Trends in the susceptibility of methicillin-resistant Staphylococcus aureus to nine antimicrobial agents, including ceftobiprole, nemonoxacin, and tyrothricin: results from the Tigecycline In Vitro Surveillance in Taiwan (TIST) study, 2006-2010.

This study investigated the in vitro susceptibilities of methicillin-resistant Staphylococcus aureus (MRSA) to nine antimicrobial agents in Taiwan. A total of 1,725 isolates were obtained from 20 hospitals throughout Taiwan from 2006 to 2010. The minimum inhibitory concentrations (MICs) of the nine agents were determined by the agar dilution method. The MICs of mupirocin and tyrothricin were determined for 223 MRSA isolates collected from 2009 to 2010. For vancomycin, 99.7 % were susceptible; however, 30.0 % (n = 517) exhibited MICs of 2 µg/ml and 0.3 % (n = 6) demonstrated intermediate susceptibility (MICs of 4 µg/ml). Nearly all isolates (≥ 99.9 %) were susceptible to teicoplanin, linezolid, and daptomycin. The MIC90 values were 2 µg/ml for ceftobiprole and 1 µg/ml for nemonoxacin. The MIC90 values of mupirocin and tyrothricin were 0.12 and 4 µg/ml, respectively. MIC creep was noted for daptomycin during this period, but not for vancomycin, teicoplanin, linezolid, or tigecycline. For isolates with vancomycin MICs of 2 µg/ml, the MIC90 values were 2 µg/ml for teicoplanin, 0.5 µg/ml for daptomycin, and 0.5 µg/ml for tigecycline. Those values were four- to eight-fold higher than those among isolates with vancomycin MICs of 0.5 µg/ml (2, 0.06, and 0.12 µg/ml, respectively). Of the nine MRSA isolates exhibiting non-susceptibility to vancomycin (n = 6), teicoplanin (n = 1), daptomycin (n = 2), or tigecycline (n = 1), all had different pulsotypes, indicating the absence of intra-hospital or inter-hospital spread. The presence of a high proportion of MRSA isolates with elevated MICs (2 µg/ml) and MIC creep of daptomycin might alert clinicians on the therapy for serious MRSA infections in Taiwan.

Determination of phloroglucinol by HPLC-MS/MS and its application to a bioequivalence study in healthy volunteers.

OBJECTIVE: The aim of this study was to compare the pharmacokinetic characteristics of phloroglucinol between an orally disintegrating tablet and an orally lyophilized tablet of phloroglucinol in healthy volunteers under fasting condition. PATIENTS AND METHODS: A rapid and simple method based on high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method has been developed and validated for the determination of phloroglucinol in human plasma. The plasma sample was prepared by liquid-liquid extraction, and paracetamol was chosen as the internal standard. Phloroglucinol and IS were separated on a C18 column with a mobile phase consisted of methanol/water (80:20 v/v) with 0.02% formic acid. HPLC-MS/MS analyses were performed on a triple- quadruple tandem mass spectrometer by monitoring protonated parent→daughter ion pairs at m/z 125.0→56.9 for phloroglucinol, and m/z 150.2→107.0 for paracetamol (IS). The method was the high sensitivity with a lower limit of quantification (LLOQ) of 1.976 ng/mL. RESULTS: Drug and IS were detected by HPLC/MS/MS with negative electrospray ionization (ESI). Accuracy and precision for the assay were determined by calculating the intra- and inter-batch variation of quality control (QC) samples at three concentration levels. The relative standard deviation (RSD) was less than 15.0%. The detection and quantitation of drug and IS within 4.5 min make this method suitable for high-throughput analyses. In this study, the Cmax of phloroglucinol were calculated to 515.6 ± 134.4 ng/mL and 536.0 ± 144.8 ng/mL for the test drug and the reference drug, respectively. The AUC0-t values were 459.5 ± 81.03 ng·mL-1·h and 491.8 ± 95.17 ng·mL-1·h for the test drug and the reference drug; 24 subjects completed the study, respectively. The geometric mean ratio (GMR) and the 90% confidence intervals (CIs) of Cmax and AUC0-t of phloroglucinol were 97.1 (90.2-103.9) and 93.8 (88.7-99.2), respectively. CONCLUSIONS: The method was employed for the first time during pharmacokinetic studies of phloroglucinol in human plasma following a single dose of phloroglucinol 160 mg tablets. There was no significant difference in pharmacokinetic profiles between the two treatments.

The role of Schwann cell differentiation in perineural invasion of adenoid cystic and mucoepidermoid carcinoma of the salivary glands.

Twenty cases of adenoid cystic carcinoma (ACC) and 18 cases of mucoepidermoid carcinoma (MEC), were examined for expression of the Schwann cell markers S100 protein and glial fibrillary acidic protein (GFAP) by immunohistochemical staining. The relationship between expression of S100 and GFAP and the occurrence of perineural invasion was assessed. Ultrastructural localization of S100 and GFAP was examined by immunoelectron microscopy, and the co-expression of S100 and muscle actin by double fluorescence immunostain. Perineural invasion was found in 11 ACCs (55%) and 0 MECs (0%). S100 and GFAP were expressed in most of the ACCs but none of the MECs; the difference in the rate of perineural invasion and expression of S100 and GFAP was significant between ACC and MEC (P<0.001). There was a correlation between the expression of S100 and GFAP and perineural invasion in salivary malignancy (P<0.001). The ultrastructures of S100- and GFAP-positive cells were consistent with the characteristics of myoepithelial cells. Double fluorescence immunostain also showed that S100 and muscle actin were expressed in the same type of ACC cells. These results indicate that Schwann cell differentiation correlates with perineural invasion in salivary malignancy, and occurs in modified myoepithelial cells of ACC.

Transcatheter bronchial brush and forceps biopsies. Histologic evaluation.

The histologic findings in transcatheter brush and forceps biopsies from 472 cases over a six-year period are evaluated. Diagnostic accuracy based on histologic findings was 38% and based on cytologic findings was 70%. When the two methods of examination were used, however, the overall accuracy was improved to 76%. In Hodgkin's disease and some inflammatory processes histologic examination is essential for the diagnosis. The transcatheter biopsies under fluoroscopic control are especially useful for securing tissues from the peripherally located lesions. When possible, examination of tissue obtained by transcatheter as well as forceps biopsies is encouraged.

Limb salvage by percutaneous transluminal recanalization of the occluded superficial femoral artery.

Six patients with rest pain and gangrene or ulceration were treated by percutaneous transluminal angioplasty using the Grüntzig balloon catheter. All had superficial femoral artery occlusion with severe stenosis or occlusion of the popliteal and tibial arteries. Two patients had previous distal bypass procedures which had failed, and none was a candidate for arterial reconstruction. The superficial femoral artery was recanalized in five patients with an increase in the above-knee pressure index from 0.5 +/- 0.1 to 1.0 +/- 0.1 (P less than 0.001) and ankle pressure index from 0.2 +/- 0.1 to 0.5 +/- 0.1 (P less than 0.001). All five patients avoided early amputation and were able to ambulate when discharged. The sixth patient could not be recanalized and required above-knee amputation. Restenosis of the recanalized superficial femoral artery occurred in four patients 2 to 5 months later, and repeat transluminal angioplasty was successful in three patients. Two patients have required below-knee amputation 4 and 5 months after recanalization. Transluminal angioplasty can extend our capability of early limb salvage.

Comparative value of four methods of investigating the pancreas.

In a prospective study for the diagnosis of pancreatic cancer, ultrasonography, radionuclide scanning, selective arteriography, and endoscopic retrograde cholangiopancreatography (ERCP) were compared. Eighty-nine consecutive patients were investigated; 58 underwent laparotomy, and 36 were found to have periampullary cancer; seven had other malignant tumors within the abdomen, and nine had pancreatitis on biopsy. Five had other benign disease, and there was one negative laparotomy. Thirty-one patients who did not have laparotomy have shown no evidence of cancer at one year follow-up. Ultrasonography was found to be more reliable than scan or arteriography in the detection and diagnosis of a mass in the pancreas. ERCP achieved the highest rate of correct definitive diagnosis.

Selective infusion of streptokinase for arterial thrombosis.

We have treated 13 patients with limb-threatening ischemia caused by acute arterial thrombosis with selective arterial infusion of streptokinase. The indications for thrombolytic therapy included medical contraindication to surgery, surgically inaccessible thrombi, arterial thrombosis following percutaneous transluminal angioplasty, and thrombosed distal arterial bypass. Patients were evaluated with arteriography, Doppler segmental arterial pressure studies, and coagulation profile. Objective evidence of complete or partial thrombolysis was demonstrated in 11 of the 13 patients (85%). Treatment after thrombolytic therapy included percutaneous transluminal angioplasty in six patients and distal bypass in two patients. Of five patients who had received no additional treatment, three required amputation. Overall limb salvage was achieved in 10 of the 13 patients. The most serious complications were puncture site bleeding in five patients, acute renal failure in one patient, and retroperitoneal hemorrhage in another patient. Bleeding was more frequent in patients with decreased serum fibrinogen levels. Although lysis of acute arterial thrombi can be achieved, thrombolytic therapy alone will allow limb salvage in only a few patients. Selective thrombolytic therapy with streptokinase must be used with caution and is associated with serious complications.

Arterial disruption and remodeling following balloon dilatation.

We studied immediate and long-term alterations in human atherosclerotic arteries subjected to balloon dilatation. Pathologic material included vessels obtained at amputation or autopsy that had been previously dilated in vivo and cadaver vessels dilated under physiologic pressure and temperature. All vessels were pressure-perfusion fixed, and morphologic observations were correlated with sequential angiograms obtained in 36 patients. Balloon dilatation resulted in disruption of both the plaque and the artery wall, with separation of the plaque from the tunica media, rupture of the tunica media, and stretching of the tunica adventitia to increase lumen cross-sectional area. The intimal plaque protruded into the lumen, accounting for the angiographic appearance of local flaps and dissection channels. Remodeling occurred by readherence of the intimal flaps with little change in plaque volume. Achievement of a sufficient radius of curvature may be necessary to achieve long-term patency. Restenosis may occur because of insufficient dilatation but may also result from extention of dissection channels into nondilated segments of the artery.

Limb salvage in poor-risk patients using transluminal angioplasty.

We performed percutaneous transluminal angioplasty (PTA) in 97 limbs of 86 patients with end-stage occlusive disease in whom vascular reconstruction was not possible. Most patients required dilation of long-segment occlusions and/or multiple lesions. Angiographic appearance was improved in 87 limbs of 78 patients (90%). Ankle-brachial pressure index increased from 0.40 +/- 0.03 to 0.64 +/- 0.03, and increased more than 0.15 in 63% of the limbs. Major amputation was required in 19 of the 87 limbs (22%) following PTA. The incidence of restenosis was 19% at three months, 42% at six months, and 57% at one year. Repeated PTA successfully maintained vascular patency in ten limbs, and four patients have since had successful distal bypass. Two limbs that initially improved needed amputation four to 19 months after dilatation. Follow-up ranged from one to 45 months; overall limb salvage rate was 76%. Thus PTA can enhance limb salvage in poor-risk patients with end-stage disease.

Retrograde brush biopsy of the ureter and renal pelvis.

In resonse to the limitations of urinary cytology which have resulted in a high incidence of false negative reports, a technique of retrograde brush biopsy has been developed. This technique aids in the diagnosis of carcinomas of the ureteral and renal collecting systems, thereby permitting earlier and more intensive treatment of malignant lesions of the urinary tract.

Evaluation of renal masses including retrograde renal brushing.

1. The evaluation of renal masses has become an increasingly important topic because of the increasing incidence of kidney cancer, the improved cure rate of renal carcinoma with the proper preoperative diagnosis, and the proliferation in renal mass diagnostic methodology. 2. A variety of benign entities can produce an abnormal renal mass with attendant difficulties in being distinguished from malignant neoplasms. Among these benign lesions are: simple renal cysts, polycystic kidneys, congenital variations in renal size and shape, segmental renal hypertrophy, renal infarcts, intrarenal hematomas, renal hamartomas, renal leiomyomas, renal adenomas, renal angiomas, renal fibrolipomatosis, hydronephrosis of a duplicated collecting system, renal abscesses, and xanthogranulomatous pyelonephritis. 3. Nephrotomography, nephrosonography (ultrasound), adrenalin renal arteriography, selective magnification renal arteriography, renal venography and cavography, lymphangiography, renal scintillation scanning, abnormal levels of enzymes in blood and urine, immunologic studies (circulating antibodies and tumor-associated antigens), percutaneous needle aspirations, and retrograde renal brushing have all increased the diagnostic accuracy of determining the etiology of renal masses. None of these diagnostic procedures is infallible. A judicious combination of procedures gives the most reliable diagnostic results. 4. A search continues for (a) chemical agent(s) or a chemical profile in the blood or urine which is (are) specific for renal carcinoma, but as yet this is an investigational area and not a practical clinical reality.

Iodixanol and ioxaglate in adult aortography and peripheral arteriography: a phase III clinical trial.

RATIONALE AND OBJECTIVES: This study compared the safety and efficacy of iodixanol with those of ioxaglate in adult patients undergoing aortography or peripheral arteriography. METHODS: Forty-six patients were enrolled in this controlled, randomized, double-blind, two-center study. The patients were monitored for adverse events, injection-related discomfort, and trends in laboratory data or vital signs. Diagnostic efficacy was assessed by the quality of contrast enhancement. RESULTS: All procedures were diagnostic, with no significant difference in quality of visualization (p = .205). No significant difference was seen in the number of patients experiencing mild or moderate adverse effects (p = .106). Patients receiving ioxaglate reported a significantly greater incidence of injection-related pain (p = .025). CONCLUSION: The results of this study support the conclusion that iodixanol at 320 mg I/kg is safe and effective for adult aortography and peripheral arteriography and causes significantly less injection-related pain than ioxaglate.

Prevalence and characteristics of areca nut chewers among junior high school students in Changhua county, Taiwan.

Some studies indicate that betel quid and its ingredients chewing can produce cell mutagenicity and tumorigenicity. In Taiwan studies, betel quid chewing is the main cause of submucous fibrosis and oral cancer. Understanding the distribution and characteristics of the areca nut chewing population is one of the first steps in the effort to prevent these oral diseases. A stratified cluster random sample of 2442 junior high school students in Changhua county, Taiwan, were surveyed for the habit of areca nut chewing. Significantly more male students chewed areca nut than female students (9.2% vs 0.9%). The proportion of students who were chewing areca nuts increased with increasing (seventh to ninth) grades. Areca nut was used by junior high school students at a higher rate in village (rural) areas as compared to town (semi-urban) and city (urban) areas (6.4%, 3.7% and 3.0%, respectively). More students in the ordinary achievement classes were chewing areca nuts than those in the high achievement classes (8.4% vs 1.6%). Areca nut chewing students tended to have users in their families. Cigarette smoking and alcohol drinking were positively associated with areca nut chewing. More than half (53.6%) of the areca nut chewing students first experimented with this habit with a family member, most often the father or grandfather.

[Effects of stimulation of locus coeruleus on cardiac contractility and renal nerve activity].

Experiments were performed on 64 cats anesthetized with chloralose-urethane, paralyzed and artificially ventilated. Electrical stimulation of locus coeruleus (LC) elicited increases in BP, HR, LVSP, dP/dt max and RNA. Buffer nerve section had no effect on the increase of these parameters, but could prolong the time of rise of BP and recovery phases. Injection of L-glutamate into LC, on the other hand, could decrease BP, HR, LVSP and dP/dt max. Intra-LC injection of kainic acid could also decrease BP. When the LC neurons showed degeneration or depolarization block after kainic acid injection, electrical stimulation of the LC could still elicit marked pressor response. The results suggest that the pressor response induced by electrical stimulation of LC might be mediated by the fibers passing through LC, while activation of LC neurons themselves would result in the depressor response.

Pseudoaneurysm of the internal iliac artery resulting in massive per-rectal bleeding.

Rectal bleeding is a common reason for presentation to hospital, with large bleeds most commonly caused by diverticular disease and angiodysplasia. Here we present an unusual aetiology of massive per-rectal bleeding attributable to pseudoaneurysm of the internal iliac artery leading to an arterial fistula to the distal large bowel. It is hoped the case will serve as a reminder that rectal bleeding can have a less common aetiology.

The development of a rapid prototyping prosthetic socket coated with a resin layer for transtibial amputees.

This article proposes a type of transtibial socket composed of an inner layer fabricated by a rapid prototyping (RP) machine and an outer layer coated with unsaturated polyester resin. This work integrates contemporary technologies including a handheld scanner and CAD systems, to design a thin primary socket shape and then manufactures the socket using a fused deposition-modeling machine. To prevent breakage caused by the layer-based forming process and to reinforce flexural strength, the current research coats the preliminary RP socket with a layer of unsaturated polyester resin. After shaping the proximal brim of the resin-reinforced RP socket to match the specific stump, this study assembles and aligns a shank and a prosthetic foot to form a prosthesis set. After completing a trial safety walk wearing the prosthesis, which is satisfactory to the amputee and a registered prosthetist, this research measures interface pressures between the stump and the resin-reinforced RP socket. Experiment results demonstrate that the resin-reinforced RP socket is applicable for transtibial amputees. In addition to strengthening the FDM socket and producing consistent socket fit, this study also demonstrates a feasible procedure that employs current technologies to design and manufacture transtibial sockets without plaster moulds.