Ostomy creation with fewer sutures using tissue adhesives (cyanoacrylates) in inflammatory bowel disease: a pilot study.

Introduction Fistula formation around the ostomy site is a stoma-related complication often requiring surgical intervention. This complication may be caused by sutures or may develop as a complication of inflammatory bowel disease. Before conducting a clinical trial, we set out to investigate the safety of ostomy creation with fewer sutures using tissue adhesives in this pilot study. Methods Patients with inflammatory bowel disease who required surgery with ostomy creation at the Hyogo College of Medicine between January 2014 and December 2015 were enrolled. Safety was assessed by evaluating the incidence of stoma-related complications. Ostomy was restricted to loop ileostomy and was created with two sutures and tissue adhesives. Results A total of 14 patients were enrolled. Mean body mass index was 18.9 ± 2.0 kg/m2. There were no cases of ostomy retraction and no severe adverse events were observed. Conclusions This pilot study demonstrates that ostomy creation using tissue adhesives is safe. Although retraction and adverse events were not observed, even in patients with inflammatory bowel disease who generally exhibit delayed wound healing, the body mass index was extremely low in this series. This study does not strongly recommend ostomy creation with tissue adhesives; further studies are needed to clarify the efficacy and safety of the procedure.

Enhanced loading regimen of teicoplanin is necessary to achieve therapeutic pharmacokinetics levels for the improvement of clinical outcomes in patients with renal dysfunction.

We evaluated the clinical efficacy and safety of teicoplanin according to the pharmacokinetics (PK) therapeutic level achieved in patients with renal dysfunction. Target trough concentration (Cmin) was ≥15-30 µg/ml which has been recommended in patients with normal renal function. Adult patients (estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2)) who were treated by teicoplanin were included in the study. We adopted two types of regimen for the initial 3 days: the conventional regimen, and the enhanced loading regimen (10 mg/kg twice daily on the 1st day, followed by 6.7-10 mg/kg once daily for the 2nd and 3rd days]. Two hundred and eighty-eight patients were evaluated for safety, and 106 patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were evaluated for clinical efficacy. A significantly higher success rate was obtained in patients who achieved the target initial Cmin compared with those that did not (75.0 % vs 50.0 %, p = 0.008). In a multivariate analysis, initial Cmin ≥15 µg/ml was an independent factor for clinical success (adjusted odds ratio: 4.20, 95 % confidence interval: 1.34-13.15). In patients with 15-30 µg/ml of maximal Cmin during therapy, nephrotoxicity occurred in 13.1 %, and hepatotoxicity in 2.6 %, and these incidences were not significantly higher compared with those patients with <15 µg/ml. In conclusion, achievement of Cmin of 15-30 µg/ml without delay was necessary to improve clinical outcomes for the treatment by teicoplanin in patients with renal dysfunction. Further investigation is required regarding the optimal loading regimen to achieve the therapeutic levels in those patients.

Value of pre- and postoperative meticillin-resistant Staphylococcus aureus screening in patients undergoing gastroenterological surgery.

BACKGROUND: Data supporting active surveillance of meticillin-resistant Staphylococcus aureus (MRSA) for the prevention of postoperative infection remain controversial. AIM: To investigate the efficacy of MRSA screening in patients undergoing gastroenterological surgery. METHOD: Nasal carriage of MRSA was screened using a polymerase chain reaction (PCR) assay on two gastroenterological surgery wards (A and B). Occurrence of postoperative MRSA infection was analysed according to nasal MRSA carriage status (pre-operative carriage and postoperative acquisition). FINDINGS: The incidence of pre-operative MRSA carriage was 9.7% on Ward A and 4.3% on Ward B (P = 0.009). Postoperative nasal MRSA acquisition was confirmed in 16.2% and 6.0% of patients, respectively (P < 0.001). There was no significant difference in the incidence of MRSA surgical site infections (SSIs) between patients with and without pre-operative nasal colonization on either ward. On Ward A, where MRSA nasal acquisition was more common, the MRSA infection rate in patients with postoperative nasal acquisition was 26.8%, which was significantly higher than the rates in patients with pre-operative MRSA colonization and patients without colonization during hospitalization. Postoperative nasal MRSA acquisition was an independent factor associated with MRSA infection on both wards [Ward A: odds ratio (OR) 7.192, 95% confidence interval (CI) 2.981-17.352; Ward B: OR 5.761, 95% CI 1.429-23.220]. CONCLUSION: MRSA SSIs were prevented by a screening-based strategy in pre-operative MRSA carriers. Postoperative nasal acquisition was a significant factor affecting MRSA infection, and the effect of screening varied according to the incidence of postoperative MRSA acquisition on the ward.

A double-blind comparative study of the safety and efficacy of caspofungin versus micafungin in the treatment of candidiasis and aspergillosis.

The safety and efficacy profile of caspofungin and micafungin in Japanese patients with fungal infections were directly compared in this prospective, randomized, double-blind study. The proportion of patients who developed significant drug-related adverse event(s) (defined as a serious drug-related adverse event or a drug-related adverse event leading to study therapy discontinuation) was compared in 120 patients [caspofungin 50 mg, or 50 mg following a 70-mg loading dose on Day 1 (hereinafter, 70/50 mg) group: 60 patients; micafungin 150 mg: 60 patients]. The overall response rate was primarily evaluated in the per-protocol set (PPS) population. The proportion of patients who developed significant drug-related adverse events was 5.0 % (3/60) in the caspofungin group and 10.0 % (6/60) in the micafungin group [95 % confidence interval (CI) for the difference: -15.9 %, 5.2 %]. The favorable overall response in the PPS population for patients with esophageal candidiasis, invasive candidiasis, and chronic pulmonary aspergillosis including aspergilloma was 100.0 % (6/6), 100.0 % (3/3), and 46.7 % (14/30) in the caspofungin group, and 83.3 % (5/6), 100.0 % (1/1), and 42.4 % (14/33) in the micafungin group, respectively. In Japanese patients with Candida or Aspergillus infections, there was no statistical difference in the safety between caspofungin and micafungin. Consistent with other data on these two agents, the efficacy of caspofungin and micafungin was similar.

Implementation of a hospital-wide project for appropriate antimicrobial prophylaxis.

The aim of this study was to confirm the effect of implementing a hospital-wide project for appropriate use of antimicrobial prophylaxis (AMP) to reduce the rate of antibiotic-resistant organisms. Fifteen different manuals for each surgical department have been simultaneously implemented since February 2007. Compliance rate was compared between pre- and postintervention periods (3 months for each period). As an effect of this intervention, we analyzed changes in the rates of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus among organisms isolated postoperatively. The number of operations was 1,627 in both periods. Among patients whose surgeries were longer than 3 h in duration, 75% received an additional intraoperative antimicrobial dose in the postintervention period and 23% in the preintervention period (P < 0.001). Although most patients received postoperative AMP with an interval of q12 h in the preintervention period, 63% of the patients received AMP with an interval of q8 h in the postintervention period. The duration of AMP use was reduced from 2.4 ± 1.9 to 1.6 ± 1.5 days (P < 0.001). Forty-seven percent of patients discontinued AMP within 24 h and 81% within 48 h. Isolation rates of P. aeruginosa among all gram-negative organisms significantly decreased from 13% (68/538 patients) to 7.3% (37/509 patients) (P = 0.004). Execution of a hospital-wide project to promote the appropriate use of AMP, including shortening the duration of AMP use, was useful to decrease the rate of P. aeruginosa isolated postoperatively.

Impact of a hospital-wide programme of heterogeneous antibiotic use on the development of antibiotic-resistant Gram-negative bacteria.

Although antibiotic heterogeneity has been proposed as a strategy to limit the emergence of antibiotic resistance, few clinical studies have been conducted to validate the concept. This paper evaluates a hospital-wide strategy of heterogeneous antibiotic use intended to reduce infections caused by resistant Gram-negative rods (GNR). A strategy termed 'periodic antimicrobial monitoring and supervision' (PAMS) was implemented between September 2006 and February 2008. The 18 month intervention period was compared with the preceding 18 months (12 months pre-establishment and 6 months preparation). During PAMS, recommended, restricted and off-supervised classes of antibiotics active against more resistant GNR were changed every 3 months according to the antimicrobial usage density and rates of resistance to those antibiotics in Pseudomonas aeruginosa during the preceding term. Usage of five categories of antibiotics was supervised by four full-time staff. Antibiotic heterogeneity was estimated using the Peterson index (AHI). AHI estimates were 0.66 and 0.74 during the observation period but rose after the introduction of PAMS (period 1: 0.84; period 2: 0.94; period 3: 0.88). The incidence of patients from whom resistant GNR were isolated decreased significantly (P<0.001), whereas isolation of multidrug-resistant (MDR) GNR decreased from 1.7% to 0.5% (P<0.001). There was no significant difference in the incidence of extended spectrum beta-lactamase-producing organisms. Rates of imipenem resistance among Pseudomonas aeruginosa improved during PAMS2. PAMS facilitated hospital-wide heterogeneous antibiotic usage which was associated with reduced rates of resistant GNR.

Molecular epidemiology of enteritis-causing methicillin-resistant Staphylococcus aureus.

In the early 1990s, severe enteritis caused by methicillin-resistant Staphylococcus aureus (MRSA enteritis) was prevalent in Japan, but the incidence has since decreased. We compared the genotypes and phenotypes of 12 isolates that caused MRSA enteritis (enteritis isolates), detected between 1990 and 1993, with 186 non-enteritis isolates detected between 1998 and 2002. Organisms were investigated using pulsed-field gel electrophoresis (PFGE), coagulase typing and reverse passive latex agglutination to detect production of staphylococcal enterotoxins (SE) and toxic shock syndrome toxin-1 (TSST-1); and polymerase chain reaction (PCR) for detection of the structural genes entA, entB, entC, entD and tst, which encode proteins SE-A, SE-B, SE-C, SE-D and TSST-1, respectively. The 12 enteritis isolates were classified into four types and four subtypes. Only seven of the 186 non-enteritis isolates had PFGE patterns indistinguishable from the enteritis isolates. Eight of the 12 enteritis isolates had entA, entC and tst, and produced high levels of SE-A and TSST-1, but not SE-C. Of the 186 non-enteritis isolates, 157 produced SE-C and TSST-1, but not SE-A. The seven non-enteritis isolates with a PFGE pattern indistinguishable from the enteritis isolates did not produce SE-A, and showed relatively low levels of TSST-1 production. These isolates may have continued to inhabit our ward since the earlier outbreak, but acquired a different phenotype. In conclusion, the disappearance of MRSA enteritis may have resulted from the decreased incidence of enteritis-causing clones and phenotypical changes.

Clinical surveillance of surgical imipenem-resistant Pseudomonas aeruginosa infection in a Japanese hospital.

In order to elucidate any changes in imipenem-resistant Pseudomonas aeruginosa (IRPA) infections in Japan, we examined 511 P. aeruginosa stains isolated from our surgical ward between 1987 and 2001. These isolates were subjected to susceptibility testing against various antipseudomonal agents including imipenem, meropenem, ceftazidime, gentamicin and ciprofloxacin. They were serotyped with the slide agglutination test and genotyped using pulsed-field gel electrophoresis (PFGE). The annual incidences of IRPA infections were particularly high in the early 1990s. Epidemiological investigations revealed that these outbreaks were due to dissemination of hospital-acquired IRPA isolates. Intensive use of imipenem promoted the selection of highly resistant strains. Further study of resistance mechanisms revealed that none of the 110 IRPA strains were metallo-beta-lactamase (MBL) producers. Polymerase chain reaction (PCR) analysis using bla(IMP) specific primers confirmed that no IMP-1 type MBL gene-positive strains were detected from our ward. Susceptibilities of those IRPA strains against other antipseudomonal agents showed relatively low levels, suggesting that imipenem resistance was mainly due to impermeability of the OprD porin. In conclusion, hospital-acquired outbreaks of IRPA were recently reduced by guidelines for, and surveillance of, appropriate use of antimicrobial agents. When the rate of IRPA isolation increases, serotyping should be performed initially and PFGE is required to confirm outbreaks. A computer-assisted genotyping technique is available to perform epidemiological studies of IRPA isolates.

Gut transit time after ileal pouch-anal anastomosis using a radiopaque marker.

PURPOSE: The aim of this study was to determine the contribution of gastrointestinal motility to bowel function and the pathogenesis of pouchitis after ileal pouch-anal anastomosis. METHODS: Gastrointestinal transit time was assessed by a radiopaque marker technique in 32 patients with ulcerative colitis. RESULTS: Small intestinal transit time and pouch emptying time were 4.1 +/- 2 hours and 4.1 +/- 2.5 hours, respectively. There was no significant difference in pouch emptying time between patients with and without pouchitis. When only patients with acute pouchitis that responded to metronidazole were analyzed, there was a trend toward a prolonged pouch emptying time compared with those without pouchitis (P = 0.095). Whole gut transit time was inversely correlated with 24-hour stool frequency in patients without pouchitis (r = -0.63, P < 0.005). In the analysis of regional transit time, only small intestinal transit time was inversely correlated with 24-hour stool frequency (r = -0.472, P < 0.05). Significant prolongation of small intestinal transit time was demonstrated in patients over a period of 41 months (the median time) after ileostomy closure compared with those whose pouches had been functioning for 6 to 41 months (5.4 +/- 1.7 hours vs. 3.1 +/- 1.3 hours, P < 0.005). CONCLUSIONS: There was an association between small intestinal motility and bowel frequency. Further investigation is necessary in the pathogenesis of acute pouchitis regarding the relationship between delayed pouch emptying and subsequent development of mucosal inflammation.

[Histopathological examination of tissues removed from the retinal surface during vitrectomy in idiopathic macular holes].

PURPOSE: We examined electron microscopically the tissues removed from the retinal surface in cases with idiopathic macular holes. MATERIALS AND METHODS: We performed vitrectomy for idiopathic macular holes in 43 eyes from June 1994 to December 1998 at Fukuoka University Chikushi Hospital. The removed tissues were evaluated with transmission electron microscope in only 8 of the 43 eyes. All cases underwent 3 port vitrectomy. After occurrence of posterior vitreous detachment, epiretinal tissues were removed around the macular hole using a micro-hook needle. RESULTS: All tissues were transparent under an operating microscope, and they curled naturally. Histopathological examination showed that the removed tissues were from 2 to 6.5 microns thick. All tissues were composed mainly of extracellular matrix. There were type 2 collagen fibers in 6 eyes and basement membrane-like structures in 2 eyes. There were few cell components. All cases had the macular hole closed by the first surgery. Four eyes had improved visual acuities of more than 2 lines. The remaining 4 eyes had the same visual acuity as before the operation. CONCLUSION: Residual vitreous on the retinal surface was the main component of the transparent tissues removed from the retinal surface during vitrectomy.

Comparison of sucrase-free isomaltase with sucrase-isomaltase purified from the house musk shrew Suncus murinus.

We purified sucrase-isomaltase and sucrase-free isomaltase from a normal and a sucrase-deficient line, respectively, of the house musk shrew Suncus murinus and examined the effects of mutation on enzyme structure and activities. Recent cDNA cloning studies have predicted that sucrase-free mutant isomaltase lacks the C-terminal 69 amino acids of normal isomaltase, as well as the entire sucrase. On SDS-polyacrylamide gel electrophoresis purified sucrase-free isomaltase gave a single protein band of 103 kDa, while sucrase-isomaltase gave two major protein bands of 106 and 115 kDa. The 115, but not 106, kDa band was quite similar to the 103 kDa band on Western blotting with Aleuria aurantia lectin and antibody against shrew sucrase-isomaltase, suggesting that the 115 and 103 kDa bands are due to normal and mutant isomaltases, respectively, in accordance with the above prediction. Purified isomaltase and sucrase-isomaltase were similar in Km and Vmax (based on isomaltase mass) values for isomaltose hydrolysis and in inhibition of isomaltase activity by antibody against rabbit sucrase-isomaltase, suggesting that the enzymatic properties of isomaltase are mostly unaffected by mutation.

[Clinical relevance of hetero-VRSA in surgical infections].

Vancomycin was used increasingly for treating methicillin-resistant Staphylococcus aureus(MRSA) infection. Recently MRSA strains which showed low-level resistance to vancomycin were isolated. Vancomycin-intermediate Staphylococcus aureus(VISA) show a vancomycin minimum inhibitory concentration(MIC) of 8 micrograms/ml. VISA appear to be rare. The vancomycin resistance phenotype is reported to be unstable in such isolates. To detect heterogeneously resistant VRSA(hetero-VRSA. MIC 1 to 4 micrograms/ml), we need to use population analysis and growth on Mu3 agar plate, because MIC cannot confirm hetero-VRSA. Hetero-VRSA is not so rare(about 0-47%). Hetero-VRSA may be responsible for failure of vancomycin therapy, but its mechanism remains unclear. Until it becomes better understood, the clinical relevance cannot be assessed.

[Bacteria isolated from surgical infections and their susceptibilities to antimicrobial agents. Special references to bacteria isolated between April 1998 and March 1999].

The annual multicenter studies on isolated bacteria from infections in general surgery and their antimicrobial susceptibility have been conducted in Japan since July 1982. This paper describes the results obtained in fiscal 1998 (from April 1998 to March 1999). The number of cases investigated as objectives was 225 for one year. A total of 429 strains (121 strains from primary infections and 308 strains from postoperative infections) were isolated from 183 cases (81.3% of total cases). In primary infections, the isolation rates of anaerobes and Escherichia coli were higher than in postoperative infections, while in postoperative infections, those of Gram-positive aerobes and Pseudomonas aeruginosa were higher than in primary infections. On the whole, among Gram-positive aerobes, the isolation rate of Enterococcus faecalis was the highest, followed by Staphylococcus aureus with high frequency in isolation from postoperative infections. Among Gram-positive anaerobes, Peptostreptococcus spp. and Streptococcus spp. were predominantly isolated. Among Gram-negative aerobes, E. coli, P. aeruginosa, Klebsiella pneumoniae and Enterobacter cloacae were frequently isolated. Among Gram-negative anaerobes, Bacteroides fragilis group was the majority of isolates. In primary infections, the percentage of Gram-negative aerobes has gradually increased since fiscal 1995 or 1996 with these years as the turning point, while those of Gram-positive and Gram-negative anaerobes have gradually declined. In postoperative infections, the percentage of Gram-negative anaerobes has increased continuously since the mid-1980s. The percentage of MRSA among S. aureus rose to 89.7%, which was the highest level since the beginning of this study. The susceptibilities of B. fragilis, which did not show apparent changes, were recognized to have decreased against cephems in fiscal 1998. Among other bacteria in B. fragilis group, development of resistance to cephems has continued on a long-term basis since the mid-1980s. E. coli and K. pneuminiae have obviously not changed in susceptibilities, however, the susceptibilities of isolated strains in fiscal 1998 against high-generation cephems, oxacephems and monobactams have declined. We found neither vancomycin-resistant nor teicoplanin-resistant strains of S. aureus and Enterococcus spp.

[Bacteria isolated from surgical infections and their susceptibilities to antimicrobial agents. Special references to bacteria isolated between April 1997 and March 1998].

The annual multicenter studies on isolated bacteria from infections in general surgery and their antimicrobial susceptibility have been conducted in 19 facilities in Japan since July 1982. This paper describes the results obtained during the period from April 1997 to March 1998. The number of cases investigated as objectives was 215 for one year. A total of 420 strains (170 strains from primary infections and 250 strains from postoperative infections) were isolated from 174 cases (80.9% of total cases). In primary infections, the isolation rate of anaerobic bacteria was higher than in postoperative infections, while in postoperative infections, those of aerobic Gram-positive bacteria and Pseudomonas aeruginosa were higher than in primary infections. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus faecalis was the highest, followed by Staphylococcus aureus, which was frequently isolated from postoperative infections. Among anaerobic Gram-positive bacteria, Peptostreptococcus spp. and Streptococcus spp. were commonly isolated from both types of infections. Among aerobic Gram-negative bacteria, Escherichia coli was most predominantly isolated from primary infections, followed by P. aeruginosa, Klebsiella pneumoniae in this order, and from postoperative infections, P. aeruginosa was most predominantly isolated, followed by E. coli and K. pneumoniae. Among anaerobic Gram-negative bacteria, Bacteroides fragilis group was the majority of isolates from both types of infections. We found neither vancomycin nor arbekacin resistant strains of S. aureus, and found no vancomycin resistant strains of Enterococcus spp. The susceptibility of P. aeruginosa against carbapenems did not decline in the year 1997, while resistance of B. fragilis group against cephems advanced increasingly.

Progression of primary biliary cirrhosis after proctocolectomy for ulcerative colitis.

We report a case of progression of primary biliary cirrhosis (PBC) after proctocolectomy for ulcerative colitis. A 43-year-old woman underwent a total proctocolectomy after being diagnosed with ulcerative colitis. In the course of the preoperative investigation, liver function test results were within the normal range. Four months after the proctocolectomy, the patient showed a high level of alkaline phosphatase (2398 IU/l) and a positive anti-mitochondrial antibody titer (>1:160). There were no associated symptoms. A liver biopsy demonstrated expansion of all portal areas by infiltrates of lymphocytes and histiocytes. These appearances indicated chronic biliary disease and were compatible with PBC. The association of PBC and ulcerative colitis is rare. However, a review of the recent literature suggests that PBC and ulcerative colitis may be associated; this combination should be kept in mind.

Unusual corneal deposit after the topical use of cyclosporine as eyedrops.

PURPOSE: To report a patient who developed bilateral corneal opacities 5 days after the beginning topical cyclosporine. METHODS: Case report. A 45-year-old woman with graft-versus-host disease presented with bilateral corneal deposits. She had been treated with topical physiological saline solution, sodium hyaluronate, ofloxacin, fluorometholone, and oxybuprocaine. Cyclosporine eyedrops were added for persistent corneal epithelial defect bilaterally. Five days after cyclosporine, she complained of visual loss and dense corneal opacities were detected that covered the pupil bilaterally. RESULTS: Deposits were also observed on the punctal plugs, and infrared spectroscopy and X-ray analysis showed that these deposits had properties of cyclosporine. CONCLUSION: Topical cyclosporine, alone or in combination with other eyedrops, may cause severe corneal deposits in patients with disturbance of the corneal epithelial barrier and decreased tear clearance.

Generation of pro-inflammatory and anti-inflammatory cytokines in the gut in zymosan-induced peritonitis.

In major systemic inflammation such as severe peritonitis, various pro-inflammatory cytokines, such as TNF-alpha, IL-1 beta and IL-6, play important roles in the development of multiple organ dysfunction syndrome (MODS). The purpose of this study was to investigate the outflow of pro-inflammatory and anti-inflammatory cytokines from the efferent mesenteric lymphatic vessels under peritonitis. Mesenteric lymph samples were collected from adult male rats at 2, 4, 6, 8 and 10 hr after an intraperitoneal injection of zymosan at a dosage of 0.1 mg/g (non-lethal dose) or 0.5 mg/g (lethal dose). Blood samples were obtained at 10 hr after zymosan administration. The amounts of drained TNF-alpha and IL-6 in the lymph peaked at 2-4 hr and 4-8 hr after zymosan administration, respectively. The amounts of drained IL-10 in the lymph gradually increased until 10 hr. The amounts of drained TNF-alpha and IL-10 in the mesenteric lymph were significantly correlated with the dosage of zymosan. In conclusion, under intraperitoneal inflammation, pro-inflammatory cytokines (TNF-alpha and IL-6) increased in the mesenteric lymph and were drained into circulation. IL-10, one of the anti-inflammatory cytokines, also increased in the mesenteric lymph after several hours' delay and its increase was remarkable in several inflammations. These findings suggested that the gut might be one of the pro-inflammatory and anti-inflammatory cytokine-generating organs under peritonitis. The lymph-drained amounts of each cytokine under peritonitis are considered to differ with the time or severity of inflammation, which may cause different conditions in patients due to the imbalance of pro-inflammatory and anti-inflammatory cytokines.

Interleukin-10 expression in intestine of Crohn disease.

Inflammatory bowel diseases are considered to be related to dysregulation of pro- and anti-inflammatory cytokines in the intestinal wall. We investigated the levels of TNFalpha, IFNgamma, and IL-10 mRNA expression in intestinal tissues resected from the patients with Crohn disease (CD) (n=29), ulcerative colitis (UC) (n=8), and controls (n=8) using reverse transcription-polymerase chain reaction (RT-PCR). In addition, we examined the relationship between the expression of these cytokine mRNA and their clinical conditions using CD activity index (CDAI) and Nutritional Surgical Risk Index (NSRI). Compared with controls, tissues in CD showed high levels of TNFalpha and IFNgamma mRNA expression both in inflamed and non-inflamed tissues, and showed high levels of IL-10 mRNA expression in inflamed tissues. In UC, high levels of IL-10 mRNA expression were detected both in inflamed and non-inflamed UC tissues, while those of TNFalpha and IFNgamma were not. In 80% of CD tissues (n=23), levels of IL-10 and TNFalpha expression were interrelated. While the remaining tissues (n=6) showed low levels of IL-10 expression despite high levels of TNFalpha expression in inflamed CD tissues, and 4 of these 6 patients had high CDAI and low NSRI. Furthermore, in low nutritional CD patients (NSRI <40, n=13), the levels of IL-10 mRNA to inhibit pro-inflammatory cytokines were poorer than in good nutritional patients (NSRI >/=40, n=16). These findings suggest the overexpressions of TNFalpha and IFNgamma in CD, and less producibility of IL-10 against these cytokine might lead to development of severe CD.

A brief course of colon preparation with oral antibiotics.

We carried out a prospective clinical trial of colon preparation with a regimen of oral antibiotics starting on the day before surgery. The patients were assigned to one of two groups consisting of either a mechanical preparation alone group (group 1, 45 cases) or a mechanical bowel preparation with oral antibiotics group (group 2, 38 cases). Group 2 received kanamycin and metronidazole three times on the day before surgery. Cefmetazole was administered for 3 consecutive days as prophylaxis in both groups. In a study using intraoperative mucosal swabs, the rates of group 2 patients with cultures yielding anaerobes or Gram-negative bacteria were significantly lower than those of group 1. There were no significant differences in the rates of patients with cultures yielding fungi or Gram-positive organisms. The positive culture rate in the peritoneal fluid of group 1 was also higher than that of group 2 (40%, 16%, P < 0.05). The surgical site infection rate was 18% in group 1 and 13% in group 2. Organisms isolated from the sites of postoperative infections were not identical with those from the peritoneal fluid. This relatively brief course preparation minimized the emergence of resistant strains. However, in spite of the colonic bacterial burden and the intraoperative inoculation in the patients with mechanical cleansing alone, their incidence of subsequent infections was comparable to that of patients who were administered oral antibiotics provided that the prophylactic antibiotic was administered for 3 days after surgery.