Transmission dynamics of a linear vanA-plasmid during a nosocomial multiclonal outbreak of vancomycin-resistant enterococci in a non-endemic area, Japan.

The spread of vancomycin-resistant enterococci (VRE) is a major threat in nosocomial settings. A large-scale multiclonal VRE outbreak has rarely been reported in Japan due to low VRE prevalence. We evaluated the transmission of vancomycin resistance in a multiclonal VRE outbreak, conducted biological and genomic analyses of VRE isolates, and assessed the implemented infection control measures. In total, 149 patients harboring VanA-type VRE were identified from April 2017 to October 2019, with 153 vancomycin-resistant Enterococcus faecium isolated being grouped into 31 pulsotypes using pulsed-field gel electrophoresis, wherein six sequence types belonged to clonal complex 17. Epidemic clones varied throughout the outbreak; however, they all carried vanA-plasmids (pIHVA). pIHVA is a linear plasmid, carrying a unique structural Tn1546 containing vanA; it moves between different Enterococcus spp. by genetic rearrangements. VRE infection incidence among patients in the "hot spot" ward correlated with the local VRE colonization prevalence. Local prevalence also correlated with vancomycin usage in the ward. Transmission of a novel transferrable vanA-plasmid among Enterococcus spp. resulted in genomic diversity in VRE in a non-endemic setting. The prevalence of VRE colonization and vancomycin usage at the ward level may serve as VRE cross-transmission indicators in non-intensive care units for outbreak control.

Concurrent positive skin tests to prophylactic antibiotics and rocuronium in two patients with life-threatening anaphylaxis after induction of anesthesia.

BACKGROUND: Prophylactic antibiotics and neuromuscular blocking agents (NMBA) are two of the major causative agents of anaphylaxis after induction of anesthesia. CASE PRESENTATION: One female and one male patients (aged 29 and 69 years, respectively) had Ring and Messmer scale grade III anaphylaxis after administration of prophylactic antibiotics following induction of anesthesia. They showed typical hemodynamic and respiratory features of life-threatening anaphylaxis. Postoperative skin tests in these two patients were positive for antibiotics and concurrently positive for rocuronium. CONCLUSIONS: Our present report suggests the possibility that both prophylactic antibiotics and NMBA concurrently and synergistically enhance anaphylactic reaction and the necessity to differentiate an immune mechanism from non-immune mechanisms when anesthesiologists encounter concurrent positive skin tests for both antibiotics and NMBA.

An outcome study of adult in-hospital cardiac arrests in non-monitored areas with resuscitation attempted using AED.

OBJECTIVES: To investigate the outcomes of patients with in-hospital cardiac arrest (IHCA) who underwent cardiopulmonary resuscitation (CPR) using an automated external defibrillator (AED) in non-monitored areas. Additionally, to detect correlated factors associated with rate of return of spontaneous circulation (ROSC) and survival rate, among collected data. METHODS: This study included 109 patients. After investigating patient characteristics and resuscitation-related factors, the correlated factors associated with ROSC rates and survival rate were analyzed using univariate and multivariate analyses. RESULTS: The rate of survival to hospital discharge was 21.1%. CPR with AED performed since 2013 was associated with a higher ROSC rate (adjusted odds ratio [AOR] 3.24, 95% confidence interval [CI]: 1.21 to 9.52, p < 0.05), but not with the survival rate after ROSC. Tracheal intubation was significantly associated with a higher ROSC rate (AOR 3.62, 95% CI: 1.27 to 11.7, p < 0.05) and a lower survival rate after ROSC (hazard ratio 6.6, 95% CI: 1.2 to 43.3, p < 0.05). Dysrhythmia as the cause of cardiac arrest and intensive care unit (ICU) admission after ROSC were associated with higher survival rates (hazard ratio 0.056, 95% CI: 0.004 to 0.759, p < 0.05, and hazard ratio 0.072, 95% CI: 0.017 to 0.264, p < 0.0001, respectively). CONCLUSIONS: The factors associated with ROSC rate and those associated with the survival rate after ROSC were different. Although initial shockable rhythms on AED were not associated with the survival rate, dysrhythmia as the etiology of cardiac arrest, and ICU admission were significantly associated with higher survival rates after ROSC.

Reversible tactile hypoesthesia associated with myofascial trigger points: a pilot study on prevalence and clinical implications.

INTRODUCTION: Tactile hypoesthesia observed in patients with myofascial pain syndrome (MPS) is sometimes reversible when pain is relieved by trigger point injections (TPIs). We aimed to investigate the prevalence of such reversible hypoesthesia during TPI therapy and topographical relations between areas of tactile hypoesthesia and myofascial trigger points (MTrP) in patients with MPS. METHODS: Forty-six consecutive patients with MTrP were enrolled in this study. We closely observed changes in areas of tactile hypoesthesia in patients who had tactile hypoesthesia at the first visit, and throughout TPI therapy. Tactile stimulation was given using cotton swabs, and the areas of tactile hypoesthesia were delineated with an aqueous marker and recorded in photographs. RESULTS: A reduction in the size of hypoesthetic area with TPI was observed in 27 (58.7%) patients. All the 27 patients experienced a reduction in pain intensity by more than 50% in a numerical rating scale score through TPI therapy. In 9 patients, the reduction in the sizes of hypoesthetic areas occurred 10 minutes after TPI. Complete disappearance of tactile hypoesthesia after TPI therapy was observed in 6 of the 27 patients. Myofascial trigger points were located in the muscles in the vicinity of ipsilateral cutaneous dermatomes to which the hypoesthetic areas belonged. CONCLUSION: Our results indicate a relatively high prevalence of reversible tactile hypoesthesia in patients with MPS. Mapping of tactile hypoesthetic areas seems clinically useful for detecting MTrP. In addition, treating MTrP with TPI may be important for distinguishing tactile hypoesthesia associated with MPS from that with neuropathic pain.

Induction of pulmonary fibrosis by methotrexate treatment in mice lung in vivo and in vitro.

Methotrexate (MTX) has been used as the first-line disease-modifying antirheumatic drug (DMARD) in patients with early progressive rheumatoid arthritis (RA). Several severe side effects such as myelosuppression, hepato-, nephro-, and pulmonary toxicities have been reported. However, the pathogenic mechanism of MTX-induced pulmonary fibrosis is still unknown. Here, we evaluated the morphological and biological changes of the pulmonary fibrosis in mice treated with MTX. Three, four and five weeks after consecutive administration of MTX (3 mg/kg/day), hydroxyproline content in the lung tissues increased significantly to about 2 times higher that of the control level. This result closely reflected to the results of hematoxylin and eosin (HE) and Azan stains. Immunohistochemical analysis revealed that MTX treatment resulted in a decrease of alveolar epithelial cells and an increase of fibroblast cells in the mouse lung tissues. When we examined the effects of MTX on primary mouse alveolar epithelial cell (MAEC) and mouse lung fibroblast (MLF) survival in vitro, the efficiency of MTX-induced cytotoxicity and apoptosis in MAEC was more sensitive than MLF cells. Thus, our results indicate that the administration of MTX by an oral route could induce a fibrotic response with cell dysfunction of the alveolar epithelium by which MTX-induced apoptosis. Our results thus suggest that MTX could induce alveolar epithelial cell injury and resulted in the loss of integrity of the alveolar-capillary barrier basement membranes followed by the recruitment and proliferation of myofibroblasts with the deposition of collagens.

Mechanism of salivary secretion enhancement by Byakkokaninjinto.

Byakkokaninjinto (BN) is a Kampo preparation used for the treatment of xerostomia induced by drug, ageing, Sjogren syndrome, etc. The mechanism for BN to induce salivary secretion has not been made clear. In this study, various rat thirst models were prepared using muscarinic receptor blockers, such as 4-diphenylacetoxy-N-methylpiperidine (4-DAMP) and atropine, or adrenoceptor blockers, such as phentolamine and propranolol, in order to investigate the efficiency of BN. When BN was orally administered to the rats in the dose range of 100 to 300 mg/kg, the salivary secretion increased in a dose-dependent manner. The suppression of salivary secretion induced by phentolamine, atropine, and 4-DAMP was recovered by the additional treatment of BN. Interestingly, BN treatment increased the expression of aquaporin 5 in rats, which is known to regulate salivary secretion from the submandibular gland. These results suggested that BN increased the expression of aquaporin 5 through activation of muscarinic M3 receptor and enhanced salivary secretion.

Effects of Byakko-ka-ninjin-to on salivary secretion and bladder function in rats.

Byakko-ka-ninjin-to (BN) is a Kampo medicine (traditional Japanese medicine) that is frequently used to treat xerostomia, which is also a side effect of anticholinergic agents such as oxybutynin and propiverine widely used for the treatment of patients with urinary incontinence or frequency. We investigated the effects of BN on salivation and bladder function in rats, in the presence and absence of oxybutynin. Treatment with BN alone resulted in a slight increase in salivary secretions. In contrast, pilocarpine, a known muscarinic agonist, produced a significant increase in salivary secretions that could be blocked by pretreatment with oxybutynin. A single oral dose of BN at 200mg/kg body weight just before oxybutynin treatment resulted in less inhibition by oxybutynin of pilocarpine-induced salivation. However, BN had no effect on the decreased amplitude of bladder contractions that result from oxybutynin administration. These results suggest that BN might be useful for the xerostomia induced by anticholinergic agents, without influencing their beneficial effect on micturition.

Impairment of innate cellular response to in vitro stimuli in patients on continuous ambulatory peritoneal dialysis.

BACKGROUND: Most crucial in the initial stages of host defence against invading micro-organisms is innate immunity, in which peripheral mononuclear cells, in particular cytokines, are pivotal. Mortality from infections is high in dialysis patients, but it remains unclear if this arises from the ineffectiveness of innate immune mechanisms. METHODS: In 20 haemodialysis (HD) patients, 20 patients on continuous ambulatory peritoneal dialysis (CAPD), and 15 age-matched controls, we studied cytokine production by monocytes and helper T-cells in response to in vitro stimuli. The most important early-response cytokines for innate immunity, tumour necrosis factor (TNF)-alpha and interleukin (IL)-1beta, were tested in monocytes, and interferon-gamma and IL-4 were studied as indicators of polarization of helper T-cells into type 1 and type 2 cells. Peripheral blood cells stimulated with lipopolysaccharide or mitogen were labelled with anti-CD14+ and -CD4+ antibodies and then subjected to intracellular cytokine staining and flow cytometry. RESULTS: CAPD patients showed significantly reduced synthesis of TNF-alpha and IL-1beta and inhibited T helper phenotype development compared with HD patients and control subjects. In contrast, HD patients showed an unaltered monokine response and a marked polarization of helper T-cells towards the type 1 phenotype. We also found that a single HD treatment potentiated monocytes to synthesize TNF-alpha. CONCLUSIONS: Circulating immune cells in CAPD patients may be hyporeactive against infections, indicating an unfavourable innate host defence.

The involvement of integrin alphavbeta3 in polymorphonuclear leukocyte-induced angiogenesis in bovine aortic endothelial cells.

We have previously reported that angiogenesis stimulated by adhesion of polymorphonuclear leukocytes (PMNs) to endothelial cells (ECs) via intercellular adhesion molecule-1 (ICAM-1) might be mediated by a transcription factor, ets-1, which regulates adhesion molecules such as integrins related to angiogenesis. However, the regulation mechanisms of PMN-induced angiogenesis mediated by ICAM-1 remain unclear. Therefore, we investigated the effects of PMN on EC attachment to the extracellular matrix (ECM), which is one of the critical elements for angiogenesis development. After the addition of PMNs, attachment of bovine aortic endothelial cells (BAECs) to vitronectin, which is known as a ligand for integrin alpha(v)beta(3), increased greatly. Stimulation of BAEC with PMN induced expressions of integrin beta(3) mRNA and protein. PMN-induced angiogenesis was inhibited by Arg-Gly-Asp (RGD) peptide and LM609 anti-alpha(v)beta(3) antibody. The PMN-induced BAEC attachment to vitronectin was inhibited by ets-1 antisense oligonucleotide and anti-ICAM-1 antibody. These results suggested that enhancement of EC attachment to ECM via integrin alpha(v)beta(3) participated in the development of PMN-induced angiogenesis. Furthermore, the increase in EC attachment to ECM by ligation of PMN to ICAM-1 might be regulated by Ets-1 expression.

Stimulation of in vitro angiogenesis by nitric oxide through the induction of transcription factor ETS-1.

The aim of this study was to examine whether transcription factor ETS-1, which is responsible for the expression of metalloproteinases and integrin beta(3), is implicated in the induction of nitric oxide (NO)-induced angiogenesis. Bovine aortic endothelial cells were cultured on type I collagen gel to measure the length of the formed tube-like structure, which is a marker for in vitro angiogenesis. The addition of S-nitroso-N-acetylpenicillamine (SNAP), an NO-donor, to confluent endothelial cells stimulated the formation of the tube-like structure, with disappearance of covered endothelial cell monolayers. Another NO-donor 2,2'-(hydroxynitrosohydrazono)bis-ethanamine (NOC 18) also induced the formation of the tube-like structure. In contrast to the induction of the formation of the tube-like structure by SNAP, it reduced cell proliferation. SNAP and NOC 18 also increased the expression of the ets-1 mRNA level in a concentration-dependent manner. The maximum expression was observed at 2h after their addition. Moreover, the SNAP-induced in vitro angiogenesis, ets-1 mRNA expression and ETS-1 protein expression were strongly reduced by the treatment with ets-1 antisense oligonucleotide. These results strongly suggest that NO stimulates in vitro angiogenesis through the induction of ETS-1 expression. NO appears to stimulate endothelial cell differentiation to the angiogenic phenotype via the induction of ETS-1 transcription factor.

Multicenter clinical trial of 22-oxa-1,25-dihydroxyvitamin D3 for chronic dialysis patients.

BACKGROUND: Conventional calcitriol treatment can suppress parathyroid hormone (PTH) secretion in hemodialysis patients, although it can cause refractory hyperparathyroidism in some patients. We attempted to elucidate clinical outcomes of intravenous 22-oxa-1,25-dihydroxyvitamin D(3) (OCT) treatment and their determinants in a multicenter clinical trial. METHODS: One hundred one patients with serum PTH levels greater than 300 pg/mL (300 ng/L) and serum calcium levels less than 11 mg/dL (2.74 mmol/L) were recruited. OCT was administered intravenously at the end of each dialysis session. The dose was decreased by 5 microg when serum PTH level was less than 300 pg/mL or serum calcium level was greater than 11 mg/dL. RESULTS: OCT was administered for 4.8 months to 101 patients (average age, 55.1 years) who were on dialysis therapy for 15.9 years. Percentages of decrease in PTH levels greater than 30% were obtained in 44 patients (43.5%). These patients were on dialysis therapy for a shorter duration than those who showed less than 30% decreases (13.0 +/- 3.3 versus 17.9 +/- 3.0 years). Multiple regression analysis of the final PTH level or percentage of decrease in PTH level with respect to initial PTH level, serum calcium level, serum phosphate level, age, and dialysis therapy duration showed that determinants of percentages of decrease in PTH levels were initial serum calcium and phosphate levels. Conversely, significant determinants of the final PTH level were initial PTH levels and initial calcium levels. CONCLUSION: These results show that the decrease in PTH levels by OCT therapy could be predicted in patients with low calcium, PTH, and alkaline phosphatase levels; high phosphate levels; and short dialysis therapy duration before the start of OCT administration.

Involvement of adenosine A2 receptors in the changes of tissue factor-dependent coagulant activity induced by polymorphonuclear leukocytes in endothelial cells.

We have already reported that polymorphonuclear leukocytes (PMNs) could increase tissue factor-dependent coagulant activity (TF activity) in endothelial cells mediated by adhesion of PMNs to endothelial cells. In the present study, the role of adenosine receptors in the changes of TF activity and of adhesion between PMNs and endothelial cells was examined. The increases of the TF activity and adhesion were significantly reduced in a concentration-dependent manner by pretreatment of adenosine (0.1 and 1.0 mM); an adenosine A1/A2-receptor agonist, CGS-21680 (5, 10 and 50 microM); and an adenosine A2-receptor agonist, 5'-(N-cyclopropyl)-carboxamidoadenosine (CPCA; 1.0, 10 and 100 nM). An adenosine A2-receptor antagonist, 3,7-dimethyl-1-(2-propynyl) xanthine (DMPX; 1.0 and 100 nM), antagonized significantly the reduction of the TF activity and the adhesion induced by adenosine (1.0 mM), while 8-cyclopentyl-1,3-dimethylxanthine (CPDMX; 1.0 and 100 nM), an adenosine A1-receptor antagonist, did not affect it. On the other hand, the TF activity and the adhesion were not changed by N6-cyclohexyladenosine (CHA; 10 and 100 nM) and 2-chloro-N-cyclopentyladenosine (CCPA; 10 and 100 nM), adenosine A1-receptor agonists in the same conditions. These results suggest that the reduction in the TF activity stimulated by PMNs is closely related to the adhesive inhibition between PMNs and endothelial cells through the adenosine A2-receptor-mediated system.

Differential roles of ICAM-1 and E-selectin in polymorphonuclear leukocyte-induced angiogenesis.

Ets-1, which stimulates metalloproteinase gene transcription, has a key role in angiogenesis. We first examined whether activated polymorphonuclear leukocytes (PMNs) enhanced angiogenesis through the induction of Ets-1. Addition of activated PMNs to endothelial cells stimulated both in vitro angiogenesis in collagen gel and Ets-1 expression. Both angiogenesis and Ets-1 expression induced by PMNs were reduced by ets-1 antisense oligonucleotide, suggesting that Ets-1 is an important factor in PMN-induced angiogenesis. Although intercellular adhesion molecule (ICAM)-1 and E-selectin are involved in PMN-induced angiogenesis, the mechanisms underlying their roles in angiogenesis have yet to be elucidated. PMN-induced Ets-1 expression was reduced by a monoclonal antibody against ICAM-1 but not E-selectin despite the inhibition of PMN-induced angiogenesis by both antibodies. Moreover, the stimulation of angiogenesis by H(2)O(2) without PMNs was inhibited by a monoclonal antibody to E-selectin but not ICAM-1. These findings suggested that ICAM-1 in endothelial cells may act as a signaling receptor to induce Ets-1 expression, whereas E-selectin seems to function in the formation of tubelike structures in vascular endothelial cell cultures.