Comparison of mirabegron and vibegron for clinical efficacy and safety in female patients with overactive bladder: a multicenter prospective randomized crossover trial.

PURPOSE: To compare the efficacy and safety of mirabegron and vibegron in female OAB patients. METHODS: We conducted a multicenter, prospective, randomized crossover study of female patients with OAB. The patients were assigned to Group MV (mirabegron for 8 weeks, followed by vibegron for 8 weeks) or group VM (vibegron for 8 weeks, followed by mirabegron for 8 weeks). The primary endpoint was the change in OABSS from baseline, and the secondary endpoint was the change in FVC parameters. After completion of the study, each patient was asked which drug was preferable. RESULTS: A total of 83 patients were enrolled (40 and 43 in groups MV and VM, respectively). At 8th and 16th week, 33 and 29 in Group MV and 34 and 27 in Group VM continued to receive the treatment. The change in PVR was not significantly different between treatment with mirabegron and vibegron. The changes in OABSS, nighttime frequency, mean, and maximum voided volume were similar between mirabegron and vibegron. The mean change in the daytime frequency was greater in the vibegron than in the mirabegron. Of the 56 patients, 15 (27%) and 30 (53%) preferred mirabegron and vibegron, respectively. The remaining 11 patients (20%) showed no preference. The change in the urgency incontinence score during vibegron was better in patients who preferred vibegron to mirabegron. CONCLUSION: The efficacies of mirabegron and vibegron in female patients was similar. The patients' preference for vibegron could depend on the efficacy of vibegron for urgency incontinence.

Reviving Sternheimer stain: A single-center retrospective study to detect the diagnostic utility of urinary tract infections in the emergency department.

INTRODUCTION: Qualitative urinalysis using the Sternheimer stain is a common method in Japan for identifying bacteriuria, but there is a lack of studies examining its test characteristics. In this study, we aimed to investigate the sensitivity and specificity of the Sternheimer stain for urine culture results and compare it with the sensitivity and specificity of the Gram stain. Our goal was to determine the usefulness of the Sternheimer stain in identifying bacteriuria. PATIENTS AND METHODS: Among 986 patients aged 16 years or older from whom samples for both urinalysis and urine culture were obtained at the emergency room of Tenri Hospital from January 2019 to December 2019, 342 patients with pyuria, defined as the presence of 10 or more white cells per cubic millimeter in a urine specimen, who had not received prior antimicrobial therapy were included. Urine cultures were used for comparison to determine the sensitivity and specificity of Sternheimer and Gram stain in this patient group. A positive Sternheimer stain result was defined as bacteriuria ≥ (1+), and that of Gram stain was defined as ≥ 1/1 field of high-power ( × 1000) oil immersion. RESULTS: Using urine culture results for comparison, the sensitivity of Sternheimer stain was 92.2%, the specificity was 48.5%, the positive likelihood ratio was 1.79, and the negative likelihood ratio was 0.16. DISCUSSION: Sternheimer stain is a rapid and useful method to exclude bacteriuria in a group of patients with pyuria in the emergency department.

Gap analysis between trainees' subjective competencies and the competencies expected by instructors in urology: A need assessment survey in Japan.

OBJECTIVE: According to the rapid progress in surgical techniques, a growing number of procedures should be learned during postgraduate training periods. This study aimed to clarify the current situation regarding urological surgical training and identify the perception gap between trainees' competency and the competency expected by instructors in Japan. METHODS: Regarding the 40 urological surgical procedures selected via the Delphi method, we collected data on previous caseloads, current subjective autonomy, and confidence for future skill acquisition from trainees (<15 post-graduate years [PGY]), and the competencies when trainees became attending doctors expected by instructors (>15 PGY), according to a 5-point Likert scale. In total, 174 urologists in Hokkaido Prefecture, Japan were enrolled in this study. RESULTS: The response rate was 96% (165/174). In a large proportion of the procedures, caseloads grew with accumulation of years of clinical practice. However, trainees had limited caseloads of robotic and reconstructive surgeries even after 15 PGY. Trainees showed low subjective competencies at present and low confidence for future skill acquisition in several procedures, such as open cystectomy, ureteroureterostomy, and ureterocystostomy, while instructors expected trainees to be able to perform these procedures independently when they became attending doctors. CONCLUSION: Trainees showed low subjective competencies and low confidence for future skill acquisition in several open and reconstructive procedures, while instructors considered that these procedures should be independently performable by attending doctors. We believe that knowledge of these perception gaps is helpful to develop a practical training program.

[Association between social participation and frailty among older adults: A longitudinal study from Japan Gerontological Evaluation Study].

Objective　In Japan, measures to prevent frailty among older adults have been implemented. Promotion of social participation is a key measure, but few longitudinal studies have examined the relationship between the types and number of social participation and frailty onset. In this study, we aimed to clarify the relationship between the types and number of social participation and frailty onset using longitudinal data from a large sample of older adults in municipalities in Japan.Methods　We used the 2016 and 2019 panel survey data from the Japan Gerontological Evaluation Study (JAGES). The analysis included 59,545 individuals from 28 municipalities who responded to the JAGES survey in both 2016 (at baseline) and 2019 (at follow-up). We excluded individuals who were dependent on activities of daily living at baseline and non-responders, and those who were frail or with no information about frailty. The dependent variable was frailty onset (≥8 out of 25 points on the basic checklist) at follow-up, and the independent variables were the types and number of types of social participation at baseline. We included 11 variables as potential confounders. We used multiple imputations to complete the missing values and used modified Poisson regression to examine the association between social participation and risk of frailty onset.Results　Of the 59,545 participants, 6,431 (10.8%) were frail onset at follow-up. After multiple imputations (minimum 64,212, maximum 64,287), the risk of frailty onset at follow-up was lower for eight types of social participation, excluding senior citizens' clubs, (nursing care [risk ratio; 0.91], paid work [0.90], volunteer groups [0.87], neighborhood associations [0.87], learning or cultural groups [0.87], activities intended to teach skills or pass experiences to others [0.85], hobby groups [0.81], and sports groups or clubs [0.80]; P<0.05), than no social participation. Additionally, individuals who participated in more types of social participation were at a lower risk of frailty than those with no social participation (P for trend <0.001).Conclusions　The risk of frailty onset was lower among individuals who participated in eight types of social participation at baseline and among those who participated in more types of social participation than those with no social participation. The results suggest that social participation is a useful measure to prevent frailty for extending healthy life expectancy.

[Pre-Operative Factors Affecting Trifecta Achievement in the Initial Series of Robot-Assisted Partial Nephrectomy].

We investigated pre-operative factors affecting trifecta achievement in robot-assisted partial nephrectomy (RAPN). We retrospectively analyzed 81 patients who underwent RAPN from December 2016 to September 2021 with final malignant pathologies. Trifecta was defined as negative resection margin (RM),warm ischemic time (WIT) less than 25 minutes, and no severe perioperative complications (Clavien-Dindo＜III). Factors affecting trifecta achievement were analyzed using sex, age, body mass index, RENAL nephrometry score (low or moderate/high complexity), surgical approach (transabdominal or retroperitoneal), tumor diameter and surgical experiences of each surgeon. Negative RM, WIT less than 25 minutes, and no severe complications were obtained in 75 (93%), 65 (80%), and 79 patients (98%), respectively. The trifecta was achieved in 60 patients (74%). In multivariate regression analysis, surgical experience (OR:0.92, 95% CI : 0.86-0.99) was significantly associated with trifecta achievement. Receiver operating characteristic curve analysis identified 9 cases as the optimal cut-off values for the predication of trifecta achievement (AUC＝0.69,p ＝0.11). The achievement of WIT less than 25 minutes (65 vs 90%, p＜0.01) and trifecta (58 vs 84%,p ＜0.05) were significantly lower in surgical experiences less than 9 cases than in 9 or greater. We conclude that surgical experience in RAPN is an important factor affecting WIT and trifecta achievement in the initial series.

[Clinical Significance of Preoperative Image Classification Systems in Robot-Assisted Laparoscopic Partial Nephrectomy].

Robot-assisted laparoscopic partial nephrectomy (RAPN) is being used in Japan as a less invasive procedure. RENAL nephrometry (RN) score, Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) Classification and Simplified PADUA Renal (SPARE) nephrometry system are tumor-specific morphometry scoring systems used for predicting the difficulty of partial nephrectomy. Adherent perinephric fat (APF) is one of the patient-specific factors related to the difficulty of partial nephrectomy. Mayo Adhesive Probability (MAP) score measures the difficulty of partial nephrectomy due to APF. Whether these scoring systems were associated with perioperative outcome of RAPN was retrospectively analyzed in 57 patients who underwent RAPN by two experienced surgeons at our hospital from December 2016 to March 2020. Forty-five patients were male and 12 were female. The right side was resected in 25 and the left side in 32 patients. The approach was transperitoneal in 42 and retroperitoneal in 15 patients. There were significant correlations among RN, PADUA and SPARE scores, while MAP score was independent from the other scores. Warm ischemic time was significantly correlated with RN (r＝0.46, p＜0.001), PADUA (r＝0.45, p＜0.001) and SPARE scores (r＝0.44, p＜0.001). Time for console was significantly correlated with MAP score (r＝0.28, p＝0.035). In conclusion, RN and MAP scores might be useful parameters to predict warm ischemic time and time for console during RAPN, respectively.

[Comparison of Perioperative Outcomes between Open and Robot-Assisted Laparoscopic Radical Cystectomy].

We compared the perioperative outcomes of open (ORC) and robot-assisted laparoscopic radical cystectomy (RARC) for patients with bladder cancer. We retrospectively investigated the intraoperative and 90-day postoperative complications of ORC and RARC performed from March 2014 to September 2021 based on the medical records. Perioperative complications were categorized according to the Clavien- Dindo classification. We used the propensity score matching to adjust for the inherent bias of the different patient characteristics at baseline including gender, age, preoperative chemotherapy, and pathological T classification. Surgery time of RARC was significantly shorter than that of ORC, and blood transfusion was significantly less frequent in RARC than in ORC (3% vs 81%, p＜0.01). The rate of overall complications of Grade III/IV was lower in RARC (8%) than in ORC (25%) (P＝0.09). The prevalence of perioperative urinary tract infection, ileus, and abscess/infectious cyst was similar in ORC and RARC. In patients who underwent RARC, the complication rate was similar in extracorporeal and intracorporeal urinary diversion. Compared to ORC, RARC is more beneficial to reduce blood loss and severe complications.

[Treatment Outcome of Ureteral Reconstruction Surgery].

We retrospectively reviewed the surgical outcome of ureteral reconstruction that was performed in Asahikawa Medical University Hospital between 2005 and 2021. A total of 14 patients (3 males, 11 females; 15 ureters) were included in this analysis. The median age was 57 years old. The reason for ureteral reconstruction was ureteral injury or stenosis due to pelvic surgery in 9 patients, transurethral lithotripsy for ureteral stone in 3, ureteral invasion of sigmoid colon cancer in one and ovarian cancer in one. The site of ureteral reconstruction was proximal ureter in 2, middle in 3 and distal in 10. The surgical procedure was ureteroneocystostomy with Boari flap in 8 patients (57%), ureteroureterostomy in 4 (21%), transureteroureterostomy in one (7%), and transureteroureterostomy combined with Boari flap for bilateral ureteral stenosis in the remaining patient (7%). Postoperatively, vesicoureteral reflux, ileus and surgical site infection were observed in 3, 2 and 1 patient, respectively. No patient required nephrostomy or ureteral catheter, or any additional procedure after the surgery. There was no episode of febrile urinary tract infection after the surgery. The mean estimated glomerular filtration rate was, respectivery 75.8 and 78.5 ml/min/1.73 m2 before surgery and at 1-101 months (median of 18) after the surgery. In conclusion, satisfactory outcome was achieved after ureteral reconstruction surgery. We emphasize the importance of selecting the most appropriate procedure for ureteral reconstruction in each patient to prevent renal function deterioration and urinary tract infection.

Comparison of Microorganism Detection, Time to Positivity, and Time-Dependent Shift in Viable Bacterial Count from VersaTREK and BacT/ALERT 3D Blood Culture Systems.

Rapid positive blood culture reporting allows early and appropriate treatment of severe infections to improve patient prognosis. This study evaluated performance of the VersaTREK system with gas pressure detection and tornado stirring method and the conventional BacT/ALERT 3D system. Time to positivity (TTP) of simulated blood cultures without whole blood using 17 ATCC strains was faster with VersaTREK than BacT/ALERT 3D, averaging 6.3 h in aerobic bottles and 12.7 hours in anaerobic bottles. In simulated blood cultures with whole blood using 53 clinical isolates, on average, VersaTREK was faster in aerobic bottles by 6.5 h but slower in anaerobic bottles by 3.8 h. Fifty of 53 simulated blood cultures with whole blood (94%) showed fastest TTP with VersaTREK. TTP of VersaTREK for anaerobic bacteria Bacteroides fragilis and Clostridium perfringens, Helicobacter cinaedi, and Candida glabrata was fast, and viable bacteria numbers in bottles using the Miles and Misra method increased quickly.

Fecal carriage and molecular epidemiologic characteristics of carbapenemase-producing Enterobacterales in primary care hospital in a Japanese city.

BACKGROUND: The worldwide spread of organisms with antimicrobial resistance is of concern, especially the trend of significantly increasing carbapenemase-producing Enterobacterales (CPE). In this study, we investigated the annual trend of intestinal CPE carriage rates in inpatients and healthy adults in a primary care hospital in Tenri, Japan. METHODS: We collected 551 samples of feces from inpatients in our institution and 936 samples from healthy people living in Tenri city from December 2012 to April 2015. All samples were cultured on MacConkey agar plates containing 4 µg/mL ceftazidime for screening test. The colonies grown on the screening medium were detected for carbapenemase genes (blaIMP-1, blaIMP-2, blaVIM, blaKPC, blaGES, blaNDM, and blaOXA-48 groups) by multiplex PCR, and CPE were identified by MALDI-TOF MS. Plasmid replicon typing and pulsed-field gel electrophoresis (PFGE) were performed on PCR-positive strains. RESULTS: The CPE carriage rate was 1.6% (9/551) in the inpatient group and 0% (0/936) in the healthy adults group. The numbers of strains positive for the carbapenemase gene were 4 for Enterobacter cloacae, 2 for Klebsiella pneumoniae, 1 for Citrobacter freundii, 1 for Raoultella ornithinolytica and 1 for Escherichia coli. In all CPE strains, the carbapenemase gene was blaIMP-6 and the plasmid replicon type was IncN. The 4 E. cloacae strains showed a similar pattern in PFGE. CONCLUSION: In the same city in Japan, CPE intestinal carriers were detected only in the inpatient group in this study but not in a healthy adults, suggesting that the spread of asymptomatic CPE carriers was confined to inpatients.

Persistence Rate with Tadalafil for Treatment of Male Lower Urinary Tract Symptoms.

OBJECTIVES: We examined the persistence rate with tadalafil for treatment of male lower urinary tract symptoms (LUTS) and explored the factors relevant to withdrawal. PATIENTS AND METHODS: We retrospectively collected the data of male patients who received tadalafil treatment for LUTS. The persistence rate and the reason for withdrawal were investigated. RESULTS: A total of 155 patients were examined. Mean age and mean observation period were 71.9 (48-93) years and 15.1 (1-52) months, respectively. During the observation period, 74 patients (48%) withdrew tadalafil. The Kaplan-Meier curve indicated a 58% persistence rate at 1 year. The reasons for withdrawal included insufficient efficacy (31 patients, 42%), adverse events (21 patients, 28%), or symptom improvement (8 patients, 11%). Patients who continued tadalafil were significantly younger than those who withdrew it due to insufficient efficiency (71.4 ± 9.6 vs. 74.9 ± 9.1 years). CONCLUSIONS: Most patients withdrew tadalafil due to insufficient efficacy. Older patients are likely to withdraw the treatment because of insufficient efficacy, thus, tadalafil for male LUTS could be more effective for younger patients.

[Initial Experiences of Dynamic Sentinel Lymph Node Biopsy (DSNB) in Patients with Penile Cancer].

We present 2 cases of penile cancer in which the inguinal lymph node was not palpable and inguinal lymph node dissection (ILND) could be safely avoided by conducting dynamic sentinel lymph node biopsy (DSNB). The first case was in a 54-year-old man complaining of penile tumor for at least 3 months. We performed partial penectomy and DSNB. The pathological diagnosis was squamous cell carcinoma (SCC), pT2-3. There was no cancer metastasis in sentinel nodes (0/2). There has been no recurrence for 6 years after operation. The second case was 65-year-old man suffering from penile tumor for at least 6 months. We performed partial penectomy and DSNB. The pathological diagnosis was SCC,pT2. There was no cancer metastasis in sentinel nodes (0/3). There has been no recurrence for 1 year after operation. ILND has been recommended for intermediate and high-risk penile cancer even in patients with non-palpable inguinal lymph nodes. However,the complication of ILND is very high. DSNB has the potential to avoid ILND if there is no cancer metastasis in sentinel nodes.

[Relationship between Early Complications after Radical Cystectomy and Psoas Muscle Mass].

Psoas muscle mass index (PMI) is related to sarcopenia. We examined whether PMI is associated with early complications after radical cystectomy. Seventy one male and 29 female patients who were 65 years old or older and who had undergone radical cystectomy at our hospital from April 2005 to March 2018 were retrospectively analyzed. Psoas muscle section area was measured manually on preoperative computed tomography (CT) scan and normalized by patient's height. Early postoperative complications of grade 3 or more occurred in 12 male (16.9%) and 5 female (17.2%) patients. PMI was lower in male patients who had early postoperative complications of grade 3 or more than in those without complications (5.61 vs 6.54 cm2 /m2, p=0. 08), although the difference was not statistically significant. There was suggested to be a relationship between early postoperative complications after radical cystectomy and preoperative PMI in elderly male patients.

A case report of pulmonary Botrytis sp. infection in an apparently healthy individual.

BACKGROUND: Botrytis species are well known fungal pathogens of various plants but have not been reported as human pathogens, except as allergenic precipitants of asthma and hypersensitivity pneumonitis. CASE PRESENTATION: The asymptomatic patient was referred because of a nodule revealed by chest X-ray. Computed tomography (CT) showed a cavitary nodule in the right upper lobe of the lung. He underwent wedge resection of the nodule, which revealed necrotizing granulomas and a fungus ball containing Y-shaped filamentous fungi, which was confirmed histopathologically. Culture of the specimen yielded white to grayish cotton-like colonies with black sclerotia. We performed multilocus gene sequence analyses including three single-copy nuclear DNA genes encoding glyceraldehyde-3-phosphate dehydrogenase, heat-shock protein 60, and DNA-dependent RNA polymerase subunit II. The analyses revealed that the isolate was most similar to Botrytis elliptica. To date, the pulmonary Botrytis sp. infection has not recurred after lung resection and the patient did not require any additional medication. CONCLUSIONS: We report the first case of an immunocompetent patient with pulmonary Botrytis sp. infection, which has not recurred after lung resection without any additional medication. Precise evaluation is necessary for the diagnosis of pulmonary Botrytis infection because it is indistinguishable from other filamentous fungi both radiologically and by histopathology. The etiology and pathophysiology of pulmonary Botrytis infection remains unclear. Further accumulation and analysis of Botrytis cases is warranted.

Long-term symptomatic outcome after transurethral resection of the prostate: A urodynamics-based assessment.

OBJECTIVES: To examine the long-term outcomes of transurethral resection of the prostate. METHODS: We retrospectively collected the data of patients who had undergone transurethral resection of the prostate before December 2010. Patients had been evaluated by urodynamics and the International Prostate Symptom Score preoperatively, and they were re-evaluated by using the International Prostate Symptom Score at the minimum 7 years after transurethral resection of the prostate. Patients who received any treatments to improve voiding symptoms were defined as having a relapse of voiding dysfunction. The Schäfer nomogram was used to assess the degree of obstruction and detrusor contractility. We assessed the change in International Prostate Symptom Score over time depending on obstruction (Schäfer grade 3-6) versus no obstruction (Schäfer grade 0-2), and normal detrusor contractility (strong and normal) versus detrusor underactivity (weak and very weak). Relapse rates of voiding dysfunction were determined using the Kaplan-Meier method. RESULTS: A total of 39 patients were included. The mean age at transurethral resection of the prostate was 69.8 years, and the mean observation period after transurethral resection of the prostate was 114 months. During the observation period, eight patients (21%) were categorized as relapse of voiding dysfunction and the mean time to relapse was 4.2 years. Patients categorized as no obstruction or detrusor underactivity had a higher recurrence rate of voiding dysfunction with a statistical significance between those with versus without obstruction. Except for patients with relapse of voiding dysfunction, improvement of the International Prostate Symptom Score was maintained over a period of 10 years after transurethral resection of the prostate. CONCLUSIONS: Favorable long-term symptomatic outcome after transurethral resection of the prostate is likely in patients with urodynamic obstruction. Patients without urodynamic obstruction are likely to have a relapse of voiding symptoms and require additional treatments in the long term.

[A Case of Adenocarcinoma of the Reconstructed Bladder 45 Years after Ileocystoplasty].

The patient was a 66-year-old man who had undergone ileocystoplasty and right nephrectomy at the age of 21 for the treatment of urinarytract tuberculosis. He had been receiving hemodialysis from the age of 58. Regular computed tomography (CT) examination at the age of 63 revealed a bladder mass, but the transurethral biopsyof the bladder mass did not reveal malignant findings. At the age of 66, his urine cytology indicated a suspicion of malignancy, and bladder tumor was detected by cystoscopy. The patient was referred to our hospital and we performed transurethral resection of the bladder tumor. Pathological diagnosis was papillaryadenocarcinoma. Because left lower ureteral cancer was also suspected byCT scan, we performed left nephroureterectomy and radical cystectomy. Pathological examination revealed adenocarcinoma of the reconstructed bladder. The patient remains free of disease for 1 year and 11 months after the operation. Forty-five cases of bladder cancer after enterocystoplasty have been reported in Japan. There are no guidelines for follow-up protocols after enterocystoplasty. A long-term follow-up is mandatory because of the possibilityof development of bladder malignancylong after the enterocystoplasty.

Molecular epidemiology of carbapenemase-producing Enterobacteriaceae in a primary care hospital in Japan, 2010-2013.

Recently, carbapenemase-producing Enterobacteriaceae (CPE) have been spreading worldwide and have become a threat in healthcare systems. We investigated the isolation frequency and molecular epidemiological characteristics of CPE isolated from clinical samples collected at a primary care hospital over the four years of 2010-2013 in Japan. CPE were detected in 17 (0.34%) of 4875 isolates by the broth microdilution method, sodium mercaptoacetate inhibition test, and modified Hodge test using meropenem disks. The frequency of CPE isolates was 0.09% in 2010, 0.17% in 2011, 0.16% in 2012 and 0.82% in 2013. Isolates positive for carbapenemase included Klebsiella pneumoniae (0.92%), Escherichia coli (0.12%), Enterobacter cloacae (0.80%), Klebsiella oxytoca (0.55%), Enterobacter aerogenes (0.81%) and Proteus mirabilis (0.08%). Antimicrobial susceptibility testing showed low MICs for piperacillin-tazobactam, amikacin, ciprofloxacin and levofloxacin, and only one multidrug-resistant strain. The carbapenemase genotype of all strains was IMP-6, and 94% of the strains were simultaneous CTX-M-2 producers. Two K. pneumoniae and 3 E. coli isolates showed the same pulsed-field gel electrophoresis group. Multilocus sequence typing detected no international high-risk clone types. Plasmid replicon typing detected IncN from all CPE strains, and IncF and IncFIB were simultaneously detected in 24% and 18%, respectively. All patients with detected CPE were inpatients, and many were elderly long-term hospitalized patients or had a history of prior vancomycin or levofloxacin antibiotic administration. The rapid spread of CPE is a concern in Japan. Preventive measures must be implemented against the spread of CPE after considering the epidemiological trend of CPE detection, antibiograms, and risk factors.

[L-shaped Partial Upper Sternotomy Approach for Aortic Valve Replacement].

Transcatheter aortic valve implantation is a recent innovation in the treatment of severe aortic stenosis. On the other hand, several reports suggested that minimally invasive aortic valve replacement (MICS-AVR) is likely to be associated with reduced postoperative discomfort and faster recovery. Of note, an upper partial sternotomy for isolated aortic valve replacement( L-shaped MICS-AVR) has been accepted as the most common approach to the MICS-AVR. Since October 2013, we have preformed L-shaped MICS-AVR at our hospital. In L-shaped MICS-AVR group(16 patients, 74.4±8.7 years),there was no operative mortality and any other complication including reexploration for postoperative bleeding, wound infection, peri-valvular leakage, pulmonary complication like re-intubation or minitracheostomy. To demonstrate the benefits of this approach, over-octogenarian subgroup( n=7)was analyzed and compared with the isolated AVR using a conventional sternotomy (C-AVR, n=10)in the same period. A trend was seen toward better postoperative course in the L-shaped MICS-AVR group than in the C-AVR group;however, this difference was not statistically significant. The mean duration of cardiopulmonary bypass(120±29 min vs 93±24 min, p=0.005)and cross clamp time(151±36 min vs 124±32 min, p=0.038)were significantly longer than C-AVR. We believe that more clinical experience is required to clarify the benefits of this approach and we must more consider the preoperative images for the attainment of the excellent exposure. Moreover, the concomitant use of this new device and L-shaped MICS-AVR may enable a big improvement in the future.

Analysis of molecular epidemiologic characteristics of extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli colonizing feces in hospital patients and community dwellers in a Japanese city.

Infectious diseases caused by extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli are prevalent because of nosocomial infection. In addition, colonization of ESBL-producing E. coli in the intestinal tract of community dwellers due to the contamination of meat or environmental water is assumed to be one of the sources, but the causes have not been clarified. To analyze these factors, we investigated the difference in clonal groups using a combination of phylogenetic groups and multilocus sequence typing of ESBL-producing E. coli, which were obtained from the feces of an inpatient group in our hospital and a community-dwelling group living in a Japanese city. The carriage rate of ESBL-producing E. coli in the inpatient group was 12.5% (32/257), similar to that of 8.5% (42/496) in the community dwellers (P = 0.082). Of the ESBL clonal groups detected from the community dwellers, 52% (22/42) were clonal groups, including D-ST1485, D-ST70, D-ST2847, B2-ST550, B2-ST3510, A-ST93, A-ST580, A-ST716 and B1-ST2787, that have not been detected from human pathogens, meat, companion animals and environmental water, whereas all clonal groups detected from the inpatients were those that had already been reported. The rate of fluoroquinolone-resistant ESBL clonal groups colonizing the intestinal tract of the inpatient group rose as the number of hospital days increased. These results indicated that different factors were related to colonization of ESBL-producing E. coli in the feces of the inpatient group and the community-dwelling group.

[Aortic root replacement with the freestyle stentless bioprosthesis for infective endocarditis associated with aortic annular destruction].

Treatment of infective endocarditis (IE) associated with aortic annular destruction remains a formidable surgical challenge. Discussions about the optimum modality for reconstruction are still continuing. In such severe endocarditis, we have performed aortic root replacement using the Freestyle stentless bioprosthesis with the full root technique. From 2005 through 2012, 11 patients who had aortic valve endocarditis with annular destruction underwent aortic root replacement at our institute. All of them were treated with the Freestyle stentless bioprosthesis. Their mean age was 69.9 years, and 8 patients were men. Two patients had native valve endocarditis and 9 patients had prosthetic valve endocarditis. Despite appropriate antibiotic therapy, 3 patients required emergency surgery because of hemodynamic deterioration. In-hospital death occurred in 1 patient due to progressive hemodynamic failure. The 10 hospital survivors were followed up for a mean of 27.7±23.1 months (range 5 to 82). Although late death occurred in 2 patients, recurrent IE was not observed in any patients during the follow-up. The results of our study suggest that the Freestyle stentless bioprosthesis could be an excellent alternative to a homograft in the treatment of infective endocarditis associated with aortic annular destruction.