Impact of antimicrobial treatment duration on outcome of Staphylococcus aureus bacteraemia: a cohort study.

OBJECTIVES: To assess the outcome of Staphylococcus aureus bacteraemia (SAB) according to factors associated with necessity for longer treatment in conjunction with the duration of treatment. METHODS: We prospectively collected the data of patients with SAB consecutively during 12 to 39 months from 11 hospitals. If multiple episodes of SAB occurred in one patient, only the first episode was enrolled. Factors associated with necessity for longer treatment were defined as follows: persistent bacteraemia, metastatic infection, prosthesis and endocarditis. If any of the factors were present, then the case was defined as longer antibiotic treatment warranted (LW) group; those without any factors were defined as shorter antibiotic treatment sufficient (SS) group. Poor outcome was defined as a composite of 90-day mortality or 30-day recurrence. Duration of antibiotic administration was classified as <14 or ≥14 days in the SS group and <28 or ≥28 days in the LW group. RESULTS: Among 2098 cases, the outcome was analysed in 1866 cases, of which 591 showed poor outcome. The SS group accounted for 964 cases and the LW group for 852. On multivariate analysis, age over 65 years, pneumonia, higher Sequential Organ Failure Assessment (SOFA) score and chronic liver diseases were risk factors for poor outcome. Administration of antibiotics less than the recommendation was associated with poor outcome, but this significance was observed only in the LW group (adjusted odds ratio = 1.68; 95% confidence interval, 1.00-2.83; p 0.05). CONCLUSIONS: Inappropriately short antibiotic treatment was associated with poor outcome in the LW group. Vigilant evaluation for risk factors to determine the duration of treatment may improve the outcome among patients with SAB.

[Operative strategy and clinical results of complex four part distal radius fractures by combined palmar and dorsal internal fixation].

Objective: To explore a standard procedure for the treatment of combined dorsal and palmar internal fixation for complex four part distal radius fractures and assess its clinical results. Methods: From May 2009 to October 2016, 38 patients(39 sides)who suffered from complex four part distal radius fractures were performed operatively with open reduction and internal fixation via combined dorsal and palmar approach in Department of Orthopaedic Trauma, Qilu Hospital of Shandong University(Qingdao). The series included 22 males(22 sides) and 16 females(17 sides). Age of the patients was 53.5 years ranging from 25 to 79 years.According to Melone classification, there were 34 sides of type of Ⅳ, 5 of type Ⅴ.According to Frykman classification, there were 15 sides of type Ⅶ, 24 sides of type Ⅷ, and all the cases were type C3 according to AO/OTA classification.Preoperatively, the key articular fragments in four part distal radius fractures were identified and the individual fracture patterns from conventional X-ray and CT-scan were analyzed. All the patients were performed combined volar and dorsal fixation.Firstly, a palmar approach which gave access to and fix the palmar-ulnar fragment and the radial styloid fragment was performed.Then a limited dorsal approach across the third extensor compartment which gave access to the dorso-ulnar fragment and a limited dorsal arthrotomy to visualize the radiocarpal joint when necessary were performed.Through dorsal approach, we can address the dorso-ulnar fragment, free intra-articular fragment and direct visualize the joint.Use of a retinacular flap was routinely advocated to help prevent against tendon irritation and rupture.The follow-up control included conventional X-ray, range of motion(ROM), grip strength, and the disabilities of the arm, shoulder and hand index(DASH), as well as the patient-rated wrist evaluation(PRWE) score for functional outcome at 6 and 12 months. Results: Thirty-three patients(34 sides) were followed up for at least 12 months.The would healed well in all cases 2 weeks postoperatively, and no soft tissue infections, necrosis or neurovascular complications occurred.All the fractures of 38 cases(39 sides)healed averaged 3.6 months(ranging from 2.5-5.7 months), and no loss of reduction occurred postoperatively.Anatomic reconstruction with a step or gap of <1 mm was achieved in 37 cases(38 sides), Whereas 5 patients were lost to follow-up at 12 months postoperatively.ROM and grip strength were all recovered to over 85% of the unaffected side(exception of the bilateral patient). Median DASH-index and PRWE were 6.5(0-17) and 9.3(0-20)respectively. Conclusion: Combined volar and dorsal approaches allow achieving anatomic reconstruction in complex four part intra-articular distal radius fractures and reveal good functional outcomes at intermediate follow-up.

Which tissues are best for microbiological diagnosis in patients with pyogenic vertebral osteomyelitis undergoing needle biopsy?

Identification of the causative microorganism is important in the management of pyogenic vertebral osteomyelitis (PVO). The aim of this study was to investigate whether culture positive rates differ between needle biopsy sites in patients with PVO, and which tissues are best for microbiological diagnosis. Between January 2005 and December 2013, we conducted a retrospective cohort study of PVO patients who had soft-tissue abscesses (paraspinal or psoas abscesses) and who received needle biopsy for microbiological diagnosis. Needle biopsy sites were classified into two anatomical categories: vertebral bodies, or soft tissues (intervertebral discs, paraspinal abscesses, or psoas abscesses). A generalized estimating equation model was developed to identify factors associated with tissue-culture positivity. During the study period a total of 136 tissues were obtained by needle biopsy from 128 PVO patients with soft-tissue abscesses. The culture positive rates of vertebral bodies and soft tissues were 39.7% (29/73), and 63.5% (40/63), respectively (p < 0.05). In a multivariate analysis, male gender (adjusted odds ratio (aOR) 2.24, 95% CI 1.00-5.02), higher C-reactive protein (aOR 1.07, 95% CI 1.01-1.15), positive blood culture (aOR 2.57, 95% CI 1.01-6.59), and soft tissues as biopsy site compared with vertebral bodies (aOR 2.28, 95% CI 1.08-4.78) were independent factors associated with tissue culture positivity. Soft tissues were the best sites for microbiological diagnosis in PVO patients undergoing needle biopsy.

Inhibition of pulmonary cancer progression by epidermal growth factor receptor-targeted transfection with Bcl-2 and survivin siRNAs.

Clinical application of small interfering RNA (siRNA) in cancer therapy has been limited by the lack of an efficient systemic siRNA delivery system. In this report we describe an efficient siRNA delivery system directed to metastasized tumors, especially in the lungs. Anticancer siRNA was condensed in the presence of 9-arginine peptides (9Arg) and then complexed with cationic O,O'-dimyristyl-N-lysyl glutamate liposomes conjugated to antibodies against the epidermal growth factor receptor (EGFR). The ternary complex of optimized anti-EGFR-9Arg-lipoplexes exhibited efficient siRNA transfection of LS174T-Luc cancer cells grown in culture or orthotopically in mouse lungs. Anti-tumor Bcl-2/survivin siRNAs loaded in the anti-EGFR-9Arg-lipoplexes effectively suppressed transcription of their target genes, resulting in an efficient cancer cell death. Repeated intravenous administrations of the anti-EGFR-9Arg-lipoplexes effectively inhibited tumor growth in the mouse lungs and prolonged survival of the mice compared with nontargeted lipoplexes. These results suggest that the ternary complexes of anti-EGFR-9Arg-lipoplexes might have clinical applications in RNA interference cancer therapy.

Surgical treatment of enophthalmos using an endoscope and T-shaped porous polyethylene fabricated with a mirror image.

Enophthalmos is corrected mostly through reducing the enlarged orbit volume by identifying intact bone edges and spanning the defect with an implant or autogenous graft. Predicting the amount of volume which must be added to correct enophthalmos is not easy using this method, and the outcome may be unsatisfactory. In this study, the authors examined 9 patients in whom enophthalmos was caused by a defect or inadequate surgery of the orbital medial wall. The authors designed an adequately shaped implant by using the mirror image obtained before surgery, and prepared a T-shaped Medpor for each patient in order to maintain the accurate contour of the medial wall and to decrease the enlarged orbital volume. During the surgery, the T-shaped Medpor was inserted while monitoring the posterior portion of the orbital wall. Satisfactory results were obtained for all the patients. Although the new method of implant design developed by the authors in this study is limited to the reconstruction of the medial wall, it is considered useful for the surgical treatment of posttraumatic enophthalmos because it takes into account both the contour and volume of the orbital wall.

Effects of Polycan, a ß-glucan, on experimental periodontitis and alveolar bone loss in Sprague-Dawley rats.

BACKGROUND AND OBJECTIVE: Polycan is a promising candidate for the treatment of periodontal disease. This study was undertaken to examine whether Polycan, a type of ß-glucan, has a protective effect on ligature-induced experimental periodontitis and related alveolar bone loss in Sprague-Dawley rats. MATERIAL AND METHODS: Polycan was orally administered, daily, for 10 d, at 21.25, 42.5 or 85 mg/kg, beginning 1 d after ligation. Changes in body weight and alveolar bone loss were monitored, and the anti-inflammatory effects of Polycan were determined by measuring the levels of myeloperoxidase (MPO), interleukin-1beta (IL-1ß) and tumor necrosis factor-alpha (TNF-α) in gingival tissue. We also evaluated inducible nitric oxide synthase (iNOS) activity and malondialdehyde (MDA) concentrations as a measure of the antioxidant effect. RESULTS: Ligature placement led to a marked decrease in body weight, increased alveolar bone loss and increased concentrations of MPO, IL-1ß, TNF-α and MDA, as well as increased iNOS activity and inflammatory cell infiltration and decreased collagen-fiber content. Histological examination revealed increases in the number and activity of osteoclast cells, decreases in alveolar bone volume and elevated percentages of osteclasts on the alveolar bone surface. Daily oral treatment with 42.5 or 85 mg/kg of Polycan for 10 d led to significant, dose-dependent inhibition of the effect of ligature placement. CONCLUSION: Taken together, these results suggest that 10 d of oral treatment with Polycan effectively inhibits ligature placement-induced periodontitis and related alveolar bone loss via an antioxidant effect.

CT scan assessment of the pathway of the true lateral approach for transforaminal endoscopic lumbar discectomy: is It possible?

We performed a prospective study to examine the influence of the patient's position on the location of the abdominal organs, to investigate the possibility of a true lateral approach for transforaminal endoscopic lumbar discectomy. Pre-operative abdominal CT scans were taken in 20 patients who underwent endoscopic lumbar discectomy. Axial images in parallel planes of each intervertebral disc from L1 to L5 were achieved in both supine and prone positions. The most horizontal approach angles possible to avoid injury to the abdominal organs were measured. The results demonstrated that the safe approach angles were significantly less (i.e., more horizontal) in the prone than in the supine position. Obstacles to a more lateral approach were mainly the liver, the spleen and the kidneys at L1/2 (39 of 40, 97.5%) and L2/3 (28 of 40, 70.0%), and the intestines at L3/4 (33 of 40, 82.5%) and L4/5 (30 of 30, 100%). A true lateral approach from each side was possible for 30 of the 40 discs at L3/4 (75%) and 23 of the 30 discs at L4/5 (76.7%). We concluded that a more horizontal approach for transforaminal endoscopic lumbar discectomy is possible in the prone position but not in the supine. Prone abdominal CT is more helpful in determining the trajectory of the endoscope. While a true lateral approach is feasible in many patients, our study shows it is not universally applicable.

Alendronate affects cartilage resorption by regulating vascular endothelial growth factor expression in rats.

This study was performed to determine effects of alendronate on the tibial proximal epiphyseal cartilage undergoing endochondral ossification and the expression of vascular endothelial growth factor (VEGF) from the cartilage. Alendronate was injected subcutaneously every other day in postnatal Day 1 Sprague Dawley rats. The rats were sacrificed 3, 5, 7, and 10 days after the first injection. The effect of alendronate treatment for 10 days was demonstrated from the morphological change that the area of the secondary ossification center in the epiphysis was significantly smaller in the alendronate group than that in the control group (P < 0.05). Strong immunoreactivity to VEGF was observed in the hypertrophied chondrocytes and some proliferating chondrocytes in the epiphyseal cartilage at postnatal Day 5 and was decreased after the alendronate treatment for 5 days. Immunoreactivity was observed in not only hypertrophied cells but also the peripheral cartilaginous matrix adjacent to the vascular canals invading into the central portion of the cartilage at postnatal Day 7. This reactivity was also reduced considerably by the alendronate treatment for 7 days. The level of VEGF expression was reduced by the alendronate treatment at both the transcription and translation levels. However, the transcriptional level of the flt-1 and flk-1 receptors was relatively unaltered by the treatment. These results suggest that VEGF expression is required for vascular invasion into the developing cartilage and alendronate can affect its resorption by downregulating VEGF expression.

Intravenous transferrin, RGD peptide and dual-targeted nanoparticles enhance anti-VEGF intraceptor gene delivery to laser-induced CNV.

Choroidal neovascularization (CNV) leads to loss of vision in age-related macular degeneration (AMD), the leading cause of blindness in adult population over 50 years old. In this study, we developed intravenously administered, nanoparticulate, targeted nonviral retinal gene delivery systems for the management of CNV. CNV was induced in Brown Norway rats using a 532 nm laser. We engineered transferrin, arginine-glycine-aspartic acid (RGD) peptide or dual-functionalized poly-(lactide-co-glycolide) nanoparticles to target delivery of anti-vascular endothelial growth factor (VEGF) intraceptor plasmid to CNV lesions. Anti-VEGF intraceptor is the only intracellularly acting VEGF inhibitory modality. The results of the study show that nanoparticles allow targeted delivery to the neovascular eye but not the control eye on intravenous administration. Functionalizing the nanoparticle surface with transferrin, a linear RGD peptide or both increased the retinal delivery of nanoparticles and subsequently the intraceptor gene expression in retinal vascular endothelial cells, photoreceptor outer segments and retinal pigment epithelial cells when compared to nonfunctionalized nanoparticles. Most significantly, the CNV areas were significantly smaller in rats treated with functionalized nanoparticles as compared to the ones treated with vehicle or nonfunctionalized nanoparticles. Thus, surface-functionalized nanoparticles allow targeted gene delivery to the neovascular eye on intravenous administration and inhibit the progression of laser-induced CNV in a rodent model.

Prognostic significance of beta-catenin in colorectal cancer with liver metastasis.

AIMS: A decreased expression of beta-catenin has been known to be associated with tumour metastasis. The prognostic value of beta-catenin expression in colorectal cancer (CRC) patients with liver metastasis was evaluated. MATERIALS AND METHODS: Seventy patients who underwent curative resection for CRC with liver metastasis were included. Tissue samples from normal colon mucosa, primary CRC and metastatic liver lesions were prepared in tissue microarrays, and were stained by immunohistochemistry with beta-catenin antibody. The beta-catenin expression of primary CRC tissues and metastatic liver tissues was analysed. RESULTS: A high expression of beta-catenin (score > 6) was observed in 42.0% and 21.9% of primary colorectal tissues and metastatic liver tissues, respectively. The beta-catenin expression in metastatic liver tissues was significantly lower than in primary CRC tissues (P = 0.022). The patients were classified into two groups according to the difference in the beta-catenin expression score between the primary CRC and the liver metastasis. Group A was defined as patients showing a remarkably decreased expression of beta-catenin in their metastatic liver tissue and group B was defined as patients showing a maintained or increased beta-catenin expression in their metastatic liver tissue in comparison with their primary CRC. The overall survival and disease-free survival rates were better in group B than in group A, and this was statistically significant (P = 0.02, P = 0.002). CONCLUSION: The decreased expression of beta-catenin in a metastatic liver lesion may be a poor prognostic marker in CRC with liver metastasis and further investigation is necessary.

Distinct downstream pathways of caspase-11 in regulating apoptosis and cytokine maturation during septic shock response.

Caspase-11 is an essential mediator of septic shock response and caspase-11-deficient mice are resistant to LPS-induced shock. Here we report that LPS-induced caspase-11 regulates lymphocyte apoptosis by activating both caspase-3 and caspase-7. The activation of caspase-11 preceded that of caspase-1 and caspases-3/-7, and in the absence of caspase-11, the activation of caspases-3/-7 was significantly reduced. The early activation of caspases-3/-7 by caspase-11 was not affected by blocking of caspase-1 activity and IL-1beta release, implying that caspase-11 activates caspases-3/-7 independently of caspase-1 activation. Furthermore, we show that caspase-11-mediated apoptosis under septic condition is Bid-independent. Our work suggests that the human homologue of caspase-11 may be an effective therapeutic target for treatment of septic shock.

E-Cadherin Expression and p53 Alterations in Soft Tissue Sarcomas: A Possible Role in Epithelial Differentiation.

PURPOSE: We investigated the expressions of E- Cadherin and p53 in soft tissue tumors to determine their significance in sarcoma development and/or progression and to assess their potential correlation with epithelial features. MATERIALS AND METHODS: A total of 79 soft tissue sarcomas, including 10 tumors comprising epithelial components, were studied immunohistochemically in paraffin-embedded tissue sections. Further analysis was performed on 61 tumors by the application of a polymerase chain reaction technique and a direct sequence analysis procedure applied to exons 5 through 8 in the p53 gene. RESULTS: E-Cadherin was expressed at the cell-cell boundaries in 8 (10%) tumors: 5 of grade 2 and 3 of grade 3. Of these, six (being 60% of the total of 10 tumors containing epithelial elements) contained and two did not contain histologic evidence of epithelial differentiation. Overexpression of p53 was detected in 26 (33%) samples, 7 of which demonstrated mutations in the p53 gene. No association was established between E-Cadherin immunoreactivities and p53 abnormalities. Tumor grade was found to be strongly correlated with p53 alterations (p=0.01) but not with E-Cadherin expression (p=0.09). CONCLUSION: These data confirm a role for altered p53 in the pathogenesis of soft tissue sarcomas and suggest a possible role for E-Cadherin in the maintenance of epithelial architecture in these tumors regardless of p53 status.

Predictors for benign solitary pulmonary nodule in tuberculosis-endemic area.

BACKGROUND: Solitary pulmonary nodule (SPN) may show different presentation in tuberculosis (TB)-endemic countries. The aim of this study was to identify clinical and radiological predictors favoring benign or malignant SPN in TB-endemic region. METHODS: Two hundred one SPNs in 201 consecutive Korean patients were included (< 3 cm in diameter, all confirmed by pathology or bacteriology, 93 benign and 108 malignant diseases). For clinical parameters, age, sex, smoking status and amount, and past history of pulmonary tuberculosis and diabetes mellitus were investigated retrospectively. For radiological parameters, size, location, margin characteristics, presence of calcification, pleural tag, surrounding satellite nodule, cavitation, internal low attenuation, open bronchus sign, surrounding ground-glass opacity, enhancement pattern of the SPNs and mediastinal lymph node (LN) enlargement were analyzed on chest CT scans. RESULTS: Patients with a older age (60.7 +/- 9.6 vs 56.2 +/- 13.1, p = 0.008) and more than 40-pack years smoking (27.8% vs 14.0%, p = 0.017) were more frequently related with malignant than benign SPN. On chest CT scans, spiculated margin, contrast enhancement more than 20 Hounsfield unit and presence of pleural tag and mediastinal LN enlargement were more frequently observed in malignant than benign SPNs. In contrast to previous studies, satellite lesions (21.5% vs 1.9%, p < 0.001) and cavitation (20.4% vs 5.6%, p = 0.001) were more frequently seen in benign than malignant SPN. Positive predictive values of benignity were 90.9% and 76.0%, respectively, when satellite lesions and cavitation were found in cases of SPN. CONCLUSION: Satellite lesions and cavitation on chest CT scan could be useful predictors for benign SPN in TB-endemic areas.

Motility restriction after resection of an extraocular muscle.

Restriction of eye movement after surgery is an unusual but troublesome complication. A patient presented with a limitation of abduction after a 5 mm resection of medial rectus muscle and an 8 mm recession of lateral rectus muscle. Since the forced duction test was positive, restrictive factors were suggested to be implicated. A reparative operation was performed at the postoperative 9 month, and the forced duction test was negative after releasing the resected medial rectus muscle. The patient showed an improved abduction after recessing the resected muscle. Even after an uneventful surgery, resection of an extraocular muscle may cause restriction of ocular rotation caused by muscle scarring to the sclera or by an increased tightness of the muscle.

Kaposi's sarcoma involving a transplanted kidney, ureter and urinary bladder: ultrasound and CT findings.

We report the imaging findings in a case of Kaposi's sarcoma involving a transplanted kidney, ureter and urinary bladder. Ultrasound and CT demonstrated multiple nodular masses in the pelvis of the transplanted kidney, ureter and bladder. The masses enhanced well on CT following i.v. contrast medium.

Magnetic interactions in the high-spin iron(III) oxooctaethylchlorinato derivative [Fe(oxoOEC)(Cl)] and its pi-cation radical [Fe(oxoOEC.)(Cl)]SbCl6.

The preparation and characterization of the beta-oxochlorin derivative [3,3,7,8,12,13,17,18-octaethyl-(3H)-porphin-2-onato(2-)]iron(III) chloride, [Fe(oxoOEC)(Cl)], and its pi-cation radical derivative [Fe(oxoOEC.)(Cl)]SbCl6 is described. Both compounds have been characterized by single-crystal X-ray structure determinations, IR, UV/vis/near-IR, and Mössbauer spectroscopies, and temperature-dependent magnetic susceptibility measurements. The macrocycles of [Fe(oxoOEC)(Cl)] and [Fe(oxoOEC.)(Cl)]SbCl6 are both saddled, and [Fe(oxoOEC.)(Cl)]-SbCl6 is slightly ruffled as well. [Fe(oxoOEC)(Cl)] shows a laterally shifted dimeric unit in the solid state, with a mean plane separation of 3.39 A and a lateral shift of 7.39 A. Crystal data for [Fe(oxoOEC)(Cl)]: triclinic, space group P1, Z = 2, a = 9.174(2) A, b = 13.522(3) A, c = 14.838(3) A, alpha = 95.79(3) degrees, beta = 101.46(2) degrees, gamma = 104.84(3) degrees. Upon oxidation, the inter-ring geometric parameters increase; the mean plane separation and the lateral shift of the dimeric unit of [Fe(oxoOEC.)(Cl)]SbCl6 are 4.82 and 8.79 A, respectively. Crystal data for [Fe(oxoOEC.)(Cl)]SbCl6: monoclinic, space group Cc, Z = 4, a = 19.8419(13) A, b = 10.027(2) A, c = 22.417(4) A, beta = 96.13(2) degrees. A broad near-IR absorption band appears at 1415 nm for the pi-cation radical, [Fe(oxoOEC.)(Cl)]SbCl6. Zero-field Mössbauer measurements at 4.2 K for both [Fe(oxoOEC)(Cl)] and [Fe(oxoOEC.)(Cl)]SbCl6 confirmed that the oxidation state of the iron atom did not change upon chemical oxidation. Solid-state magnetic susceptibility measurements for [Fe(oxoOEC.)(Cl)]SbCl6 resulted in a large temperature dependence of the magnetic moment that can best be fit with a model that includes a zero-field splitting parameter of D = 6 cm-1, antiferromagnetic intermolecular iron-iron coupling (2JFe-Fe = -0.14 cm-1), antiferromagnetic intramolecular iron-radical coupling (2JFe-r = -76 cm-1), and antiferromagnetic radical-radical coupling (2Jr-r = -13 cm-1).