Microbiological and Clinical Profile of Uropathogenic Escherichia coli Isolates in Kathmandu University Hospital.

BACKGROUND: Treatment of patients infected by multidrug resistant bacteria is a major challenge. Immunocompromised status, prolonged hospital stay, malignancy, diabetes are some of the risk factors for emergence of multidrug resistance. Our study focused on microbiological and clinical profile of multidrug resistant uropathogenic Escherichia coli. METHODS: This was a cross-sectional study conducted between June 2014-May 2015 in Kathmandu University Hospital. Urine sample from outpatients and inpatients from which Escherichia coli isolated was included. Specimen collection, culture, identification tests were done following guidelines given by American Society for Microbiology. RESULTS: Total number of urine samples received during the study were 3,554. Escherichia coli isolates were 645(18.14%) and 245(37.98%) were Extended Spectrum Beta-Lactamase producer. Extended Spectrum Beta-Lactamase producers were found more among inpatients 148(60.41%) [p<0.001], patients with underlying urological abnormalities 38 (15.51%) [p=0.0039], pregnant ladies 46(18.77%) [p=0.0028], diabetic patients 27 (11.02%) [p=0.0084], patients who received prior antibiotic therapy 155 (63.26%) [p=0.0043] than Extended Spectrum Beta-Lactamase non-producer. Malignancy was seen more among Extended Spectrum Beta-Lactamase producer having patients 5 (2.04%) [p=0.031] and all these isolates were more resistant to fluoroquinolones 168(68.57%), Trimethoprim-sulfamethoxazole 239 (97.55%) [p=0.0633], aminoglycosides [p=0.0001] but only 2(0.80%) were resistant to carbapenems. CONCLUSIONS: Diabetes, pregnancy, malignancy, prior antibiotic therapy, underlying urological abnormalities were found associated with emergence of Extended Spectrum Beta-Lactamase producer in urine samples. Proper antibiotic usage may help to overcome the problem of emergence of antibiotic resistance.

Can health systems be enhanced for optimal health services through disease-specific programs? Results of field studies in Viet Nam and Cambodia.

Developing better health systems is the key to delivering optimal health services, although more evidence of effective strategies to do so is needed. Field surveys were conducted in Viet Nam and Cambodia to identify best practices in addressing health system bottlenecks to scale up disease control programs. The two countries were compared over time using a framework for analysis developed by the authors. In Viet Nam, a health system was in place for decades at the central to municipal levels, although it was fragile until the 1990s, when the government started taking measures. In Cambodia, the previous health system had been destroyed during previous internal conflict. In the post-conflict period, the health system was rebuilt with support for programs followed by centralization of health services. In different settings, different measures were taken to deal with similar bottlenecks. In Cambodia, vertical programs were dominant, so the government sought to centralize drug management to deal with shortages of essential drugs, while Viet Nam sought to mobilize resources to ensure drug distribution at all levels. This study shows there is no single successful approach to health systems, and a systemic approach needs to be taken because elimination of one bottleneck may reveal another. Efforts to enhance disease-specific programs may not always contribute to overall enhancement of the health system, and the best possible approach may not be the same in different countries. Further study is needed to explore common issues and principles for effective strategies to enhance health systems in different contexts.

The unilocular fat-cell graft.

Autologous fat grafting has become a common procedure for augmenting soft tissue. However, there are still some problems with resorption and cyst formation after injection, which mainly arise from insufficient nourishment of the transplanted fat tissues. In this study, using a mouse model, we enzymatically digested fat tissues into unilocular fat cells, and then transplanted the unilocular fat cells by sub-dermal injection to allow the transplanted cells to easily spread within the injected area. Fat tissue was harvested from a green fluorescent protein transgenic mouse (C57BL/6), and the optimal digestion time was determined to be 30 min. The fat cells were then injected into the sub-dermal layer of the head skin of a C57BL/6 mouse. As a control, minced fat without digestion was also injected. The animals were sacrificed immediately after injection and on days 1, 2 and 3, as well as at weeks 1, 2 and 4 after injection, and the recipient skins were collected for microscopic observation. The unilocular fat cells were observed to spread in a solitary manner among the recipient tissues, and no necrotic areas or cysts were observed. The minced-fat-graft control showed central necrosis in the transplanted region. In addition, the minced fat tissue needed to be injected with an 18-gauge syringe, but the unilocular fat cells could be injected with a 26-gauge syringe. Thus, the unilocular fat-cell graft was determined to be a superior alternative to conventional fat grafts.

Modulation of gonadotrophin-releasing hormone pulse generator activity by the pheromone in small ruminants.

In small ruminants, such as goats and sheep, a primer pheromone produced by males induces an out-of-seasonal ovulation in anoestrous females, a phenomenon known as the male effect. The male effect is unique in that an external chemical stimulus can immediately modulate the activity of the hypothalamic gonadotrophin-releasing hormone (GnRH) pulse generator. We have established a monitoring method of the GnRH pulse generator activity in Shiba goat. Using this method as a sensitive bioassay to assess the male effect pheromone activity, we have shown that the male effect pheromone is synthesised in an androgen-dependent manner in the sebaceous glands or their vicinity in specific body regions in goats. Although chemical identity of the pheromone is yet to be determined, analyses of male goat hair extracts by gas chromatography fractionation suggest that the male effect pheromone is a volatile substance with relatively small molecular weight. From morphological and molecular biological studies in goats, it is suggested that the pheromone molecule is detected by a member of the V1R family located on both the olfactory neurones and the vomeronasal sensory neurones, and the pheromone signal is conveyed to the medial nucleus of amygdala via the main olfactory and vomeronasal pathways and, subsequently, to the hypothalamic GnRH pulse generator to enhance its activity.

Alar groove plasty using a subcutaneous flap technique in bulbous nose repair after cleft lip plasty.

BACKGROUND: Bulbous nose is a ball-like nasal deformity, frequently seen in postoperative cleft lip patients, that is hard to prevent despite numerous techniques available for nasal tip plasty. Here we describe a new method for correcting bulbous nose in cleft lip patients by creating an ideal alar groove. METHODS: A subcutaneous flap with the pedicle of the overlying skin connected circumferentially is made just beneath the position for the ideal alar groove. The subcutaneous flap is fixed to the septum cartilage to create the alar groove depression on the nasal tip. This method is generally performed in conjunction with other rhinoplasty using the open nasal approach. RESULTS: Three postoperative cleft lip and nose patients underwent alar groove plasty combined with rhinoplasty. All retained good contour after the operation. CONCLUSION: Alar groove plasty using the subcutaneous flap technique improves bulbous nose deformities of cleft lip patients and can retain good postoperative contour.

Helicobacter pylori eradication decreases blood neutrophil and monocyte counts.

BACKGROUND: The effect of Helicobacter pylori infection on systemic disorders is not well understood. AIM: The purpose of this study was to elucidate the systemic effects of H. pylori infection by comparing differential counts of leukocytes and platelets in peripheral blood before and after eradication of H. pylori. METHODS: A total of 164 H. pylori-positive patients underwent eradication therapy, and populations of peripheral blood leukocytes and platelets before and 0 (just after therapy), 1, 3 and 12 months after eradication were retrospectively analysed. RESULTS: In the eradicated group (n = 138), blood leukocytes, neutrophils and monocytes decreased significantly after eradication, but there was no significant change in eosinophils, basophils, lymphocytes or platelets. In the non-eradicated group (n = 26), there was no significant change in any studied parameter. With regard to smoking status, although leukocytes and neutrophils did not decrease after eradication in the smoking group, they significantly decreased after eradication in the nonsmoking group. CONCLUSIONS: These findings suggest that: (1) H. pylori infection increases neutrophil and monocyte counts in the peripheral blood, which indicates a significant role of H. pylori infection in systemic disorders; and (2) Smoking may mask the effect of H. pylori eradication on peripheral leukocytes, which would explain the controversy in previous reports concerning H. pylori infection and peripheral leukocytes.

The protective effect of rebamipide on paracellular permeability of rat gastric epithelial cells.

BACKGROUND: Barrier function in gastric epithelial cells is essential for the gastric defence mechanism against acid back-diffusion into the mucosal layer. Our previous study indicated that trans-epithelial resistance (TER) of rat gastric epithelial cells was rapidly increased when the cells were exposed to acid. This response to acid was diminished by indometacin. AIM: Evaluate the effects of a mucoprotective agent, rebamipide, on the nonsteroidal anti-inflammatory drug (NSAID)-induced increase of gastric epithelial permeability. METHODS: Rat gastric epithelial cells were plated on tissue culture inserts. Cells were exposed to a NSAID (indometacin, 10-7 M). Trans-epithelial permeability was measured by TER and diffusion rate of 14C-mannitol. The effect of rebamipide was evaluated by measuring TER. Endogenous prostaglandin E2 (PGE2) production in culture medium was also measured. RESULTS: Indometacin gradually and significantly decreased TER and increased 14C-manitol permeability. Rebamipide reversed the indometacin-induced changes in epithelial permeability and induced PGE2 synthesis. This induction was blocked by either indometacin or a Cyclooxygenase (COX)-2 specific inhibitor. CONCLUSIONS: COX inhibitors such as indometacin inhibit regulation of epithelial permeability by reducing PGE2. COX-1 has an important role in the gastric defense mechanism. Rebamipide suppressed an indometacin-induced increase in gastric epithelial permeability by increasing PGE2 levels in a COX-2 dependent manner.

A solid cystic tumor of the pancreas with ossification and possible malignancy, coexisting nonfusion of the pancreatic ducts.

We report the case of a 34-year-old woman with a solid cystic tumor (SCT) of the pancreas accompanied by ossification and possible malignancy, coexisting nonfusion of the pancreatic ducts. There was a 24 x 29 x 33-mm mass with a prominent calcified lesion in the tail of the pancreas detected by abdominal ultrasonography, computed tomography, and magnetic resonance imaging. There were no distal metastases detected. Endoscopic retrograde pancreatography revealed nonfusion of the pancreatic ducts. The resected tumor consisted of solid and cystic components. The tumor was not encapsulated and included a severely ossified lesion inside. On microscopy, the tumor cells were small, eosinophilic, and proliferated in a solid or pseudo-papillary pattern. The tumor cells infiltrated into the surrounding normal pancreas parenchyma and invaded part of the mesentery. The immunostaining was positive for alpha-1-antitrypsin, neuron-specific enolase, vimentin, and chromogranin A. In the literature, only a few cases of SCT of the pancreas described ossification. As far as we know, only three cases of SCT of the pancreas, which demonstrated nonfusion of the pancreatic ducts, have been reported. Thus, SCT of the pancreas with ossification, possible malignancy, and coexisting nonfusion of the pancreatic ducts is extremely rare.

Involvement of the interaction between p21 and proliferating cell nuclear antigen for the maintenance of G2/M arrest after DNA damage.

Although a major effect of p21, a cyclin-dependent kinase inhibitor, is considered to be exerted during G(1) phase of the cell cycle, p21 gene knock-out studies suggested its involvement in G(2)/M checkpoint as well. Here we demonstrate evidence that p21 is required for the cell cycle arrest at G(2) upon DNA damage. We found that expression of wild-type p21 (p21(WT)), not mutant p21 (p21(PCNA-)) lacking the interaction with proliferating cell nuclear antigen (PCNA), caused G(2) cell cycle arrest in p53-deficient DLD1 colon cancer cell line after the DNA damage by treatment with cis-diamminedichloroplatinum (II). We also found that p21(WT) was associated with Cdc2/cyclin B1 together with PCNA. Furthermore, coimmunoprecipitation experiments revealed that PCNA interacted with Cdc25C at the G(2)/M transition, and this interaction was abolished when p21(WT) was expressed presumably due to the competition between p21(WT) and Cdc25C in the binding to PCNA. These findings suggest that p21 plays a regulatory role in the maintenance of cell cycle arrest at G(2) by blocking the interaction of Cdc25C with PCNA.

Pancreaticobiliary arteriovenous malformation with common bile duct dilation in a patient with hemobilia.

Arteriovenous malformation of the pancreas is a very rare entity. We describe a case involving the head of the pancreas associated with progressive hemobilia bleeding from the lower part of the common bile duct. The patient was a 50-year-old man with acute epigastralgia. Endoscopic retrograde cholangiopancreatography revealed hemobilia and cystic dilation of the common bile duct. Angiography demonstrated increased blood volume in the head of the pancreas and early filling of the superior mesenteric and portal veins. Abdominal pain and progressive anemia caused by hemobilia required surgical treatment. Histologic examination of the resected specimen revealed marked proliferation of the blood vessels in the pericholedochal area and the exact point of bleeding from the pancreaticobiliary arteriovenous malformation.

Percutaneous radio-frequency ablation therapy using a clustered electrode for malignant liver tumors.

GOALS: To examine the safety and effectiveness of percutaneous radio-frequency ablation therapy (PRAT) for malignant liver tumors, using a needle with cluster radio-frequency (RF) electrodes. STUDY: The subjects were 13 patients with solitary malignant liver tumors: 10 had hepatocellular carcinoma and 3 had metastatic liver tumors. One session of PRAT with cluster RF electrodes was performed until roll-off occurred two times. Dynamic computed tomography (CT) and fine needle tumor biopsy under ultrasonographic guidance were conducted to assess the therapeutic efficacy. Aspartate aminotransferase, alanine aminotransferase, lactic dehydrogenase, and total bilirubin were evaluated before and 1, 3, and 7 days after PRAT. RESULTS: There were no serious complications. Aspartate aminotransferase, alanine aminotransferase, and lactic dehydrogenase levels peaked 1 day after PRAT and decreased thereafter. No icterus occurred. Of the 13 tumors, 12 showed complete necrosis on dynamic CT; however, one of them showed histologically incomplete necrosis in the tumor biopsy. In both of the ineffective cases, the tumors were located near relatively large vessels. There was no recurrence in the liver in all cases of PRAT that were effective (observation periods: 6--14 months; mean, 10 months). CONCLUSIONS: Percutaneous radio-frequency ablation therapy using a clustered electrode is a safe and effective treatment of malignant liver tumors, if the tumor is not located near the large vessels.

Percutaneous radiofrequency ablation therapy using a clustered electrode in the animal liver.

BACKGROUND/AIMS: The aim of the present study was to examine the safety and effectiveness of percutaneous radiofrequency ablation therapy using a needle with cluster radiofrequency electrodes in an animal model. METHODOLOGY: A total of 10 radiofrequency applications were performed in the normal liver of 5 domestic pigs with real-time ultrasonography until roll-off occurred two times. Aspartate aminotransferase, alanine aminotransferase, lactic dehydrogenase, and total bilirubin were evaluated before the procedure and 1 h, 24 h, and 7 days following percutaneous radiofrequency ablation therapy. The animals were euthanized 1 or 2 weeks after percutaneous radiofrequency ablation therapy, and the livers were removed for gross and histopathologic analysis for coagulation necrosis. RESULTS: There were no complications in any of the experimental animals. Aspartate aminotransferase, alanine aminotransferase, and lactic dehydrogenase levels peaked 24 h following percutaneous radiofrequency ablation therapy, and decreased with time thereafter. Total bilirubin was not elevated in any of the animals at any time. Macroscopic examination revealed that the area of coagulated necrosis was 28 x 21 mm when using a 2.0-cm needle, and 41 x 35 mm when using a 3.5-cm needle. Coagulation necrosis did not occur near large vessels. Microscopic examination of the fixed tissue revealed that coagulation necrosis occurred in preserving lobular structure. CONCLUSIONS: Percutaneous radiofrequency ablation therapy using a clustered electrode is a safe and effective treatment for liver tumor. Incomplete coagulation necrosis, however, can occur when percutaneous radiofrequency ablation therapy is performed for tumors located near large vessels.

What are the appropriate indications for endoscopic mucosal resection for early gastric cancer? Analysis of 256 endoscopically resected lesions.

BACKGROUND AND STUDY AIMS: Although endoscopic mucosal resection (EMR) for early gastric cancer (EGC) without ulceration or scarring has been very popular in Japan and thought to be beneficial, curability by EMR is still lower than that for surgical resection. We investigated patients whose EGCs were resected endoscopically in order to identify the factors affecting curability by EMR. PATIENTS AND METHODS: We investigated retrospectively 256 EGC lesions (251 patients) which were subjected to EMR between 1989 and 1998 with respect to patient profile, macroscopic type, location, maximum diameter of tumors, resection method and histological typing. The prognoses of the patients were also investigated as far as possible. RESULTS: The curative total resection rate for EMR of EGC was 74.2 %. Concerning the factors affecting curability, the size of the lesion (over 15 mm), the method of resection (divisional resection), and histological typing (poorly differentiated) had a statistically significant effect on the complete resection rate. Multivariate analysis of the factors confirmed these results. Submucosal invasion was suspected in 16 patients after EMR, but submucosal cancer was found in only one patient after further surgery. Where there was recurrence, the longest recurrence-free period after EMR of EGC was 48 months, whereas the mean recurrence-free period was 195.4 days. CONCLUSIONS: The appropriate indication for EMR for EGC is thought to be an intramucosal differentiated-type adenocarcinoma without ulceration or scarring, and no more than 15 mm in size regardless of macroscopic type. Periodic follow-up for at least 5 years is necessary.

Inactivation of aerobic and hypoxic cells from three different cell lines by accelerated (3)He-, (12)C- and (20)Ne-ion beams.

The LET-RBE spectra for cell killing for cultured mammalian cells exposed to accelerated heavy ions were investigated to design a spread-out Bragg peak beam for cancer therapy at HIMAC, National Institute of Radiological Sciences, Chiba, prior to clinical trials. Cells that originated from a human salivary gland tumor (HSG cells) as well as V79 and T1 cells were exposed to (3)He-, (12)C- and (20)Ne-ion beams with an LET ranging from approximately 20-600 keV/micrometer under both aerobic and hypoxic conditions. Cell survival curves were fitted by equations from the linear-quadratic model and the target model to obtain survival parameters. RBE, OER, alpha and D(0) were analyzed as a function of LET. The RBE increased with LET, reaching a maximum at around 200 keV/micrometer, then decreased with a further increase in LET. Clear splits of the LET-RBE or -OER spectra were found among ion species and/or cell lines. At a given LET, the RBE value for (3)He ions was higher than that for the other ions. The position of the maximum RBE shifts to higher LET values for heavier ions. The OER value was 3 for X rays but started to decrease at an LET of around 50 keV/micrometer, passed below 2 at around 100 keV/micrometer, and then reached a minimum above 300 keV/micrometer, but the values remained greater than 1. The OER was significantly lower for (3)He ions than the others.

Two-dimensional changes of muscle fiber types in growing rat hind limb.

In the present study, we examined the changes in two-dimensional distribution of fiber types in the whole area of the rat skeletal muscle and the effect of growth on this distribution. Muscles of rats aged 3 (body weight 58 g), 4 (89 g), 8 (276 g), 12 (312 g), 18 weeks (368 g), and 6 months (450 g) were stained for myofibrillar adenosine triphosphatase (mATPase) with preincubation at pH 4.35. Muscle fibers were classified into type I (slow oxidative), IIA (fast oxidative), IIB (fast glycolytic), and IIX (fast oxidative glycolytic). The x-y coordinates of each fiber were used to analyze the growth-related changes using an image analyzing system. In the tibialis anterior (TA) muscle, type I fibers were predominant in the deep and middle regions at 3 to 4 weeks of age, but became restricted to the deeper region with growth. In the extensor digitorum longus (EDL) muscle, type I fibers were predominant in the deep region at 3 to 8 weeks of age, but decreased gradually with growth and completely disappeared at 6 months of age. Compared with the TA and EDL, type I fibers of the soleus (SOL) muscle were spread throughout the muscle and the number of these fibers tended to increase with growth. Type IIA and IIX fibers of the SOL decreased in number and became restricted to the superficial region with growth. No type IIB fibers were detected in the SOL throughout life. Our results indicated that the growing process influences the distribution, proportion and characteristics of individual muscle fiber types in the rat hind limb muscles.

Toxic shock syndrome after suction lipectomy.

We present a case of toxic shock syndrome with necrotizing fasciitis after suction lipectomy. The patient underwent aesthetic suction lipectomy of the abdomen, buttocks, and thighs during an office procedure by a cosmetic surgeon. On postoperative day 2, the patient was referred to the emergency department of our hospital because of pain. On admission, the patient was in toxic shock. She required intensive medical treatment for about 1 month, along with psychiatric help to adapt after the illness. Although toxic shock syndrome is a rare postoperative complication, every plastic surgeon should be acquainted with it. A combination of early recognition, diagnosis, and aggressive supportive therapy is the only successful treatment.

Evidence that de novo protein synthesis is dispensable for anti-apoptotic effects of NF-kappaB.

The transcription factor NF-kappaB is a positive transcription factor for a number of genes and has been recognized as an anti-apoptotic regulator. However, the mechanism by which NF-kappaB blocks apoptosis is still controversial. Here, we demonstrate the evidence that NF-kappaB could attenuate the TNF-alpha-induced apoptosis without de novo protein synthesis using human pancreatic cancer cell lines, MIA PaCa-2 and Capan-2. The TNF-alpha-induced apoptosis was blocked by IL-1beta, a potent inducer of NF-kappaB activation. This inhibitory effect of IL-1beta was evident when cells were treated with protein synthesis inhibitors such as cycloheximide (CHX). Moreover, NF-kappaB decoy oligonucleotides could not block the anti-apoptotic effect of IL-1beta at doses sufficient to block the NF-kappaB-dependent transcription induced by IL-1beta. To confirm the role of NF-kappaB in blocking apoptosis, we generated stable cell lines expressing IkappaBdeltaN, a highly stable form of IkappaBalpha, a cytoplasmic inhibitor of NF-kappaB. In these stable transfectants, the antiapoptotic effect of IL-1beta was totally abolished, indicating that the anti-apoptotic action of IL-1beta could be ascribed to the NF-kappaB action. These findings show that de novo protein synthesis is dispensable for anti-apoptotic effects of NF-kappaB and support the possibility that NF-kappaB could exert its anti-apoptotic action through protein-protein interaction.

Ascending cholangitis as a cause of pyogenic liver abscesses complicated by a gastric submucosal abscess and fistula.

Ruptures of nonamebic (pyogenic) liver abscesses into the thorax and peritoneum are very uncommon; but, hepatoduodenal and hepatocolonic fistulas are ever more rare. We report a case where ascending cholangitis was associated with pyogenic liver abscess formation and a gastric fistula. Drainage into the stomach was demonstrated by gastroduodenal endoscopy for gastric bleeding. After fistula formation, we could successfully treat the inflammation caused by infection of Citrobacter freundii and Candida albicans with intravenous infusion of both antibiotic and antifungal agents.

[A case of tuberculous uveitis complicated by myelodysplastic syndrome].

BACKGROUND: Recently, the incidence of tuberculosis in compromised hosts has increased. CASE: A 52-year-old man suffering from myelodysplastic syndrome (MDS) had pulmonary tuberculosis. On June 22, 1996, we found a disc-sized choroidal lesion with milky appearance on the paramacular in his right eye. After 1 month, a similar choroidal lesion was found near the disc in the same eye. In spite of chemotherapy for MDS and antituberculosis medications, those choroidal lesions gradually enlarged. In November, satellite lesions were found around them. Some retinal exudates and hemorrhage were also detected in both eyes. He died on April 6, 1997. We found Langhans' giant cells in the choroid on the specimen of his eyes. So we judged the choroidal lesions to be tuberculous uveitis. CONCLUSION: This case showed choroidal tuberculosis and choroidal miliary tuberculosis in the same eye that were resistant to medications. We thought resistance to medication was due to destruction of the immune system by MDS.