Nosocomial outbreak of epidemic keratoconjunctivitis accompanying environmental contamination with adenoviruses.

An outbreak of acute keratoconjunctivitis involving 27 patients occurred in the Department of Ophthalmology, Kurume University Hospital. Adenoviral DNA was detected in four inpatients, one outpatient and one healthcare worker. Sequence-based typing of adenoviral DNA indicated serotype 3 from one inpatient, the rest being serotype 37. At a later stage of the outbreak adenoviral DNA types 37 and/or 3 were also detected from almost all environmental instruments and commonly used eye drops, despite thorough disinfection of the environment and enforcement of various infection control measures. The detection rate of adenoviral DNA in environmental swabs was 81%. A further second disinfection of the environment reduced the detection rate of adenoviral DNA to 38%. The outbreak ceased after closing the ophthalmology ward and outpatient consulting room, accompanied by enhanced cleaning of environmental instruments and the introduction of disposable eye drops for individual patients.

Immunohistochemical evaluation of canine peripheral nerve sheath tumors and other soft tissue sarcomas.

Seventeen cases of canine peripheral nerve sheath tumors (PNSTs), 11 malignant PNSTs (MPNSTs), and six benign PNSTs (BPNSTs) were examined. The prognosis in five of six dogs with BPNSTs was excellent, whereas all dogs with MPNSTs died within 2 years after the last surgical resection. One BPNST formed a recurrent mass with features of a MPNST. Histopathologically, the predominant tumor cell of MPNSTs was either spindle or round in shape with epithelioid characteristics. Other atypical cells had abundant granular cytoplasm or were multinucleated giant cells with periodic acid-Schiff-positive cytoplasmic globules. Furthermore, two MPNSTs contained cartilaginous and osseous metaplasia. On the contrary, most BPNSTs exhibited typical features of schwannoma or neurofibroma, whereas two BPNSTs had atypical morphology. One BPNST consisted of epithelioid cell proliferation with some tumor cells revealing nuclear atypia. Immunohistochemically, the expression of vimentin (100%), S-100 (73%), nerve growth factor receptor (NGFR, 64%), and myoglobin (64%) was commonly found in MPNSTs. The two BPNSTs with atypical histologic appearances were positive for vimentin, S-100, NGFR, and neuron-specific enolase, and one of these had moderate immunoreactivity for cytokeratin. Most BPNSTs were positive for glial fibrillary acidic protein, as well as S-100 and NGFR. Although most rhabdomyosarcomas (RMSs) and canine hemangiopericytomas (CHPs) also showed focal immunoreactivity for S-100, most RMSs were intensely positive for myoglobin and negative for NGFR. Most CHPs (80%) exhibited focal alpha-smooth muscle actin (alpha-SMA) expression, whereas all PNSTs were negative. These results indicate that immunohistochemistry for NGFR and alpha-SMA might be useful for differentiating canine PNSTs from RMSs or CHPs, respectively.

Evidence of B cell clonal expansion in HIV type 1-infected patients.

HIV-1 infection results in a gradual decrease in CD4(+) T cell counts and progressive immune deficiency. Increased T cell turnover in HIV-1-infected patients, which can be interpreted as T cell clonal expansion, has been thought to be relevant to its pathogenesis. To investigate whether B cell clonal expansion also occurs in HIV-1-infected patients, we examined the expressed V(H)DJ(H) gene sequences of peripheral B cells in HIV-1-infected patients with hypergammaglobulinemia. Identical V(H)DJ(H) gene rearrangements with additional nucleotide differences in V(H) genes were analyzed as a marker of clonally related B cells. From healthy individuals and HIV-1-uninfected patients with hypergammaglobulinemia, clonally related B cells were detected in none of 10 (0%) and 2 of 10 (20%), respectively. No clonally related B cells were detected in any of the nine HIV-1-infected patients with detectable viral loads and normal Ig levels (0%). In contrast, from 9 of 14 HIV-1-infected patients with hypergammaglobulinemia (64%), clonally related B cells were detected. In addition, no HIV-1-infected patients who exhibited normal Ig levels after antiretroviral therapy had clonally related B cells. These findings suggest that B cell clonal expansion is present in HIV-1-infected patients with hypergammaglobulinemia.

Pancreatoduodenectomy for pancreatic head carcinoma with or without pylorus preservation.

BACKGROUND/AIMS: With the concept of less invasive surgery, PpPD (pylorus-preserving pancreatoduodenectomy) has taken the place of conventional Whipple pancreatoduodenectomy (Whipple) as a standard operation for pancreatic head carcinoma. The aim of this paper is to compare early and late postoperative results of PpPD and Whipple for pancreatic head carcinoma. METHODOLOGY: Postoperative clinical follow-up data and outcome of 50 Japanese patients with pancreatic head carcinoma who underwent pancreatoduodenectomy with or without pylorus preservation were reviewed to scrutinize the demerits and merits of the pylorus preservation. RESULTS: Preoperative and postoperative serum chemistry was not different between the two groups. Mean operation time of the Whipple group was 517 minutes, which was significantly shorter than 624 minutes of the PpPD group (P = 0.0006). Cumulative stage was not different between the two groups. Cumulative curability of the PpPD group was superior to the Whipple group; of the 27 patients with Whipple, A in 4, B in 5 and C in 18, while of the 23 patients with PpPD, A in 12, B in 2 and C in 9 (P = 0.0182). Gastric tube was removed on POD 6.0 in the Whipple group, while on POD 39 in the PpPD group (P < 0.0001). Oral intake was started on POD 14.0 in the Whipple group, while on POD 28.3 in the PpPD group (P = 0.0018). Discharge was on POD 57.8 in the Whipple group, while POD 86.9 in the PpPD group (P = 0.0023). At the time of discharge and postoperative 6, 12, and 18 months, body weight loss from the preoperative level was 1kg smaller in the PpPD group than in the Whipple group. 1-year and 3-year survival rates of the Whipple group was 53.8% and 15.8%, while 62.8% and 19.6% of the PpPD group, showing no significant difference. CONCLUSIONS: These data show that delayed gastric emptying is evident in the PpPD group, resulting in longer hospital stay, while long-term body weight loss is smaller in this group. The clinical outcome is similar between the two groups. PpPD can be accepted as a standard operation for pancreatic head carcinoma.

[Effect of highly active antiretroviral therapy (HAART) on hypergammaglobulinemia in HIV infected patients].

To investigate the mechanism of hypergammaglobulinemia in HIV infected patients, the effect of highly active antiretroviral therapy (HAART) on the hypergammaglobulinemia was analyzed. Involved in this study were 34 untreated, 21 HAART-effective (complete response) and 14 HAART-non-effective (partial response) patients. Serum levels of HIV-RNA and gammaglobulin and immunoglobulin (Ig) isotypes were measured. Mean HIV-RNA levels of untreated and partial response patients were 1.6 x 10(4) copies/ml and 0.4 x 10(4) copies/ml, respectively. HIV-RNA levels of all complete response patients were below 4.0 x 10(2) copies/ml. Mean gammaglobulin percentages of untreated, partial response and complete response patients were 24.4%, 21.8% and 17.9%, respectively (p < 0.01 in untreated vs complete response patients). Mean IgG levels in the three groups were 2,489 mg/dl, 1,947 mg/dl and 1,618 mg/dl, respectively (p < 0.001 in untreated vs complete response patients). IgA levels were high in some untreated patients and lower in complete response patients. IgE levels were increased in some untreated and partial response patients, but there was no significant difference among the three groups. These results suggested that the hypergammaglobulinemia found in HIV infected patients was associated with HIV replication. The activation mechanism might differ by Ig isotypes.

The predictive value of p53, Ki-67 and angiogenetic factors in primary hypopharyngeal carcinoma.

To evaluate the predictive role of the oncogene p53, the proliferating marker Ki-67, angiogenic factors platelet-derived endothelial cell growth factor/thymidine phosphorylase (PD-ECGF/dThdPase) and vascular endothelial growth factor (VEGF) in primary hypopharyngeal carcinoma, we immunohistochemically studied a series of 84 primary hypopharyngeal carcinoma patients who were treated at the Department of Otolaryngology of Kurume University Hospital between 1990 and 1997. The correlation of each score according to the intensity and percentage of the labeled cells with the TNM stage, histological grade, metastasis and survival status was analyzed. The positive rate of p53 was 52.4%. The percentages of Ki-67 labeled cells in patients with or without metastasis showed a significant difference (p = 0.011). VEGF also showed a significant difference between the live and death groups (p < 0.05) and also among the differentiation group (p < 0.05). A statistically significant correlation was also seen between the score of Ki-67 and VEGF (r = 0.438, p < 0.001) or the score of Ki-67 and PD-ECGF (r = 0.259, p < 0.001), respectively. In conclusion, the present study suggests that a correlation exists between proliferating and angiogenesis, and VEGF and Ki-67 are thus considered to be possible prognostic discriminators in hypopharyngeal carcinoma.

[Laser debulking surgery prior to radiotherapy for T1T2 carcinoma of the hypopharynx].

The local control rate for T1-T2 carcinomas of the hypopharynx is rather high whereas the overall survival rate is unsatisfactory, irrespective of treatment modalities. Radical radiotherapy has yielded a local control rate of 40-70% and an overall 5-year survival of 30-50%, while surgical treatment with or without postoperative radiotherapy has yielded a local control rate of 60-90% and an overall 5-year survival rate of 30-60%. Based on these reasons, for the patients with minor hypopharyngeal lesions, such as T1-T2 carcinomas, in the Kurume University Hospital radiotherapy has often been selected as a first choice instead of partial pharyngectomy. If the primary lesion is exophytic and has a large volume, laser debulking surgery has been employed prior to radiotherapy to improve the local control rate. The purpose of the present study is to describe the details of laser debulking surgery prior to radiotherapy (LDSR) for the treatment of T1-T2 carcinomas of the hypopharynx. In addition, the preliminary results for this treatment procedure will also be compared with the results of partial pharyngectomies preserving the larynx (PPPL) that were performed in the Kurume University Hospital. In this study 20 patients (T1: 4, T2: 16) who had undergone PPPL and 16 patients (T1: 4, T2: 12) who had undergone LDSR were included. For patients undergoing PPPL, the 5-year local control rate, 5-year larynx conservation rate and disease specific 5-year survival rate were 83.6%, 70.4%, and 75.0%, respectively, whereas for patients undergoing LDSR these were 87.1%, 93.8%, 87.5% respectively. Although the treatment outcomes by LDSR did not show a significant drastic improvement compared with those by PPPL, the quality of life of the patients undergoing LDSR was not aggravated. LDSR may thus be preferable to PPPL for selected cases of T1-T2 carcinomas of the hypopharynx.

Management of impaired vocal fold movement during sleep in a patient with Shy-Drager syndrome.

A 46-year-old woman with Shy-Drager syndrome is presented. She has impaired vocal fold abduction during sleep, but has no laryngeal dysfunction while she is awake. In order to reduce laryngeal obstruction during sleep, she initially underwent laterofixation of 1 vocal fold (Ejnell's method) with little lasting success because of accidental slipping of the ligature. Later, she successively underwent arytenoidectomy with the use of CO2 laser. Her noctural breathing improved markedly after arytenoidectomy.

The distribution of HIV-1 subtypes in Fukuoka, Japan.

To determine the incidence of human immunodeficiency virus type-1 (HIV-1) subtypes in Fukuoka, Japan, viruses from 41 HIV-1 infected individuals were subtyped. Subtyping by V3-loop enzyme-linked immunosorbent assay (ELISA) showed 31 of the 41 subjects as subtype B (MN type), one as subtype A, one as subtype C, and eight untypable. The subject infected with subtype C was identified as a foreigner; the subtype A subject was Japanese. A phylogenetic analysis of nucleic acid sequences from the env C2-V3 region was also conducted. Genetic subtyping was successful for 25 samples: 23 samples were determined as subtype B, one subtype A and one subtype E. One of the individuals infected with subtype B, as well as the subtype A and subtype E subjects, were not Japanese. This study indicated that subtype B (USA and European type) is still dominant among HIV-1 infections in Fukuoka. Further, no Japanese were subtype E positive, which is increasing in the Kanto region. It is notable, however, that subtype A and subtype C infections, which are rare in Japan, were found in Fukuoka, located far from the metropolitan area of Tokyo.

[An epidemic of aseptic meningitis caused by echoviruses in Fukuoka Prefecture during April 1997 to August 1998].

An epidemic of aseptic meningitis in Fukuoka Prefecture during April 1997 to August 1998 was studied to determine the serotype of viruses isolated in Fukuoka Prefecture. In Fukuoka Prefecture, bimodal peaks were seen in July and December 1997. Monthly changes of reported aseptic meningitis patients and period of virus isolation revealed that epidemics of the earlier part in 1997 was caused by echovirus 9 (E 9) and the latter part due to echovirus 30 (E 30). E 9 was isolated mainly in Chikugo Area from June to October 1997 but, E 30 was isolated all in areas of Fukuoka Prefecture. Isolation of E 30 continued after January 1998 in Fukuoka Prefecture. Isolation of echovirus 18 started in June 1998. The main serotypes of isolates are changing. The E 30 isolates are serotyped by neutralization with the aid of antiserum pools for enterovirus type differentiation, but serotyping was difficult with commercially available antiserum. The result of neutralization tests with standard serum and an immune albino rabbit serum prepared in our laboratory with the E 30 isolates indicated that the isolates in Fukuoka Prefecture was an antigenic variant.

Effect of leucine 13-motilin (KW5139) on early gastric stasis after pylorus-preserving pancreatoduodenectomy.

OBJECTIVE: To test a hypothesis that exogenously administered motilin would improve early gastric stasis after pylorus-preserving pancreatoduodenectomy (PPPD). SUMMARY BACKGROUND DATA: Prolonged gastric stasis is a frequent complication after PPPD. We demonstrated that this might at least in part be attributable to delayed recovery of phase III activity of the gastric migrating motor complex due to low concentrations of plasma motilin caused by resection of the duodenum. METHODS: Ten patients with a mean age of 54 years (range, 33-70) who underwent PPPD were studied. An assembly of manometric tubes was placed in the gastric antrum and jejunum (neoduodenum) at surgery. A gastrostomy tube was added for drainage and volume measurements of the gastric juice. After baseline recording, saline as a placebo was given intravenously on day 14 and 0.5 microg/kg of KW5139 (leucine-13 motilin) was given on days 17 and 18 every 2 hours, 6 times a day. The daily volume of gastric juice output and a gastric motility index were measured. RESULTS: The mean period until the first appearance of phase III activity in the stomach was 41 +/- 2 days. The injection of saline did not change the gastric motility index (7.3 +/- 1.1 to 7.1 +/- 1.3 mmHg; p = 0.72). In contrast, motilin resulted in a significant increase in the gastric motility index (7.5 +/- 1.0 to 17.7 +/- 2.0 mmHg; p < 0.001). The saline injection produced no change in the daily gastric juice output (1175 +/- 140 to 1393 +/- 193 mL; p = 0.09). Motilin significantly decreased the gastric juice output (1387 +/- 157 to 934 +/- 142 mL; p = 0.01). CONCLUSIONS: These data indicate that KW5139 is a safe and effective prokinetic drug for the treatment of early gastric stasis after PPPD.

Comparison of endoscopic retrograde and magnetic resonance cholangiopancreatography in the surgical diagnosis of pancreatic diseases.

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is a newly developing noninvasive examination of the biliopancreatic trees. Roles of MRCP in the diagnosis of pancreatic diseases have not been scrutinized. METHODS: Endoscopic retrograde cholangiopancreatography (ERCP) and MRCP were reviewed in 52 Japanese patients with various pancreatic diseases and 6 patients with normal pancreas to compare their diagnostic usefulness and limitation. RESULTS: In those with normal pancreas, only the main pancreatic duct was visualized by MRCP, while both the main pancreatic and branch ducts were clearly delineated by ERCP. In 3 patients with serous cystadenoma, the tumor was not visualized by ERCP, whereas it was visible as a high-intensity mass on MRCP. Of 18 patients with a "mucin hypersecreting" tumor of the branch type, MRCP demonstrated cystically dilated branch ducts in all, while ERCP failed to visualize the dilated ducts in 6 patients. However, the details of the cystic lesions (mural nodule, communication with the main pancreatic duct) were more exactly demonstrated by ERCP than MRCP. In 5 patients with a mucin hypersecreting tumor of the main pancreatic duct type, the dilated main pancreatic duct and the presence of mural nodules were similarly demonstrated both by ERCP and MRCP. In 12 patients with pancreatic adenocarcinoma, indirect findings were similarly demonstrated both by ERCP and MRCP, ie, stenosis (4 patients) and obstruction (8) together with dilation of the main pancreatic duct (9). In 3 patients, the center of the mass showed high intensity on MRCP, suggesting the secondary change of pancreatic carcinoma. In 8 patients with obstruction of the main pancreatic duct due to carcinoma, the distal pancreatic duct was visualized by MRCP but not by ERCP. In 9 patients who had undergone pylorus-preserving or standard pancreatoduodenectomy, follow-up MRCP was obtainable in all examined and displayed the main pancreatic duct. CONCLUSIONS: MRCP plays a complementary role in the surgical diagnosis of pancreatic disorders and is especially useful to examine the pancreatic duct after pancreatoduodenectomy.

Litmus paper helps detect potential pancreatoenterostomy leakage.

BACKGROUND: Leakage of pancreatoenterostomy remains as a serious and fatal complication after pancreatectomy. Several risk factors have been reported, ie, normal pancreatic parenchyma, small pancreatic duct, a large amount of intraoperative blood loss, management of the cut surface of the pancreas, and the presence of preoperative jaundice. Transected pancreatic ductules on the cut surface of the pancreas that are not drained into the main pancreatic duct after pancreatectomy are one of the risks. The pancreatic juice is alkaline and turns red litmus to blue. METHODS: In order to detect the transected pancreatic ductules on the cut surface of the pancreas, red litmus paper is applied to the cutting surface of the pancreas after stimulation of secretin. RESULTS: Nondrained, transected pancreatic ductules on the cut surface of the pancreas can be detected as blue spots on the red litmus paper. The corresponding areas to the blue spots can be transfixed with sutures to close the nondrained and transected pancreatic ductules. CONCLUSION: Litmus paper can be expected to detect pancreatoenterostomy leakage after pancreatectomy.

[Analysis of genome types of adenovirus type 7 isolated in Fukuoka Prefecture in 1996].

Adenovirus type 7 (Ad7) was rarely isolated in Japan till 1994, but during April 1995 to August 1996, isolations of Ad7 were reported 230 cases. We isolated Ad7 in January and July 1996 in Fukuoka prefecture. We analyzed its genome type by using 14 restriction endonuclease and studied seroepidemiology of Ad7 infection in Fukuoka prefecture. Isolated Ad7 strains were identical by 14 restriction endonuclease. Between new Ad7 isolates and prototype (Gomen; Ad7p), 4 restriction endonuclease patterns were identical but 10 restriction endonuclease patterns were different. From the result of restriction endonuclease pattern analysis, genome type of Ad7 isolated in Fukuoka may be the same to Ad7c reported by Noda et al. (1996). The alterations in the cleavage sites of 10 restriction endonucleases between new Ad7 isolates and Ad7p were revealed at least 12 sites. Ad7 antibody positive rates in serum specimens collected in Fukuoka Prefecture were 3.6% in 1994 and 9.7% in 1996.

Some aspects of vocal fold bowing.

Bowing of the vocal fold frequently occurs in patients with vocal fold paralysis (VFP), those with sulcus vocalis, and those who have had laser surgery. Additionally, there are vocal folds that present bowing with no noticeable organic lesion. For the purpose of investigating the causes and mechanisms of vocal fold bowing, consecutive fiberscopic videorecordings of 127 patients with VFP, 33 with sulcus vocalis, 33 with laser surgery, and 33 with dysphonia having no clinically noticeable organic lesion were reviewed. Sixty-nine percent of the paralyzed vocal folds had bowing, and the occurrence of bowing was significantly related to the activity of the thyroarytenoid muscle as measured by electromyography. The cricothyroid activity had no significant relationship to vocal fold bowing. All vocal folds with sulcus presented with bowing. Thirty-five percent of the vocal folds that had had laser surgery had bowing. The extent of tissue removal was closely related to the occurrence of bowing. Twelve cases with no organic lesion had vocal fold bowing. Of these 12 patients, 8 were male and 9 were older than 60 years. Some aging process in the mucosa was presumed to be the cause of the bowing in this age group of patients without clinically noticeable organic lesions. Causes of vocal fold bowing in the younger group of patients without organic lesions were not determined in this study.

Decreased protein concentration and improved metastability of bile induced by ursodeoxycholate.

Previous studies demonstrated that higher biliary protein is associated with reduced metastability of bile. This study attempted to examine the induced effect of ursodeoxycholate on metastability of bile by measuring the nucleation time and biliary protein in cholesterol gallstone patients. Thirty-seven patients with functioning gallbladders were studied 10 control patients without gallstones and 27 with cholesterol gallstones. Ten of 27 cholesterol gallstone patients were treated with ursodeoxycholate (600 mg/day) prior to surgery. Twelve of 17 untreated gallstone patients had cholesterol crystals in gallbladder bile while cholesterol crystals were absent in the ursodeoxycholate-treated gallstone patients and in the controls. Total protein concentration and cholesterol saturation index were significantly greater in the untreated gallstone patients with crystals than in those without crystals in bile. The treatment with ursodeoxycholate significantly decreased biliary protein concentration and cholesterol saturation index associated with the prolonged nucleation time. Cholesterol nucleation time correlated with biliary total protein concentration and cholesterol saturation index but not with total lipid concentration. It is concluded from the present study that ursodeoxycholate decreases biliary protein thereby partly increasing metastability of gallbladder bile.