Lung perfusion scintigram showed multiple embolism. She was treated with anticoagulants and recovered well. We should pay attention to the possibility of pulmonary thromboembolism after video-assisted thoracic surgery as well as thoracotomy, especially when patients have risk factors for pulmonary thromboembolism.

[Concomitant lobectomy for lung cancer under intraaortic balloon pumping and coronary bypass grafting].

A 71-year-old man was admitted because of an abnormal shadow on the chest X-ray film. Chest computed tomography (CT) revealed a tumor in the right upper lobe. The diagnosis of lung cancer was made by transbronchial lung biopsy. He had suffered an infarction of the inferior myocardial wall at the age of 55 years. Preoperative coronary angiography revealed total occlusion of segment 1, 75% stenosis of segments 5 and 6, and 90% stenosis of segment 13. Since these coronary lesions could cause perioperative and postoperative myocardial infarction, the patient was scheduled to undergo surgery of both the heart and lung in a one-stage operation. Under intraaortic balloon pumping (IABP), we performed a right upper lobectomy of the lung, and coronary artery bypass grafting with cardiopulmonary bypass through median sternotomy. During the lobectomy and first postoperative day, a stable circulation was achieved with IABP. The postoperative course was uneventful. At present, that is 33 months after the operation, the patient presents no sighs of recurrence of lung cancer and has not suffered any anginal attack during follow-up. Lung cancer and coronary artery disease can be treated simultaneously by this procedure.