A bundle that includes active surveillance, contact precaution for carriers, and cefazolin-based antimicrobial prophylaxis prevents methicillin-resistant Staphylococcus aureus infections in clean orthopedic surgery.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of orthopedic surgical site infections (SSIs). The aim of this study was to evaluate the effect of a bundle approach in the prevention of orthopedic MRSA SSIs. MATERIAL AND METHODS: MRSA active surveillance and decolonization were performed preoperatively at our institution from July 2004 until 2007. In January 2008, a bundle approach comprising contact precautions for MRSA-positive patients and cefazolin-based antimicrobial prophylaxis (AMP) stewardship was implemented. Data on the prevalence of MRSA SSIs, antimicrobial use density, duration of AMP, and the use of an alcohol antiseptic agent (L/1,000 patient-days) were evaluated during 2 periods: July 2004-December 2007 (period A) and January 2008-December 2012 (period B). RESULTS AND DISCUSSION: The MRSA SSI rate during period B (0.97%; 19 out of 1,966) was significantly lower than that during period A (2.17%; 29 out of 1,333; P = .003). The infection rate correlated negatively with both the cefazolin antimicrobial use density (r = -0.76; P = .0002) and the use of an alcohol antiseptic agent (r = -0.68; P = .002). CONCLUSIONS: An infection-prevention bundle consisting of contact precautions for carriers and AMP stewardship in addition to active surveillance was associated with a significant decrease in the incidence of orthopedic MRSA SSIs.

Immobilization and functional reconstitution of antibody Fab fragment by solid-phase refolding.

In this study, we demonstrated the successful preparation of a Fab antibody-immobilized hydrophilic polystyrene (phi-PS) plate via one- and two-step solid-phase refolding methods. Both polystyrene-binding peptide (PS-tag)-fused Fd fragment of heavy chain (Fab H-PS) and full-length of light-chain (Fab L-PS) were individually produced in insoluble fractions of Escherichia coli cells, and they were highly purified in the presence of 8M of urea. Antigen-binding activities of Fab antibody immobilized were correctly recovered by the one-step solid-phase refolding method that a mixture of Fab H-PS and Fab L-PS was immobilized in the presence of 0.5-2M urea, followed by surface washing of the phi-PS plate with PBST. These results indicate that by genetic fusion of a PS-tag, a complex between Fab H and Fab L was efficiently immobilized on the surface of a phi-PS plate even in the presence of a low concentration of urea, and was then correctly refolded to retain its high antigen-binding activity via removal of the urea. A two-step solid-phase refolding method whereby Fab H-PS and Fab L-PS were successively refolded on the surface of a phi-PS plate also resulted in Fab antibody formation on the plate. Furthermore, both the binding affinity and the specificity of the Fab antibody produced by the two-step method were highly maintained, according to the results of sandwich ELISA and competitive ELISA using Fab antibody-immobilized plate via two-step solid-phase refolding. Thus, the solid-phase refolding method demonstrated in this study should be quite useful for the preparation of a Fab antibody-immobilized PS surface with high efficiency from individually produced Fab H-PS and Fab L-PS. This method will be applicable to the preparation of a large Fab antibody library on the surface of a PS plate for use in antibody screening.

Lack of the consensus sequence necessary for tryptophan prenylation in the ComX pheromone precursor.

ComX, an oligopeptide pheromone that stimulates the natural genetic competence controlled by quorum sensing in Bacillus subtilis and related bacilli, contains a prenyl-modified tryptophan residue. Since ComX is the only protein known to contain prenylated tryptophan, the universality of this unique posttranslational modification has yet to be determined. Recently, we developed a cell-free assay system in which the tryptophan residue in the ComX(RO-E-2) pheromone precursor derived from B. subtilis strain RO-E-2 can be geranylated by the ComQ(RO-E-2) enzyme. We report here our attempt to identify the consensus sequence surrounding the geranylated tryptophan residue by using the cell-free system with various ComX(RO-E-2) pheromone precursor analogs. We found that [47-58]ComX(RO-E-2), corresponding to the C-terminal 12-residue peptide of the pheromone precursor, contained a short sequence essential for geranylation. We also found that the length of the sequence between the tryptophan residue and the C-terminus was important for geranylation, and that some [47-58]ComX(RO-E-2) pheromone precursor amino acids were involved in the geranylation reaction. However, we could not identify a consensus sequence surrounding the geranylated tryptophan. Our evidence suggests that, like Rab which lacks a consensus sequence yet is geranylgeranyl-modified on a cysteine residue, the ComX pheromone and its precursor also lack a consensus sequence.

Laparoscopic resection of epidermoid cyst arising from an intrapancreatic accessory spleen: a case report with a review of the literature.

We describe a rare case of epidermoid cyst arising in an intrapancreatic accessory spleen that presented as a cystic mass in the tail of the pancreas, and for which laparoscopic distal pancreatectomy was performed successfully. A 36-year-old woman with a cystic mass in the tail of the pancreas, which had been discovered incidentally at a medical checkup, was referred to our department for further examination. Endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography and positron emission tomography demonstrated a multilocular cyst in the tail of the pancreas without any evidence of malignancy, although differential diagnosis was extremely difficult because of the neoplasm-like appearance of the lesion. Therefore, we performed laparoscopic distal pancreatectomy under a preoperative diagnosis of mucinous cystic neoplasm. Postoperative pathologic examination demonstrated an epidermoid cyst arising from a heterotopic spleen within the pancreas. This is the first report of successful laparoscopic distal pancreatectomy for an epidermoid cyst arising in an intrapancreatic accessory spleen. One virtually has no chance to diagnose an epidermoid cyst in an accessory spleen on the basis of preoperative diagnostic workup, and consequently the type of surgical resection (open vs. laparoscopic) would be conditioned by factors other than the clinical entity suspected at the preoperative period.

A novel approach for sentinel lymph node identification using fluorescence imaging and image overlay navigation surgery in patients with breast cancer.

BACKGROUND: We reported a novel technique of sentinel lymph node (SLN) identification using fluorescence imaging of indocyanine green injection. Furthermore, to obtain safe and accurate identification of SLN during surgery, we introduce the image overlay navigation surgery and evaluate its efficacy. METHODS: This study enrolled 50 patients with a tumors <2 cm in diameter. Initially, we obtained three-dimensional (3-D) imaging from multidetector-row computed tomography (MD-CT) by volume rendering. It was projected on the patient's operative field with the clear visualization of lymph node (LN) through projector. Then, the dye of indocyanine green (ICG) was injected subdermally in the areola. Subcutaneous lymphatic channels draining from the areola to the axilla were visible by fluorescence imaging immediately. Lymphatic flow was reached after LN revealed on 3-D imaging. After incising the axillary skin on the point of LN mapping, SLN was then dissected under the guidance of fluorescence imaging with adequate adjustment of sensitivity and 3-D imaging. RESULTS: Lymphatic channels and SLN were successfully identified by Photodynamic eye (PDE) in all patients. And the sites of skin incision also were identical with the LN being demonstrated by 3-D imaging in all patients. The mean number of SLN was 3.7. The image overlay navigation surgery was visually easy to identify the location of SLN from the axillary skin. There were no intra- or postoperative complications associated with SLN identification. CONCLUSIONS: This combined navigations of fluorescence and 3-D imaging revealed more easy and effective to detect SLN intraoperatively than fluorescence imaging alone.

Intraoperative exploration of biliary anatomy using fluorescence imaging of indocyanine green in experimental and clinical cholecystectomies.

BACKGROUND/PURPOSE: We evaluated the usefulness of intraoperative exploration of the biliary anatomy using fluorescence imaging with indocyanine green (ICG) in experimental and clinical cholecystectomies. METHODS: The experimental study was done using two 40-kg pigs and the clinical study was done in 12 patients for whom cholecystectomy was planned from January 2009 to June 2009. Initially we used a laparoscopic approach for the evaluation of fluorescence imaging of the biliary system in the two pigs. Then the clinical study was started on the basis of these experimental results. ICG (1.0 ml/body of 2.5 mg/ml ICG) was infused 1-2 h before surgery. With the subjects under general anesthesia we observed in real time the condition of the biliary tract under the guidance of fluorescence imaging employing an infrared camera or a prototype laparoscope. ICG was added intravenously to observe the location or flow condition of the cystic artery. RESULTS: We obtained a clear view of the biliary tract and the location of the cystic duct in the two pigs. Local compression with a transparent hemispherical plastic device was effective for offering a clearer view. The biliary tract, except for the gallbladder, was clearly recognized in all clinical subjects. Local compression with a transparent hemispherical plastic device for open cholecystectomy and a flat plastic device for laparoscopy provided clearer visualization of the confluence between the cystic duct and common bile duct or common hepatic duct. The location of the cystic artery was revealed after division of the connective tissues, and the flow condition of the cystic artery was confirmed 7-10 s after intravenous re-infusion of ICG. There were no adverse events related to the intraoperative procedure or the ICG itself. CONCLUSIONS: This method is safe and easy for the identification of the biliary anatomy, without requiring cannulation into the cystic duct, X-ray equipment, or the use of radioactive materials. Although fluorescence imaging is still at an early stage of application in comparison with ordinary intraoperative cholangiography, we expect that this method will become routine, offering a lower degree of invasiveness that will help avoid bile duct injury.

Direct immobilization of functional single-chain variable fragment antibodies (scFvs) onto a polystyrene plate by genetic fusion of a polystyrene-binding peptide (PS-tag).

Single-chain Fv antibodies (scFv) genetically fused with polystyrene-binding peptides (PS-tags, (PS19-1; RAFIASRRIRRP, PS19-6; RIIIRRIRR)) were generated by recombinant Escherichia coli for direct and site-specific immobilization of scFv on polystyrene supports with high antigen-binding activity. PS-tag-fused scFvs (scFv-PS-tags) specific for human C-reactive protein (CRP) were successfully over-expressed as an inclusion body and were refolded using the batch-dilution method. When scFv-PS-tags were immobilized on a hydrophilic PS (phi-PS) plate in the presence of Tween 20, they showed high antigen-binding activity comparable to, or greater than, that of a whole monoclonal antibody (mAb) on a hydrophobic PS (pho-PS) plate, which has been the exclusive method for enzyme-linked immunosorbent assay (ELISA). Furthermore, when a scFv-PS-tag was used as a ligand antibody in one- and two-step ELISA, the assay time was reduced without loss of sensitivity. These results indicate that strong and specific attachment of PS-tags onto the phi-PS surface prevented scFv conformational changes and consequently, the high antigen-binding activities of scFvs were preserved. Nearly identical results were obtained by use of PS-tag-fused scFvs with different VH/VL pairs. Therefore, a variety of scFvs could be functionalized onto phi-PS plates by genetic fusion of PS-tags. ScFv-PS-tags, which possess high antigen-binding activity on the phi-PS plate, are more useful ligand antibodies than whole mAbs. Thus, scFv-PS-tags are applicable in both clinical diagnosis and proteomic research.

Undifferentiated carcinoma of the esophagus with rapid growth of lymph node. A case report and review of the literature.

We present a case of undifferentiated carcinoma of the esophagus (UCE) treated with chemotherapy consisting of 5-fluorouracil plus nedaplatin and radiotherapy. The patient developed rapid growth of lymph nodes and died of massive hematemesis 2 months after the diagnosis. UCE is rare but highly malignant. Since there is no established treatment for UCE, its clinical outcome is invariably poor. We also reviewed the effectiveness of chemotherapy against UCE.

Progesterone receptor antagonists with a 3-phenylquinazoline-2,4-dione/2-phenylisoquinoline-1,3-dione skeleton.

Novel non-steroidal progesterone receptor antagonists with a 3-phenylquinazoline-2,4-dione/2-phenylisoquinoline-1,3-dione skeleton were developed and their structure-activity relationships were investigated. Among the prepared compounds, 4-(4,4-diethyl-3,4-dihydro-1,3-dioxoquinolin-2(1H)-yl)benzonitrile (DEPIQ-4CN) showed the most potent activity, with IC(50) values of 74-78nM in alkaline phosphatase activity and reporter gene assays.

Intraoperative identification of sentinel lymph nodes by near-infrared fluorescence imaging in patients with breast cancer.

We present a novel method for sentinel lymph node (SLN) identification by fluorescence imaging that provides a high detection rate and a low false-negativity rate. Twenty-five breast cancer patients with tumors less than 3 cm in diameter were enrolled. A combination of indocyanine green and indigo carmine was injected subdermally in the areola. Subcutaneous lymphatic channels draining from the areola to the axilla were immediately showed by fluorescence imaging. After incising the axillary skin near the point of disappearance of the fluorescence, the SLN was dissected under fluorescence guidance. In all patients, the lymphatic channels and SLN were successfully visualized. The mean number of fluorescent SLN and blue-dyed SLN were 5.5 and 2.3. Eight patients were found to have lymph node metastases pathologically. All of them were recognized by fluorescence imaging. This method is feasible and safe for intraoperative detection of SLN allowing real-time observation without any need for training.

Improvement of survival of skin flaps by combined gene transfer of hepatocyte growth factor and prostacyclin synthase.

BACKGROUND: Increasing the local blood flow is a critical factor for long-term survival of skin flaps. Thus, a molecular therapy to increase the blood flow by means of an angiogenic factor is considered to be a useful strategy to improve skin flap survival. We focused on a combined strategy to stimulate not only angiogenesis, but also vasodilation of local microvessels, using co-transfection of the hepatocyte growth factor (HGF) and prostacyclin synthase (PGIS) genes to enhance the survival of random-pattern skin flaps. METHODS AND RESULTS: A 2 x 8 cm full thickness cranial pedicled random-pattern flap was made on the back of each 12-week-old male rat. At 3 days before operation, 400 microg of human HGF and PGIS naked plasmid DNA or control plasmid was transfected into the flaps by needle-less injection using a Shima Jet, resulting in successful expression of human HGF and PGIS in the skin flaps. Transfection of both genes into the distal half of skin flaps at 3 days prior to operation significantly increased the survival rate of skin flaps, while transfection all over the flaps did not. In addition, transfection prior to operation was more effective than simultaneous treatment. Moreover, co-transfection of these genes improved the survival area of skin flaps, accompanied by an increase in blood flow of skin flaps, even in a diabetic model. CONCLUSIONS: Overall, these results indicate that combination treatment with HGF and PGIS genes by Shima Jet could be an effective strategy to improve skin flap survival.

New antineoplastic agent, MK615, from UME (a Variety of) Japanese apricot inhibits growth of breast cancer cells in vitro.

MK615 is an extract mixture containing hydrophobic substances from Japanese apricot. In this study, the antineoplastic effects of MK615 against breast cancer cells were investigated. Two breast cancer cell lines, MDA-MB-468 (MDA) and MCF7, were cultured with (600, 300, and 150 mug/mL) or without MK615. After 72 hours of incubation, growth inhibition was evaluated by MTT assay. The cells were then cultured with MK615 (300 mug/mL) and morphological changes were studied by light and electron microscopy. Finally, the mechanism of the antineoplastic effect of MK615 was evaluated by cell cycle and apoptosis assay. MK615 inhibited the growth of MDA and MCF7 in a dose-dependent manner. The percentage growth inhibition of MDA at dosages of 600, 300, and 150 mug/mL was 59.2%, 52.4%, and 23.3%, respectively, and that for MCF7 was 83.5%, 52.7%, and 16.6%, respectively. Morphological changes after MK615 treatment included massive vacuolization in the cytoplasm and apoptotic changes in the nucleus. These changes began to be apparent after at least 6 hours of incubation. Cell cycle analysis showed that MK615 increased the proportion of cells in the G2-M phase in both MDA (7.8-11.7%) and MCF7 (8.1-18.7%), and finally both cell lines became apoptotic. The proportion of apoptotic cells increased with incubation time. MK615 effectively inhibits the growth of breast cancer cells in vitro, possibly by cell cycle modification and apotosis induction. MK615 should be further investigated as a promising anti-breast cancer agent.

Design, synthesis, and evaluation of a novel series of alpha-substituted phenylpropanoic acid derivatives as human peroxisome proliferator-activated receptor (PPAR) alpha/delta dual agonists for the treatment of metabolic syndrome.

A series of alpha-alkyl-substituted phenylpropanoic acids was prepared as dual agonists of peroxisome proliferator-activated receptors alpha and delta (PPARalpha/delta). Structure-activity relationship studies indicated that the shape of the linking group and the shape of the substituent at the distal benzene ring play key roles in determining the potency and the selectivity of PPAR subtype transactivation. Structure-activity relationships among the amide series (10) and the reversed amide series (13) are similar, but not identical, especially in the case of the compounds bearing a bulky hydrophobic substituent at the distal benzene ring, indicating that the hydrophobic tail part of the molecules in these two series binds at somewhat different positions in the large binding pocket of PPAR. alpha-Alkyl-substituted phenylpropanoic acids of (S)-configuration were identified as potent human PPARalpha/delta dual agonists. Representative compounds exhibited marked nuclear receptor selectivity for PPARalpha and PPARdelta. Subtype-selective PPAR activation was also examined by analysis of the mRNA expression of PPAR-regulated genes.

[Pilot study of primary systemic chemotherapy with docetaxel (DOC), epirubicin (EPI) and capecitabine (Xeloda) in patients with advanced breast cancer].

We evaluated the safety and efficacy of primary systemic chemotherapy (PSC) with docetaxel (DOC), epirubicin (EPI) and capecitabine (Xeloda:XLD) in 10 patients with advanced breast cancer. Their mean age was 54.7 years,and preoperative stages were IIB, seven cases; IIIA, two; and IV, one,respectively. The regimen consisted of XLD (2,400 or 3,000 mg/day) orally for 14 consecutive days, and DOC (60 or 70 mg/m2) and EPI (50 or 60 mg/m2) intravenously on day 8. This was repeated 4 times every 3 weeks. One patient discontinued this regimen after one course at her own request. Although the results revealed leucopenia and neutropenia of more than grade 3 in 8 and 10 patients,they could be treated on an outpatient basis with the use of G-CSF to maintain this regimen. Alopecia of grade 2 was found in all patients,neutropenic fever of more than 38.5 degrees C in 5,and hand-foot syndrome in 3. Downstaging after PSC was demonstrated in 7 cases (Stage IIB to I, three cases; IIB to IIA, three; and III A to I, one), with a response rate of 77.8%. Breast conserving therapy was performed in 8/10 patients. Pathological findings on cytological degeneration showed grade 0, one; grade 1a,seven; grade 2, one; and grade 3, one, respectively. Axillary lymph node metastasis was revealed in 7 cases. This regimen would be an alternative to PSC on an outpatient basis while taking great care of myelosuppression and hand-foot syndrome.

Laryngeal tuberculosis following laryngeal carcinoma.

Laryngeal tuberculosis is a rare entity and the disease related to laryngeal cancer is extremely rare. We describe a case of laryngeal tuberculosis in a 74-year-old man with a history of radiotherapy for laryngeal carcinoma four months earlier. Laryngoscopy demonstrated a white mass on the right vocal fold at the site carcinoma had previously occupied. Recurrence of the cancer was suspected, but the biopsy result showed histological features of tuberculosis. We discuss the derangement of the host's mucosal barrier by the malignancy as a contributing factor in secondary tuberculous infection. Tubercular bacilli may be reactivated due to the immunosuppression associated with the therapy.

Endoscopic transantral orbital floor repair with antral bone grafts.

OBJECTIVE: To evaluate the endoscopic transantral insertion of antral bone grafts into the orbit for repair of orbital floor defects. DESIGN: A retrospective analysis with a mean follow-up of 5.3 months. PATIENTS: Eleven patients who underwent surgical repair of orbital floor fractures. SETTING: Municipal hospital. MAIN OUTCOME MEASURES: Preoperative and postoperative Hess screen tests and the presence of diplopia, enophthalmos, donor site complications, cosmetic deformity, infection, and graft extrusion. RESULTS: Subjectively, 3 patients with diplopia had complete resolution of their symptoms after surgery, and 8 patients had improvement of their symptoms. Objectively, 11 patients had significant improvement in the postoperative Hess area ratio compared with the preoperative Hess area ratio. In 1 patient with a floor defect measuring 2.5 cm, enophthalmos existed after surgery, but reoperation was not performed in this case because diplopia was improved. There were no donor site complications, cosmetic deformity, infection, or graft extrusion. CONCLUSIONS: The endoscopic transantral insertion of antral bone grafts through the floor defect into the orbit is an effective technique that prevents injury to the lower eyelid, carries minimal donor site morbidity, and provides an optimal support function for the globe. It merits consideration in cases of orbital defects less than 2 cm in diameter.

Brain herniation into the middle ear following temporal bone fracture.

Otorrhea of leaked cerebrospinal fluid and meningitis in a 33-year-old male originated from an encephalic herniation into the middle ear following traumatic temporal bone fracture. CT demonstrated a mixed-type fracture consisting of a longitudinal fracture and a posterior oblique fracture of the left temporal bone. The left tegmen tympani was broken into a bellows-like shape and a bone splinter from it had stuck in the epitympanum at the level of the incus body. Surgery via a middle cranial fossa approach confirmed penetration of the brain tissue between the incus and lateral semicircular canal. The diagnosis and management of this condition are discussed in the context of a literature review.

[Experience with capecitabine in patients with anthracycline and/or taxane-resistant recurrent breast cancer].

We evaluated the safety and efficacy of capecitabine in 12 patients with anthracycline and/or taxane-resistant metastatic breast cancer on an outpatient basis. Their mean age was 57 years, and they previously received chemotherapy consisting of anthracycline in 7 cases, taxane in 12 and doxifluridine in 8. Their mean disease-free interval was 28.5 months, HER 2/neu and ER and/or PgR-positive was shown in 2 and 8 cases, respectively. The recurrent sites were lymph node in 9 cases, lung in 6, skin in 5, pleural effusion in 4, liver, bone and pleura in 3, brain and CBS in 2, and thyroid, ascites and pericardial effusion in one, respectively. The administration dose was 2,400 mg/day in 11 cases and 3,000 mg/day in one. Capecitabine was administered orally for 21 consecutive days followed by a one-week rest. The mean follow-up period was 6.5 months. The overall response rate was 18.2% in 11 cases, including 2 partial responses, 4 stable diseases and 5 progressive diseases. Clinical benefit was 36.4% including two long stable diseases. The mean time to treatment failure was 6.5 months. Adverse events included Hand-Foot Syndrome in 5 cases, nausea in 3, diarrhea, appetite loss and high fever in one, respectively. In two of them administration was discontinued due to adverse events. Capecitabine had satisfactory effects with tolerable adverse events for anthracycline- and/or taxane-resistant metastatic breast cancer.

Risk of second primary malignancy after esophagectomy for squamous cell carcinoma of the thoracic esophagus.

PURPOSE: To assess the risk of subsequent malignancies after esophagectomy for squamous cell carcinoma of the thoracic esophagus for the establishment of an adequate follow-up program. PATIENTS AND METHODS: We statistically analyzed clinical factors in 114 cases of second malignancy after esophagectomy that developed in 94 of 679 patients who underwent curative resection. The cancer incidence rates in the general population estimated by the Research Group for Population-Based Cancer Registration in Japan were used as standards for comparison. RESULTS: The 10-year cumulative risk of second malignancy was 34.5%, and the overall relative risk (RR) was 2.98 (95% CI, 2.41 to 3.65). The risk of head and neck cancer was markedly elevated (RR, 34.9; 95% CI, 24.3 to 48.6), followed by the risks of lung cancer (RR, 3.24; 95% CI, 1.89 to 5.19) and stomach cancer (RR, 2.00; 95% CI, 1.17 to 3.21). Multifactor analysis demonstrated that independent factors affecting the risk of subsequent malignancies were presence of other malignancies detected before esophagectomy and any of the following factors: masculine sex, alcohol consumption, and smoking. The 5-year survival rate after detection of subsequent malignancy was 45%. The outcome in patients with subsequent head and neck cancer was significantly less favorable as a result of difficulty in early detection. CONCLUSION: Patients had a remarkably high risk of subsequent cancer of the upper aerodigestive tract after esophagectomy, in particular, head and neck cancer. Minute postoperative surveillance is strongly recommended, especially in patients with a history of malignancies before esophagectomy. Early detection of second malignancies allowed less invasive treatment with favorable outcome.