Improvement of Surgical View and Working Space at the Lower Pole by Three-Dimensional Exoscope-Assisted Coblation Tonsillectomy: A Case Series.

Advantages of hot devices for tonsillectomy, represented by coblation, have been highlighted in recent years. During hot technique tonsillectomy it is important to identify and coagulate the vessels of the tonsillar capsule, especially at the lower pole of the tonsil. Hot technique tonsillectomy under microscope or endoscope has therefore been recommended to achieve accurate identification of the microstructure of the surgical field. We have applied ORBEYE, a three-dimensional surgical exoscope system, to coblation tonsillectomy. Advantages of using ORBEYE include high definition and high magnification images, and flexibility of camera position and angle. This means there is an improved surgical view and working space, particularly at the lower pole during performance of coblation tonsillectomy. Here, we demonstrate that ORBEYE can be an effective surgical instrument in coblation tonsillectomy.

Impact of the practical guideline on appropriate usage of antimicrobial treatments for surgical site infections in reconstructive surgery of head and neck cancer.

OBJECTIVES: In 2016, Japanese Society of Chemotherapy and Japan Society for Surgical Infection presented the practical guideline for appropriate usage of antimicrobial agents to prevent postoperative infections. This study aims to exhibit the validity of the guideline as a series of effective strategies for prevention of surgical site infections (SSIs) during reconstructive surgery of the head and neck cancer. METHODS: We retrospectively evaluated patients who underwent head and neck reconstructive surgery with free or pedicle flaps in a single institute in Japan between July 2010 and July 2020. We evaluated the incidence of SSIs, patient backgrounds, and microbiological characteristics on the basis of antimicrobial prophylaxis recommended by the guideline. RESULTS: Enrolled in this study were 102 patients in our institution who underwent head and neck reconstructive surgery with free or pedicle flaps between July 2010 and July 2020. In the period between January 2018 to July 2020 after the SSI guideline was advocated (SSI guideline period), the ratio of administration of sulbactam/ampicillin (SBT/ABPC) was significantly higher (P < 0.001) and the duration of prophylactic antimicrobial treatment was significantly shorter than in the period between July 2010 to December 2017 before the SSI guideline was advocated (Pre-SSI guideline period) (P < 0.001). Incidence of SSIs were similar, even when antibiotic use was changed to be short-term single-agent administration in accordance with the practical guideline. CONCLUSIONS: Adherence to the current Japanese practical guideline on appropriate antimicrobial prophylaxis for SSIs can shorten the duration of usage of antimicrobial treatment without increasing the risk for occurrence of SSIs.

Investigation on the virulence of non-encapsulated Streptococcus pneumoniae using liquid agar pneumonia model.

INTRODUCTION: Since the introduction of pneumococcal conjugate vaccine, there have been warnings of an increase in infections caused by non-vaccine type of Streptococcus pneumoniae strains. Among them, nonencapsulated Streptococcus pneumoniae (NESp) has been reported to cause invasive infections, especially in children and the elderly. Due to low virulence, however, basic experimental reports on invasive infections are limited. METHODS: We applied a liquid-agar method to establish a mouse model of invasive NESp infection. Mice were intratracheally administered a bacterial suspension including agar. With this technique, we investigated the pathogenicity of NESp and the effect of Pneumococcal surface protein K (PspK), a specific surface protein antigen of NESp. NESp wild-type strain (MNZ11) and NESp pspK-deleted mutant strain (MNZ1131) were used in this study. The survival rate, number of bacteria, cytokine/chemokine levels in the bronchoalveolar lavage fluid, and histology of the lung tissue were evaluated. RESULTS: Mice that were intratracheally administered MNZ11 developed lethal pneumonia with bacteremia within 48 h. Conversely, MNZ1131 showed predominantly low lethality without significant pro-inflammatory cytokine production. NESp was found to cause severe pneumonia and bacteremia upon reaching the lower respiratory tract, and PspK was a critical factor of NESp for developing invasive infections. CONCLUSIONS: The current study demonstrated the ability of NESp to develop invasive diseases, especially in connection with PspK by use of a mouse pneumonia model.

Pneumococcal capsular phase shift is associated with invasion into cell-to-cell junctions and is inhibited by macrolides.

Streptococcus pneumoniae frequently colonizes the human nasopharynx beginning in the early childhood. Pneumococci exhibit a spontaneous and reversible phase shift between opaque and transparent allowing them to adapt to different environments. This is the first report of the dynamics of pneumococcal phase shift during the course of adhesion and subsequent invasion into epithelial cell monolayers by bacteria-cell co-culture assay with a time-lapse microscopy. The invasion of an inoculum between the human epithelial cells was dependent on the transparent phenotype, but successful replication of the cells within the cell layer was strongly associated with its transformation into an opaque-like variant. We also observed that sub-MIC levels of clarithromycin inhibited the spontaneous pneumococcal phase shift. Our results show that the pneumococcus can modulate its fitness in part because it can switch phenotype in response to the environment during not only inflammation but also during the establishment of colonization. Our current findings provide a more in depth understanding not only of how the pneumococcal phase shift acts to protect pneumococci from commensal flora and the immune status of the host, but also illustrate a novel strategy for antimicrobial treatments to interfere with pneumococcal colonization.

Improvement in the appropriate antimicrobial usage for treating pediatric acute otitis media in Japan: A descriptive study using nation-wide electronic medical record data.

OBJECTIVES: We investigated changes in prescriptions for antimicrobial agents to treat children with acute otitis media (AOM). METHODS: A descriptive study using an electronic medical record database. Of 199,896 patients enrolled between 2001 and 2019, a total of 10,797 were aged <16 years and had AOM as their first and primary disease (overall pediatric AOM cohort). In addition, 4786 patients with AOM without other comorbidities (pediatric AOM cohort) were included. RESULTS: In the overall pediatric AOM cohort, the age distribution ranged from 11% to 23% for those younger than 2 years and from 66% to 77% for those younger than 6 years, with no change over time. In the pediatric AOM cohort, the antimicrobial prescription rate was 91% in 2001 but declined to 40% by 2019. Antimicrobial use increased from 0% to 75% for penicillins, whereas use of cephalosporins decreased from 84% to 10%. The prescription rate for acetaminophen alone increased from 33% to 58%. There were no differences in the incidence of adverse reactions among the prescribed antimicrobials. CONCLUSIONS: Due to education efforts and promotion of the proper use of antimicrobials through means such as the Clinical practice guidelines for the diagnosis and management of acute otitis media in children (2006) and the Manual of Antimicrobial Stewardship (2016), a change in the use of antimicrobials occurred, leading to a trend to more proper use of these agents.

Genetic characteristics of Haemophilus influenzae and Streptococcus pneumoniae isolated from children with conjunctivitis-otitis media syndrome.

Acute conjunctivitis is the most common ocular disorders among children and frequently concomitant with acute otitis media (AOM) as conjunctivitis-otitis syndrome. In this study, we evaluated prevalence of causative pathogens and PCR-based genotypes of Haemophilus influenzae and Streptococcus pneumoniae among children with conjunctivitis-otitis media syndrome. Nontypeable H. influenzae (NTHi) is identified most often at 61.8% in conjunctiva exudates followed by S. pneumoniae at 28.2% and Moraxella catarrhalis at 19.1%. Genetic ß-lactamase nonproducing ampicillin resistant (gBLNAR) strains of NTHi and genetic penicillin resistant S. pneumoniae (gPRSP) were identified at 72.1% and at 74.2% among conjunctiva isolates by polymerase chain reaction (PCR), respectively. Pneumococcal strains having either ermB or mefE genes were identified at 93.5% among conjunctiva isolates. The restriction fragment of patterns of 89.7% pairs of H. influenzae isolates and 100% pairs of pneumococcal isolates from conjunctiva exudates, middle ear fluids (MEFs) and nasopharyngeal swabs were identical. In contrast to the previous reports, most prevalent strains from conjunctivitis-otitis media syndrome was BLNAR H. influenzae in this study. The causative pathogen responsible for acute conjunctivitis will be originated from the nasopharynx. In the absence of MEFs one can possibly rely on the nasopharyngeal culture to guide an appropriate treatment.

Leuconostoc mesenteroides subsp. strain NTM048 ameliorated nasal symptoms in patients with Japan cedar pollinosis: Randomized, double-blind, and placebo-controlled trial.

BACKGROUND: Lactobacillales including L mesenteroides have beneficial effects on human health, including improvement of psychological status and alleviation of allergic rhinitis. In mice, L mesenteroides subsp. strain NTM048 (NTM048) increased intestinal s-IgA. In humans, however, the effects of NTM048 on s-IgA secretion have been unclear. STUDY: This 16-week trial was performed using a double-blind, placebo-controlled, parallel group design. We aimed to establish whether Leuconostoc mesenteroides subsp. strain NTM048 increases the secretion of s-IgA in saliva. Forty healthy adults and forty patients with Japanese cedar pollinosis were recruited. Participants took either 2 test capsules including NTM048 (1010 CFU/day), or 2 placebo capsules per day, for 16 weeks. They were asked to collect their saliva and answered POMS2, a questionnaire about psychological status. The patients also answered questions about nasal symptoms. Blood samples were collected from the patients with Japanese Cedar pollinosis. Stool samples were collected at the start and on the last day of the trial. RESULTS: All subjects completed the trial. It was conducted during the season when Japanese cedar pollen is most scattered. Serum concentration of Japanese cedar pollen-specific IgE was > 2.0 UA/mL in patients with Japanese cedar pollinosis. The amount of s-IgA in saliva was not increased by NTM048 in overall subjects, and Japanese cedar pollen-specific IgE was not changed by NTM048 in patients with Japanese cedar pollinosis. The symptom of nasal blockage was improved by NTM048 12 weeks after the start of trial. post hoc analysis indicated a positive correlation between improving psychological status and the increase in occupation ratio of lactobacillus including NTM048. CONCLUSION: The amount of s-IgA in saliva was not increased by NTM048, but nasal blockage was improved by it. Psychological status might be improved if dosage of NTM048 is raised to the degree that NTM048 might be increased in the intestinal tract.

Lateral approach contributes to shortened surgical time in video-assisted neck surgery (VANS) for thyroid nodule.

Background: Despite endoscopic thyroid surgery contributing to excellent cosmetic outcomes, it requires longer surgical time than open surgery. This study evaluates the factors associated with operative time in video-assisted neck surgery. Methods: We retrospectively reviewed patients who underwent hemithyroidectomy by video-assisted neck surgery at a single hospital between 2017 and 2021. The clinical parameters were evaluated: age, sex, body weight, body mass index, coexistence of Hashimoto thyroiditis, side of operation, surgical approach to thyroid (midline approach or lateral approach), operation time, amount of blood loss during surgery, maximum tumor diameter and tumor volume, and postoperative complications. These parameters were compared to investigate the association of operative time and surgical approach. Results: Seventy consecutive patients were enrolled in this study, the median age at operation was 50 years, and there were 6 (8.6%) men and 64 (91.4%) women. The median body weight and body mass index at operation were 56.6 kg and 21.5, respectively. Coexistence of Hashimoto thyroiditis was found in 17 (24.3%) patients. Significant differences were found between the groups with longer and shorter operation time than median 201 minutes in surgical approaches to the thyroid (P < .001) and the amount of bleeding during surgery (P = .039). There were no differences in other candidates between the groups. Median operation times were 242 minutes in midline approach and 131 minutes in lateral approach (P < .001). Conclusion: The lateral approach of video-assisted neck surgery to the thyroid can contribute to shortened surgical time in the case of benign thyroid nodules.

The Roles of Transient Receptor Potential Vanilloid 1 and 4 in Pneumococcal Nasal Colonization and Subsequent Development of Invasive Disease.

Transient receptor potential (TRP) channels, neuronal stimulations widely known to be associated with thermal responses, pain induction, and osmoregulation, have been shown in recent studies to have underlying mechanisms associated with inflammatory responses. The role of TRP channels on inflammatory milieu during bacterial infections has been widely demonstrated. It may vary among types of channels/pathogens, however, and it is not known how TRP channels function during pneumococcal infections. Streptococcus pneumoniae can cause severe infections such as pneumonia, bacteremia, and meningitis, with systemic inflammatory responses. This study examines the role of TRP channels (TRPV1 and TRPV4) for pneumococcal nasal colonization and subsequent development of invasive pneumococcal disease in a mouse model. Both TRPV1 and TRPV4 channels were shown to be related to regulation of the development of pneumococcal diseases. In particular, the influx of neutrophils (polymorphonuclear cells) in the nasal cavity and the bactericidal activity were significantly suppressed among TRPV4 knockout mice. This may lead to severe pneumococcal pneumonia, resulting in dissemination of the bacteria to various organs and causing high mortality during influenza virus coinfection. Regulating host immune responses by TRP channels could be a novel strategy against pathogenic microorganisms causing strong local/systemic inflammation.

Recurrent bacterial translocation from gut and sepsis in Head and neck cancer patients and its prevention by probiotics.

Head and neck cancers are the 6th most common cancer type in human malignant tumors and treated with chemoradiotherapy and surgery. Chemotherapy during these treatment modalities leads to damage of intestinal epithelial barriers and results in translocation of intestinal bacteria in bloodstream through invasion in these damaged regions. In this report, we report two cases of hypopharyngeal cancer patients, both of whom received chemotherapy before surgery. The patients demonstrated repeated sepsis before and after surgery, supporting translocation of intestinal bacteria. Proper continuous probiotic use prevented proliferation and intestinal bacterial translocation. Hypothesis of bacterial translocation and prevention by probiotics are discussed.

Transcutaneous immunization with pneumococcal surface protein A in mice.

OBJECTIVE: Pneumococcal infection caused by Streptococcus pneumoniae is a major upper respiratory tract disease that causes severe illness and mortality. Therefore, it is important to develop safe and effective vaccines to prevent pneumococcal infections. The goal of the study was to investigate the effectiveness of transcutaneous immunization (TCI) for induction of pneumococcal surface protein A (PspA) responses in the upper respiratory tract. METHODS: C57BL/6 mice were transcutaneously immunized with 1 µg of PspA and 2 µg of cholera toxin (CT) six times at weekly intervals and compared with transcutaneously treated controls (PBS alone/PspA alone/CT alone). Two weeks after the final immunization, nasal washes (NWs), saliva, and plasma samples were collected and subjected to a PspA-specific ELISA. Three weeks after the final immunization, mice were challenged with S. pneumoniae strain EF3030, and the numbers of CFUs in NWs and nasal passages (NPs) were determined. RESULTS: Higher levels of PspA-specific IgM, IgG, and IgA Abs were noted in plasma of TCI with PspA plus CT compared with controls. Transcutaneous immunization mice also had significantly increased PspA-specific S-IgA Ab responses in NWs and saliva and, importantly, showed significantly lower numbers of bacteria CFUs in NWs and NPs compared with controls. CONCLUSION: These results show that TCI with PspA plus CT induces antigen-specific mucosal and systemic immune responses. This suggests that this method is an effective mucosal immunization strategy for induction of protective pneumococcal-specific Ab responses in blockade of S. pneumoniae colonization of the nasal cavity. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:E91-E96, 2018.

[Immuno-histological and-cytological examinations on distribution of newly reported co-stimulatory molecules in germinal center of human tonsils].

OBJECT: Co-stimulatory molecules are important for cell-cell interactions between immune cells, not only for cell activation, but for suppression. Several new co-stimulatory molecules have recently been discovered, and in this study we used immuno-histological and -cytological methods to investigate the distribution of such molecules in the germinal center of human tonsils. MATERIALS AND METHODS: Tonsils surgically removed from patients with sleep apnea and habitual tonsillitis were examined. Expression of co-stimulatory molecules in immune cells was investigated immuno-histologically in frozen sections, and immuno-cytologically by flow cytometry. RESULTS: PD-L1 was found to be expressed on both GCDCs (germinal center dendritic cells) and FDCs (follicular dendritic cells). ICOS and PD-1 were expressed on activated CD4 T cells located in the light zone of the germinal centers. 4-1BB was expressed on the FDCs, in human tonsils, but not on activated T cells. CONCLUSION: GCDCs and FDCs are likely to function not only T cell activation but in negative regulation of T cells through PD-L1 expression. ICOS molecules contributing to positive signals, and PD-1 to negative signals were simultaneously expressed on a subset of activated T cells, suggesting that signal balance between ICOS and PD-1 is important for T-cell fate.

A molecular mucosal adjuvant to enhance immunity against pneumococcal infection in the elderly.

Streptococcus pneumoniae (the pneumococcus) causes a major upper respiratory tract infection often leading to severe illness and death in the elderly. Thus, it is important to induce safe and effective mucosal immunity against this pathogen in order to prevent pnuemocaccal infection. However, this is a very difficult task to elicit protective mucosal IgA antibody responses in older individuals. A combind nasal adjuvant consisting of a plasmid encoding the Flt3 ligand cDNA (pFL) and CpG oligonucleotide (CpG ODN) successfully enhanced S. pneumoniae-specific mucosal immunity in aged mice. In particular, a pneumococcal surface protein A-based nasal vaccine given with pFL and CpG ODN induced complete protection from S. pneumoniae infection. These results show that nasal delivery of a combined DNA adjuvant offers an attractive potential for protection against the pneumococcus in the elderly.

An application of outer membrane protein p6-specific enzyme-linked immunosorbent assay for detection of haemophilus influenzae in middle ear fluids and nasopharyngeal secretions.

An enzyme-linked immunosorbent assay specific to outer membrane protein P6 (P6-ELISA) was applied for detecting Haemophilus influenzae in middle ear fluids (MEFs) from acute otitis media (AOM) patients and in nasopharyngeal secretions (NPSs) from acute rhinosinusitis patients. P6-ELISA had a sensitivity of 83.3% for MEFs and 71.5% for NPSs and a specificity of 85.6% for MEFs and 92.5% for NPSs, respectively. Real-time PCR exhibited significant differences in the number of ompP1 gene copies among samples determined by P6-ELISA to be positive and negative for H. influenzae. However, because the P6-ELISA test has the reactivity in Haemophilus species include two commensals H. haemolyticus and H. parainfluenzae, it is thus a weak method in order to detect only NTHi correctly. Consequently, diagnosis using the P6-ELISA should be based on an overall evaluation, including the results of other related examinations and clinical symptoms to prevent misleading conclusions in clinical setting.

Evaluation of a rapid immunochromatographic ODK-0901 test for detection of pneumococcal antigen in middle ear fluids and nasopharyngeal secretions.

Since the incidence of penicillin-resistant Streptococcus pneumoniae has been increasing at an astonishing rate throughout the world, the need for accurate and rapid identification of pneumococci has become increasingly important to determine the appropriate antimicrobial treatment. We have evaluated an immunochromatographic test (ODK-0901) that detects pneumococcal antigens using 264 middle ear fluids (MEFs) and 268 nasopharyngeal secretions (NPSs). A sample was defined to contain S. pneumoniae when optochin and bile sensitive alpha hemolytic streptococcal colonies were isolated by culture. The sensitivity and specificity of the ODK-0901 test were 81.4% and 80.5%, respectively, for MEFs from patients with acute otitis media (AOM). In addition, the sensitivity and specificity were 75.2% and 88.8%, respectively, for NPSs from patients with acute rhinosinusitis. The ODK-0901 test may provide a rapid and highly sensitive evaluation of the presence of S. pneumoniae and thus may be a promising method of identifying pneumococci in MEFs and NPSs.

Clinical effectiveness of ototopical application of mupirocin ointment in methicillin-resistant Staphylococcus aureus otorrhea.

OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) otorrhea has become an increasing problem with regard to infection through the tympanic membrane perforation and postsurgical infection. In particular, dry ear, at the preoperative stage, is considered to be a crucial factor in surgery. We evaluated how to control MRSA otorrhea before and after ear surgery. PATIENTS AND METHODS: Twenty-six patients having MRSA otorrhea were enrolled in the present study and randomly divided into 2 groups, namely, mupirocin ointment therapy for 16 patients and ofloxacin ear drops for 10 patients. Approximately 0.6 mg of mupirocin ointment was administered locally to the tympanic membrane and the promontory around and through the perforation with its adjacent external ear canal 1 to 4 times for 2 or 3 weeks at the clinic. On the other hand, ofloxacin ear drops were administered daily by the patients for 2 or 3 weeks at home. RESULTS: Complete elimination of MRSA from the ear was obtained in all patients of the mupirocin group. This showed a significant improvement (p < 0.001) as compared with the ofloxacin group (improvement + cure rate, 40%). Local application of mupirocin did not aggravate hearing acuity of any patients who were evaluated by pure-tone audiometry before and after treatment. CONCLUSION: The present findings first indicate that minimally essential application of mupirocin ointment is an extremely useful ototopical agent against MRSA otorrhea without ototoxicity.

Genetic dissection of anxiety in autoimmune disease.

Systemic lupus erythematosus (SLE), a complex multigenic disease, is characterized by hypergammaglobulinemia, autoantibody production and immune complex-type lupus nephritis. In addition to these signs and symptoms in SLE, there can be symptoms of neurological disorders, including anxiety. To clarify mechanisms governing the anxiety seen in lupus, we carried out genome-wide scans, and found that the region including interferon-alpha (IFN-alpha) on NZB chromosome 4 is significantly linked to the anxiety-like behavior seen in SLE-prone New Zealand Black (NZB) x New Zealand White (NZW) F(1) (B/W F(1)) mice. This finding was confirmed by anxiety-like performances of mice with heterozygous NZB/NZW alleles in the susceptibility region onto the NZW background. In B/W F(1) mice, neuronal IFN-alpha levels were elevated, and blockade of the micro (1) opioid receptor or corticotropin-releasing hormone receptor 1, possible downstream effectors for IFN-alpha in the brain partially overcame the anxiety-like behavior seen in the B/W F(1) mice. Consistently, neuronal corticotropin-releasing hormone levels were higher in B/W F(1) than NZW mice. Furthermore, pretreatment of micro (1) opioid receptor antagonist abolished anxiety-like behaviour seen in IFN-alpha-treated NZW mice. Anxiety is shown to be mediated by multiple mediators. Our data suggest that a genetically determined endogenous excess amount of IFN-alpha in the brain may form one aspect of anxiety-like behavior seen in SLE-prone mice.