Posterior hip fracture-dislocation associated with posterior wall fracture of the acetabulum and ipsilateral comminuted trochanteric fracture of the femur: A case report.

INTRODUCTION AND IMPORTANCE: Traumatic posterior dislocation of the hip is often associated with fractures of the femoral head and posterior wall of the acetabulum. However, hip fracture-dislocation that includes the posterior wall of the acetabulum and the ipsilateral femoral trochanter is rare. There is no consensus on the bone that should be operated on first, the operative position, and the choice of implant for femoral fixation. CASE PRESENTATION: A 67-year-old man was brought to our emergency department after a 2-m fall. He was diagnosed with a hip fracture-dislocation associated with posterior wall acetabular fracture and ipsilateral femoral trochanteric fracture. Surgical reconstruction was performed with intramedullary nail (IMN) fixation of the femoral trochanteric lesion, followed by anatomically rigid acetabular fixation in the lateral decubitus position. At the 5-year follow-up after the injury, the patient showed good objective and subjective clinical outcomes. CLINICAL DISCUSSION: Fixing the femur first could allow an easier reduction and traction. The lateral decubitus position was useful, because fixation of the femur and the acetabulum could be performed without changing the position. When fixing the femoral trochanteric lesion, attention was paid to reduce the anteromedial cortex of the proximal fragment extramedullarly to the distal fragment to prevent complications such as cutout and implant breakage. CONCLUSION: Anatomically rigid fixation of the posterior wall of the acetabulum secondary to IMN fixation of the femur, with anteromedial cortical support in the lateral decubitus position, could achieve good objective and subjective clinical outcomes.

[Bacteria that eat human lurking in the Ariake Sea-Vibrio vulnificus infection].

There are currently 76 species of bacteria in the genus Vibrio, which is a halophilic gram-negative bacillus, 12 of which are pathogenic in humans. It is usually known as a foodborn infectious bacterium related to gastrointestinal tract. Vibrio vulnificus develops muscle tissue necrosis of limb and septic shock in 1 to 3 days when infected in patients with liver injury or immune function deterioration and many die from multiple organ dysfunction. Since V. vulnificus is suitable for inhabitation and proliferation in the warm brackish water area, many infection of V. vulnificus onset occurred in the prefecture adjacent to the closed bay such as Ariake Sea, Ise Bay and Mikawa Bay.

Identification of 62-kDa protein as an immunogenic antigen of Vibrio vulnificus for humans.

Vibrio vulnificus infection can cause necrotizing fasciitis and sepsis and can develop within a few days despite intensive care. The mortality rate is up to 60% in vulnerable people. Most patients infected with this microbe have chronic liver disease, especially liver cirrhosis or cancer, as an underlying disease. V. vulnificus infection is opportunistic, and there is an urgent need to develop an anti- V. vulnificus vaccine. Thus, it is important to identify immunogenic antigens. We collected human sera from three subject groups: patients with V. vulnificus infection, patients with chronic liver disease but without V. vulnificus infection, and healthy volunteers with normal liver function. Immunoblots of cytosolic and membrane proteins of seven strains of V. vulnificus and one of V. parahaemolyticus were performed with sera from these groups. Although we could not demonstrate differences in antibody response between the groups, all sera showed a strong antibody response to a 62-kDa protein that was common to all strains examined. Immunoblots of Escherichia coli and Klebsiella pneumoniae also showed strong antibody response to this 62-kDa protein, and the possibility of cross-reaction cannot be denied. We identified this 62-kDa protein as an immunogenic antigen of V. vulnificus for humans.

Distribution of virulence markers among Vibrio vulnificus isolates of clinical and environmental origin and regional characteristics in Japan.

BACKGROUND: Vibrio vulnificus is an opportunistic human pathogen that is widely distributed in estuarine environments and is capable of causing necrotizing fasciitis and sepsis. In Japan, based on epidemiological research, the incidences of V. vulnificus were concentrated in Kyusyu, mainly in coastal areas of the Ariake Sea. To examine the virulence potential, various genotyping methods have recently been developed. This study aimed to investigate the distribution of virulence markers among V. vulnificus isolates of clinical and environmental origin in three coastal areas with different infection incidences and to determine whether these isolates have the siderophore encoding gene viuB. METHODOLOGY/PRINCIPAL FINDINGS: We examined the distribution of genotypes of the 16S ribosomal ribonucleic acid (rRNA) gene, vvhA, vcg, and capsular polysaccharide (CPS), and the presence of viuB in 156 isolates collected from patients and environmental samples in Japan. The environmental samples were collected from three coastal areas: the Ariake Sea, Ise & Mikawa Bay, and Karatsu Bay. The results showed disparity in the ratios of genotypes depending on the sample origins. V. vulnificus isolates obtained from patients were classified into the clinical type for all genotypes. In the environmental isolates, the ratios of the clinical type for genotypes of the 16S rRNA gene, vvhA, and vcg were in the order of the Ariake Sea>Ise & Mikawa Bay>Karatsu Bay. Meanwhile, CPS analysis showed no significant difference. Most isolates possessed viuB. CONCLUSIONS: Many V. vulnificus belonging to the clinical type existed in the Ariake Sea. Three coastal areas with different infection incidences showed distinct ratios of genotypes. This may indicate that the distribution of clinical isolates correlates with the incidence of V. vulnificus infection.

Simultaneous measurement of urinary total nicotine and cotinine as biomarkers of active and passive smoking among Japanese individuals.

OBJECTIVES: Measuring urinary cotinine is a popular and established method of biologically monitoring exposure to tobacco smoke. However, the lower detection limit of cotinine often impedes the evaluation of passive (second-hand) smoking and this, together with unconverted nicotine, does not reflect actual levels of exposure. Furthermore, a portion of the Japanese population might have decreased ability to metabolize nicotine. The present study was therefore carried out to validate the simultaneous analysis of total concentrations of free nicotine and cotinine and their glucuronides to determine actual levels of voluntary and involuntary exposure to cigarette smoke. METHODS: Urine samples from 118 Japanese smokers and 117 non-smokers were analyzed using gas chromatography-mass spectrometry. Voluntary and involuntary smoking status was self-reported and workplace smoking restrictions were objectively evaluated. RESULTS: The integrated sum of all concentrations showed 2.2- and 2.4-fold higher total levels (free and glucuronide) of nicotine and cotinine relative to the free levels. Median (quartiles) of total nicotine and cotinine were 1635 (2222) and 3948 (3512) ng/mL in smokers, and 3.5 (5.3) and 2.8 (4.2) ng/mL in non-smokers. Concentrations of urinary nicotine were higher than those of cotinine in 21 % of smokers and in 54 % of non-smokers. Nicotine and cotinine levels were significantly associated with a smoking habit, as well as being significantly associated with the workplace and home environments of non-smokers. CONCLUSIONS: The present method can monitor voluntary and involuntary exposure to tobacco smoke. Measuring total urinary nicotine levels might be useful for analyzing exposure to cigarette smoke among non-smokers.

Clinical features of Vibrio vulnificus infections in the coastal areas of the Ariake Sea, Japan.

Vibrio vulnificus infection can result in necrotizing fasciitis and sepsis and is associated with high mortality. Most patients infected with this microbe have liver dysfunction as an underlying disease. However, because of the sporadic nature of outbreaks and unidentified cases, extensive evaluation of clinical features and identification of factors affecting prognosis have not been performed. We retrospectively analyzed 37 cases in Japan from 1984 to 2008 to review clinical features and to identify risk factors associated with prognosis. Statistical differences between clinical features (patient's characteristics, initial clinical laboratory data, symptoms upon admission, and other risk indicators) and prognosis were analyzed by use of the chi(2) test or the Mann-Whitney U test. Multivariate logistic regression analysis was also performed to assess factors which potentially affect hospital mortality. The mortality rate was 64.9%. An underlying liver disease was observed in 91.6% of the patients. The presence of liver cirrhosis tended to be related to hospital mortality; however, statistical significance was not achieved. Advanced age, lower platelet counts, and the presence of extensive skin lesions at onset affected outcomes with statistical significance. The prognosis of this disease is poor, because septic shock and necrotizing fasciitis often develop within a few days. Early diagnosis and treatment are needed to improve the prognosis of V. vulnificus infection.

[Rapid detection of Vibrio vulnificus using a loop-mediated isothermal amplification method].

Vibrio vulnificus is found in marine waters near the coast around the world. Infection with this gram-negative rod, via ingestion of raw seafood or via a skin wound following contact with contaminated estuarine or marine water, can cause necrotizing fasciitis and sepsis. Most of patients with Vibrio vulnificus infection have underlying liver dysfunction or diabetes mellitus. Due to the high mortality and short latent periods, control of this infection depends on early identification of the bacterial species and prompt initiation of intensive care. Accordingly, the development of a technique that can identify this microbe quickly and accurately is of great importance. Loop-mediated isothermal amplification (LAMP) is a novel nucleic acid amplification method to detect specific genes with rapidity and high sensitivity. In this study, we developed LAMP for the detection of Vibrio vulnificus. Using 28 Vibrio vulnificus strains and 53 other bacterial strains, we confirmed the high specificity of this method. Moreover, our LAMP method also showed high sensitivity, with a minimum detection level of one colony-forming unit per test. Furthermore, we developed simplified and conventional pretreatments for the method using experimental animal models. All of these attempts have lod to our non being able to detect Vibrio vulnificus within 1 hour.

A fatal case of necrotizing fasciitis due to bacterial translocation of Klebsiella oxytoca.

We report a 73-year-old man with hepatocellular cell carcinoma who had eruptions on and severe pain in the lower leg. Within several hours, the patient's skin lesions had progressed markedly. Magnetic resonance imaging findings were consistent with necrotizing fasciitis. Klebsiella oxytoca was isolated from cultures of biopsy samples taken from the leg. The resulting DNA fingerprint pattern revealed that the enteric bacterium was the same as that obtained from the biopsy samples taken from the leg. Furthermore, a dendrogram showed that genetic proximity between samples was extremely high. These results confirmed that translocation of Klebsiella oxytoca as an enteric pathogen caused the necrotizing fasciitis in this patient.

Survival case of Vibrio vulnificus infection with multiple endocrine neoplasia type I.

A 35-year-old female with malabsorption syndrome who underwent a pancreatoduodenectomy for multiple endocrine adenomatosis 13 years prior was admitted to our hospital with diarrhea, general fatigue, high fever, and eruption in the lower legs. The patient had consumed raw shrimp a few days before onset and presented systemic inflammatory response syndrome at the time of hospitalization. Vibrio vulnificus was isolated from a blood culture performed before admission to the intensive care unit. We excised necrotizing tissue in the legs after improvement of her general condition. During the treatment process, glucose, catecholamine, and appropriate antibiotics were administered for hypoglycemia, hypotension, and high fever, respectively. The patient was discharged 107 days after contracting the disease. Of 18 septic patients with V. vulnificus infection admitted to our hospital, this was the first to develop septicemia in the absence of a previous liver dysfunction. In order to prevent this type of fatal infection, public education for immuno-compromised individuals as well as those with liver disease is essential. For early diagnosis and appropriate treatment, more effective strategies are required, such as the establishment of a network system where family physicians and emergency hospital staff could discuss information regarding high-risk patients.

A chromogenic substrate culture plate for early identification of Vibrio vulnificus and isolation of other marine Vibrios.

Vibrio vulnificus infection can result in necrotizing fasciitis and sepsis, which have short latentcy periods and high mortality rates. Thus, an easy and quick detection method is needed to improve the outcome. To distinguish V. vulnificus from other pathogens that cause necrotizing fasciitis, we developed a selective isolation culture agar plate (Chromochecker Vibrio Agar-1; CVA-1) for use in environmental monitoring and in the clinical setting. One hundred four strains of V. vulnificus, already identified biochemically, showed typical colony form and color when grown on CVA-1. Thirty-six of 51 marine bacteria samples suspected to be V. vulnificus on CVA-1 were subsequently identified as V. vulnificus by a biochemical identification system. Of 8 bacteria known to cause necrotizing fasciitis, only V. vulnificus grew on CVA-1. In addition, growth on CVA-1 allowed ready differentiation of Vibrio species. CVA-1 can be used to distinguish pathogenic Vibrios according to colony form and chromatic differences.

[A collective review of Vibrio vulnificus infection in Japan].

Vibrio vulnificus is found globally in marine coastal waters. Infection with this organism, via ingestion of raw shellfish or exposure to marine water, can cause necrotizing fasciitis and sepsis, which have high mortality and short latency. In Japan, many cases have been reported since 1980, mainly from hospitals in western prefectures. However, because of the sporadic nature of infection outbreaks, a thorough epidemiologic survey has not been done. We studied the epidemiological and clinical characteristics of Vibrio vulnificus infections reported in Japan from 1975 to 2005. We identified 185 cases using the medical article search engines Ichushi (Japan Medical Abstracts Society), CiNii (Citation Information by National Institute of Informatics), and PubMed over 30 years. The median age of patients was 59. The number of male patients was eight times the number of female patients; however, no significant difference in mortality was found between genders. In yearly distributions of patients, 20 cases were reported in 2001, a year in which we experienced more rainfall and a longer rainy season in Northern Kyushu. In monthly distribution, about 80% of cases were reported from July to September when sea water temperatures rise. About 40% of cases were reported in four prefectures around the Ariake Sea. The underlying disease indicated liver dysfunction in 90% of patients, but mortality was the same regardless of the infection pathway (oral ingestion or wound). Because of its rapid aggravation and high mortality rate, public education is important to prevent new cases. It is also highly recommended that patients with preexisting liver dysfunction avoid raw fish and limit exposure to marine water during the summer.

Calcium dynamics and vasomotion in rat mesenteric arteries.

Smooth muscle cell calcium dynamics and diameter were measured in intact pressurized rat mesenteric artery segments during vasoconstriction and vasomotion. Arteries showed a certain norepinephrine (NE) threshold (0.3-0.4 microM) for the onset of vasomotion, during a cumulative NE concentration-response curve. This was due to a necessary [Ca2+]i threshold (increase over basal level of 22.2 +/- 2.6%) to elicit oscillations. The calcium oscillations obtained were synchronous over the entire vessel length and phase-shifted (in advance by 1.7 +/- 0.3 seconds) with respect to the diameter oscillations. A similar result was obtained using a KCl depolarization to contract the arteries, even though the [Ca2+]i threshold was much smaller in this case (increase over basal level of 9.9 +/- 4.3%), as compared with the NE-elicited vasomotion. Blockade of the Na+/K+-ATPase with 1 microM ouabain, or of the Na+/Ca2+ exchanger (NCX) with 1 microM KB-R 7943, did not abolish the calcium oscillations, thus showing that these two pumps are only modulatory elements, while on the other hand, voltage-gated calcium channels have been found to be important in the vasomotion mechanism.

Effects of running exercise during recovery from hindlimb unloading on soleus muscle fibers and their spinal motoneurons in rats.

The effects of hindlimb unloading and recovery with or without running exercise on morphological and metabolic properties of soleus muscle fibers and their spinal motoneurons in rats were investigated. Ten-week-old rats were hindlimb suspended for 2 weeks and thereafter were rehabilitated with or without voluntary running exercise for 2 weeks. A decreased percentage of type I fibers and atrophy of all types of fibers were observed after hindlimb unloading. In addition, decreased oxidative enzyme activity of all types of fibers was observed after hindlimb unloading. In contrast, an improvement in the decreased percentage of type I fibers, decreased fiber cross-sectional area, and decreased fiber oxidative enzyme activity was observed after recovery with running exercise, but not without running exercise. There were no changes in the number, cell body size, or oxidative enzyme activity of motoneurons innervating the soleus muscle after hindlimb unloading or recovery with or without running exercise. These results indicate that running exercise is beneficial for the recovery of the decreased percentage of type I fibers and the atrophy and decreased oxidative enzyme activity of all types of fibers in the soleus muscle induced by hindlimb unloading and that there are no changes in morphological or metabolic properties of spinal motoneurons innervating the soleus muscle following decreased or increased neuromuscular activity.

Growth-related changes in cell body size and succinate dehydrogenase activity of spinal motoneurons innervating the rat soleus muscle.

Cell body sizes and oxidative enzyme (succinate dehydrogenase) activities of spinal motoneurons innervating the soleus muscle were determined in rats ranging in postnatal age from 3 to 13 weeks. The soleus motoneurons were labeled by a retrograde neuronal tracer, nuclear yellow. The mean cell body sizes of motoneurons increased from 3 to 7 weeks of age, while the mean succinate dehydrogenase activities of motoneurons decreased from 3 to 7 weeks of age. There were no changes in mean cell body size or mean succinate dehydrogenase activity of motoneurons from 7 to 13 weeks of age. An inverse relationship between cell body size and succinate dehydrogenase activity of motoneurons was observed, irrespective of age. These results indicate that motoneurons innervating the rat soleus muscle show the adult pattern of cell body size and succinate dehydrogenase activity at an earlier stage of postnatal growth, 7 weeks of age.

Role of membrane potential in vasomotion of isolated pressurized rat arteries.

Vasomotion, the phenomenon of vessel diameter oscillation, regulates blood flow and resistance. The main parameters implicated in vasomotion are particularly the membrane potential and the cytosolic free calcium in smooth muscle cells. In this study, these parameters were measured in rat perfused-pressurized mesenteric artery segments. The application of norepinephrine (NE) caused rhythmic diameter contractions and membrane potential oscillations (amplitude; 5.3 +/- 0.3 mV, frequency; 0.09 +/- 0.01 Hz). Verapamil (1 microM) abolished this vasomotion. During vasomotion, 10(-5) M ouabain (Na(+)-K(+) ATPase inhibitor) decreased the amplitude of the electrical oscillations but not their frequency (amplitude; 3.7 +/- 0.3 mV, frequency; 0.08 +/- 0.002 Hz). Although a high concentration of ouabain (10(-3) M) (which exhibits non-specific effects) abolished both electrical membrane potential oscillations and vasomotion, we conclude that the Na+-K+ ATPase could not be implicated in the generation of the membrane potential oscillations. We conclude that in rat perfused-pressurized mesenteric artery, the slow wave membrane type of potential oscillation by rhythmically gating voltage-dependent calcium channels, is responsible for the oscillation of intracellular calcium and thus vasomotion.