Mortality related to drug-resistant organisms in surgical sepsis-3: an 8-year time trend study using sequential organ failure assessment scores.

The difference in sequential organ failure assessment (SOFA) scores from the baseline to sepsis is a known predictor of sepsis-3 outcome, but the prognostic value of drug-resistant organisms for mortality is unexplained. We employed sepsis stewardship and herein report an observational study. Study subjects were patients admitted to the Departments of Surgery/Chest Surgery from 2011 through 2018 with a diagnosis of sepsis and a SOFA score of 2 or more. Our sepsis stewardship methods included antimicrobial and diagnostic stewardship and infection control. We determined the primary endpoint as in-hospital death and the secondary endpoint as the annual trend of the risk-adjusted mortality ratio (RAMR). For mortality, we performed logistic regression analysis based on SOFA score, age, sex, comorbid disease, and the presence of methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase inhibitor-producing bacteria. In a total of 457 patients, two factors were significant predictors for fatality, i.e., SOFA score of 9 or more with an odds ratio (OR) 4.921 and 95% confidence interval [95% CI] 1.968-12.302 (P = 0.001) and presence of MRSA with an OR 1.83 and 95% CI 1.003-3.338 (P = 0.049). RAMR showed a decrease during the study years (P < 0.05). Early detection of MRSA may help patients survive surgical sepsis-3. Thus, MRSA-oriented diagnosis may play a role in expediting treatment with anti-MRSA antimicrobials.

Paracecal hernia due to membranous adhesion of the omentum to the right paracolic gutter.

BACKGROUND: Paracecal hernias, also known as pericecal hernias, are an exceptionally rare type of internal hernia. We report a unique case of paracecal hernia due to membranous adhesion of the omentum to the right paracolic gutter. CASE PRESENTATION: An 86-year-old female was admitted to our hospital with vomiting and abdominal pain. Laboratory findings showed a slightly elevated C-reactive protein level. Computed tomography scan showed dilated loops of the small intestine in the right paracolic gutter with medial displacement of the cecum and ascending colon. Internal hernia around the cecum due to postoperative adhesion after appendectomy was suspected, and she underwent emergency laparotomy. Intraoperative findings revealed the adhesion between the omentum and right paracolic gutter forming a cavity with the small intestine incarcerated. No abnormal adhesion in the ileocecal region was seen. We transected the omental adhesion from the orifice to the far end of the cavity near the hepatic flexure of the colon to release strangulation and to prevent recurrence. The patient was discharged on postoperative day 14 without complications. CONCLUSIONS: Paracecal hernias have a type of membranous adhesion of the omentum to the right paracolic gutter. Surgeons should be aware of this paracecal hernia type, when they encounter the internal hernia.

Single-incision laparoscopic surgery for gallstone ileus: An alternative surgical procedure.

INTRODUCTION: Gallstone ileus (GI) results from the passage of a stone through a cholecystoenteric fistula, subsequently causing a bowel obstruction. The ideal treatment procedure for GI remains controversial. PRESENTATION OF CASE: A 63-year-old female was admitted to our hospital following persistent nausea and vomiting for 7 days. Computed tomography revealed a partially calcified 4-cm circular object in the jejunum, and the proximal intestine was dilated, with concomitant pneumobilia. Based on the preoperative diagnosis of GI, enterotomy with stone extraction by single-incision laparoscopic surgery (SILS) was performed. The patient's postoperative course was uneventful, and the cholecystoduodenal fistula closed spontaneously 4 months after the surgery. DISCUSSION: Recent studies have reported that enterotomy with stone extraction alone is associated with better outcomes than with more invasive techniques. This case also suggests that enterotomy with stone extraction alone and careful postoperative follow-up is feasible for the management of GI. Although the use of laparoscopy in the management of GI has been described previously, laparoscopic surgery has not been widely performed, and SILS is not generally performed. When only this less demanding procedure is required, laparoscopic surgery, including SILS, can be a viable option. CONCLUSION: SILS can be an alternative surgical procedure for the management of GI.

Does antimicrobial homogeneity index influence surgical site infection? A 10-year study in lung, breast, and general surgery.

To address whether hospital antimicrobial use influences surgical site infection (SSI), we investigated factors including antimicrobial homogeneity index (AHI), an indicator of prescription diversity, with a retrospective study during 120 months for patients undergoing lung, breast, and general surgery (n = 4,510). We analyzed the odds ratios of background factors for SSI and the correlation between AHI and drug susceptibility in isolates of SSI. A total of 243 cases of SSI (5.4%) occurred. Factors that significantly contributed for SSI were operative time [odds ratio (OR), 1.78; 95% confidence interval (CI), 1.33-2.39; P < 0.001], American Society of Anesthesiologists' score (OR, 1.68, 95% CI, 1.23-2.28; P < 0.001), endoscopic use (OR, 0.10, 95% CI, 0.04-0.24; P < 0.001), lung and breast surgery versus general surgery (OR, 0.12, 95% CI, 0.06-0.22; P < 0.001), increased AHI (OR, 0.72, 95% CI, 0.55-0.95; P = 0.020), and older age (OR, 2.08, 95% CI, 1.39-3.11; P < 0.001). AHI showed a positive correlation coefficient (CC, P < 0.05) with susceptibility to ampicillin (CC = +0.327), cefotaxime (CC = +0.142), imipenem/cilastatin (CC = +0.101), and sulbactam/cefoperazone (CC = +0.145). AHI, which has been described to help prevent drug resistance, was associated with increased susceptibility in microbes of SSI. This finding in part may explain that increase in AHI reduced SSI.

Esophageal ruptures: triage using the systemic inflammatory response syndrome score.

Esophageal rupture is a rare entity. Delay in the diagnosis and treatment may threaten the patient's life. The decision for surgical or nonsurgical treatment, however, remains controversial because advocates of both treatments have reported comparable results. To quantify the decision making, we suggest the systemic inflammatory response syndrome (SIRS) score for triage of an esophageal rupture. Using this criterion for 12 patients resulted in the survival of all of them. Therefore, we advocate use of the SIRS score for triage of an esophageal rupture.

Combined approach with Doppler echocardiography and B-type natriuretic peptide to stratify prognosis of patients with decompensated systolic heart failure.

BACKGROUND: Based on the importance of left ventricular (LV) diastolic function in stratification of the cardiac prognosis in patients with systolic heart failure (SHF), we attempted to identify the prognostic impact of Doppler echocardiographic examinations and plasma B-type natriuretic peptide (BNP) concentration. METHODS: Of 73 patients admitted with decompensated SHF (ejection fraction <45%), 58 were included. Among these, 21 patients had ischemic heart disease and 27 non-ischemic dilated cardiomyopathy. In all patients, Doppler echocardiographic examinations and measurements of the plasma B-type natriuretic peptide concentration were simultaneously performed before discharge. Patients were followed up for 36 months after discharge. Primary end point for the follow-up was readmission for acute decompensated heart failure or cardiac death. RESULTS: During the mean follow-up period of 28±12 months, 16 patients (27.6%) were readmitted with decompensated heart failure. Based on the stepwise multivariate Cox regression analysis, mitral E/A ratio (chi-square=6.5, relative risk=1.7, p=0.01) and BNP (chi-square=3.9, relative risk=1.7, p=0.04) were identified as independent predictors of primary endpoints. Based on ROC analysis, the optimal cutoff point of E/A was 1.05 (AUC=0.836, p=0.002) and that of plasma BNP concentration was ≥254.5 pg/ml (AUC=0.768, p=0.002). In high-risk patients with E/A ≥1, event-free survival rates were significantly lower in patients with BNP <254.5 pg/ml (p<0.001). CONCLUSIONS: The complementary assessment of Doppler transmitral flow and plasma BNP concentration may be reliable in identifying the prognosis of patients with SHF.

Stratification of impaired relaxation filling patterns by passive leg lifting in patients with preserved left ventricular ejection fraction.

METHODS: We evaluated diastolic functional reserve in 108 patients with normal left ventricular ejection fraction (LVEF)> or =50% but abnormal relaxation (ratio of transmitral peak velocity of early and late diastolic flow (E/A)<1) using passive leg lifting. We calculated the pulmonary venous systolic to diastolic flow ratio (S/D) as a marker of left atrial reservoir function, and the time difference between the duration of pulmonary venous retrograde flow (PVAd) and the duration of the mitral A wave (PVAd-Ad) as a marker of left ventricular end-diastolic pressure (LVEDP). RESULTS: During leg lifting, the E/A was > or =1 in 39 patients (the inverted group); the remaining 69 patients comprised the stable group. Comparing the inverted group with the stable group at baseline, S/D was smaller (1.5+/-0.4 vs. 1.8+/-0.5, P=0.002) and PVAd-Ad greater (11+/-23 ms vs. -23+/-28 ms, P<0.001). Multiple logistic regression analysis revealed that PVAd-Ad and S/D predicted E/A inversion with leg lifting after adjustment for age, LV wall thickness, LV dimension, LVEF, deceleration time of E, and E/E'. CONCLUSION: In patients with preserved LVEF but early diastolic dysfunction, passive leg lifting may identify patients having a less compliant left ventricle and impaired left atrial reservoir function.

Echolucent carotid plaques as a feature in patients with acute coronary syndrome.

BACKGROUND: Carotid arterial ultrasound examination may be helpful for screening populations at high risk for acute coronary syndrome (ACS), so the present study was designed to identify the carotid arterial characteristics of patients with ACS. METHODS AND RESULTS: Carotid ultrasound examinations were performed in 172 patients with ACS, 166 patients with stable coronary artery disease (CAD), and 96 control subjects. Common carotid arterial structures were assessed by the intima - media thickness (IMT), interadventitial diameter (IAD), lumen diameter (LD), the IMT to LD ratio (IMT/LD), and the plaque burden based on the plaque score. Plaque morphology was assessed by the echogenecity based on the gray-scale median (GSM). IMT, IAD, IMT/LD, and plaque score did not differ between the ACS and stable CAD groups. The GSM in the ACS group was lower (47.5+/-25.3, p<0.001) than in the control (70.1+/-22.5) and stable CAD (73.7+/-23.4) groups. Multiple logistic regression analysis showed that the presence of carotid echolucent plaques (GSM

Peak C-reactive protein concentration correlates with left ventricular thrombus formation diagnosed by contrast echocardiographic left ventricular opacification in patients with a first anterior acute myocardial infarction.

BACKGROUND: Wall motion abnormality in the apical legion of the left ventricle (LV) with stagnant flow alone is not sufficient to identify patients at high risk for LV thrombus formation among those with first anterior acute myocardial infarction (AMI). The aim of this study was to identify the determinants of LV thrombus formation using contrast echocardiography. METHODS AND RESULTS: In 75 patients with first anterior AMI, standard and contrast echocardiography was performed to detect LV thrombus. Although LV thrombus was found in 10 patients (13%) using standard echocardiography, it was found in 15 patients (20%) using contrast echocardiography. Apical stagnant flow was observed in 14 patients (93%) with LV thrombus. In addition, patients with LV thrombus had a higher peak C-reactive protein (CRP) concentration (18.2+/-4.3 vs 7.9+/-5.5 mg/dl, p<0.0001). In multivariate analysis, only peak CRP concentration was identified as an independent predictor of LV thrombus (p=0.02, odds ratio: 1.400, confidence interval: 1.040-1.884). The receiver-operating characteristics (ROC) analysis revealed the best cutoff value of a peak CRP concentration >10.7 mg/dl to identify patients with LV thrombus (sensivity 0.93, specificity 0.75, area under ROC curve 0.91). CONCLUSIONS: The peak CRP concentration is a useful marker of patients with first anterior AMI who are at high risk for LV thrombus.

The wake of a large vortex is associated with intraventricular filling delay in impaired left ventricles with a pseudonormalized transmitral flow pattern.

UNLABELLED: Although an intraventricular filling delay has been observed in patients with a psuedonormalized transmitral flow pattern, little is known about the underlying hydrodynamic nature of this phenomenon. METHODS: To examine those hydrodynamics, we studied every echocardiographic frame showing ventricular inflow (80 Hz) in the apical long-axis view and M-mode image using contrast echocardiography in 29 patients with a psuedonormalized pattern and in 26 normal controls. The velocity of the filling flow front (Vp), the ratio of Vp to E, and the mean radius of the vortices associated with the filling flow were measured. RESULTS: In both groups, vortices were observed at the ridge of the mitral valve during acceleration of the E-wave. The mean radius of the vortices was greater in the pseudonormalized filling group than that in the control group (8 +/- 2 vs 3 +/- 1 mm, P < 0.0001). Vp was smaller in the pseudonormalized group than in the control group (36 +/- 6 vs 47 +/- 6 cm/sec, P = 0.0008). Vp/E was < 1 and smaller in the pseudonormalized group than that in the control group (0.46 +/- 0.13 vs 0.59 +/- 0.07, P = 0.014) and negatively correlated with the mean radius of the vortices (r = 0.54, P < 0.0001). CONCLUSIONS: Contrast echocardiography identified uniform flow characteristics with blood in the filling flow front moving in well-developed vortices and resulting in a left ventricular filling delay in the impaired left ventricle in spite of an increased early transmitral flow velocity.

Continuous intravenous administration of a low dose of epoprostenol greatly decreased serum concentrations of endothelin-1 in primary pulmonary hypertension--a case report.

Endothelin-1 (ET-1) is known to be a principal factor in the pathogenesis of primary pulmonary hypertension (PPH). Recently intravenous administration of epoprosterol improved the survival rate in PPH. However, the effect of epoprosterol on ET-1 remains to be investigated. Therefore, we studied a patient with PPH who was treated with a low dose of epoprosterol and examined the serum concentration of ET-1 during the treatment. Epoprosterol greatly decreased the serum concentration of ET-1 in parallel with improvement of the clinical course, suggesting that ET-1 level may be a marker for treatment of PPH.

Relationship between mitral annular calcification and severity of carotid atherosclerosis in patients with symptomatic ischemic cerebrovascular disease.

OBJECTIVES: Many studies have reported the association between mitral annular calcification (MAC) and stroke. MAC has been speculated to be a direct embolic source of stroke. Recently, the association between MAC and atherosclerosis in the coronary artery, aorta, and carotid artery has been reported. This prospective study investigated the association between MAC and severity of carotid atherosclerosis in patients with symptomatic ischemic cerebral disease to evaluate the association between MAC and atherosclerosis as a cause of stroke. METHODS: We studied 377 patients with ischemic cerebral disease (253 men, 124 women, mean age 68 +/- 11 years) who underwent echocardiography to determine the presence of MAC and carotid ultrasonography to determine the severity of carotid atherosclerosis. Plaque score was the sum of the maximum intimamedia thickness in the common carotid region, the bifurcation bulb region, and the internal carotid artery region, including both right and left arteries. RESULTS: MAC was found in 86 patients, and was more frequent in women, the elderly, and patients with diabetes or hyperlipidemia (p < 0.05). Plaque score was higher in patients with than without MAC (8.3 +/- 5.8 vs 5.2 +/- 5.2 mm, p < 0.001). Multivariate regression analysis identified MAC (r = 0.26, p < 0.0001), female sex (r = -0.12, p = 0.03), and age (r = 0.23, p < 0.0001) as independently associated with plaque score. CONCLUSIONS: MAC is independently associated with severity of carotid atherosclerosis in patients with symptomatic ischemic cerebral disease. This association suggests MAC may be indirectly related to cerebrovascular disease as a marker of the presence of progressive arteriosclerosis for thromboemboli causing stroke.

A case of sinus of Valsalva-right ventricle fistula without a typical aneurysm, and a single origin of the coronary arteries.

Few previous reports have described a sinus of Valsalva fistula without an aneurysm in Japanese patients. A single origin of the coronary arteries is a rare coronary anomaly. We describe a 75-year-old woman with a single origin of the coronary arteries and a sinus of Valsalva fistula without a typical aneurysm. Echocardiography showed turbulent flow from the right coronary sinus of Valsalva to the right ventricle throughout the cardiac cycle. Aortography confirmed the presence of a right coronary sinus of Valsalva-right ventricle shunt jet. Echocardiography and aortography demonstrated that there was no deformity of the sinus of Valsalva. Cardiac catheterization revealed that the left-to-right shunt rate was 29% and the Qp/Qs was 1.41. Aortography and coronary angiography did not identify a right coronary artery originating from the right sinus of Valsalva. Coronary angiography revealed that the right coronary artery arose from the proximal part of the left anterior descending artery and did not detect significant organic stenosis of the coronary artery. She was diagnosed as having a sinus of Valsalva to right ventricle fistula without an aneurysm, and a single origin of the coronary arteries.

[Recurrence of esophageal cancer treated by combination TS-1/CDDP therapy].

A 68-year-old man underwent subtotal esophagectomy with two fields lymphadenectomy and postoperative chemotherapy so called low dose FP therapy for advanced esophageal cancer (Stage IIIa, pT 3, pN 1, M 0) in October 1999. As he was diagnosed with a recurrence of esophageal cancer as metastatic lymph node tumors which were placed in the right anterocervical and supraclavicular region in March 2001, he underwent enucleation of metastatic lymph node tumors and postoperative chemoradiation therapy, so-called low-dose FP-R therapy. Recently, since other metastatic lymph node tumors in the neck appeared again in August 2001, he underwent radical neck lymph node dissection and postoperative chemoradiation treatment, so-called FAP-R therapy. In October 2003, a chest CT showed multiple lung tumors. He was diagnosed with multiple metastatic lung tumors originating from esophageal cancer. Then, two courses of a combined chemotherapy consisting of TS-1 and CDDP were administered at an interval of one month. We judged the effect of this chemotherapy to be a partial response (PR), because the largest metastatic lung tumor 18 mm in diameter showed a reduction rate of 81.9%, and other tumors had almost disappeared in the chest CT after the combined therapy. No severe adverse effects of more than grade 3 were observed during this combined therapy. This combined chemotherapy consisting of TS-1 and CDDP may prove effective for treating recurrent cases of esophageal cancer.

Assessment of propagation velocity by contrast echocardiography for standardization of color Doppler propagation velocity measurements.

BACKGROUND: Color Doppler propagation velocity (Vp) (color-Vp) has not yet been standardized, although it should be able to specifically reflect the intraventricular movements of left ventricular (LV) inflow. Because contrast echocardiography can depict a specified flow, we used this modality to standardize measurements of color-Vp of LV inflow. METHODS: We performed contrast echocardiographic examinations in 100 patients (70 men, 30 women; age 53 +/- 12 years). Four types of color-Vp were measured: by the flow wave front method and by aliasing method using 3 aliasing velocity levels based on the peak velocity of early diastolic flow of transmitral flow. We also determined contrast echocardiographic Vp by M-mode imaging of LV inflow (contrast-Vp). RESULTS: Contrast-Vp and all 4 types of color-Vp could be compared in 86 patients. Contrast-Vp was significantly lower than color-Vp ( P < .01), except for color-Vp measured at the aliasing level 50% > peak velocity of early diastolic flow >/= 40% (color-Vp 40). A close relationship was observed between contrast-Vp and color-Vp 40 ( r = 0.801, P < .0001). Contrast-Vp and color-Vp 40 showed high ability to detect abnormal transmitral flow patterns according to receiver operating characteristics curves (area under curve for contrast-Vp, 0.94; for color-Vp 40, 0.90). CONCLUSIONS: Our results should be useful in standardization of color-Vp measurement to specifically reflect propagation of the fluid elements derived from LV inflow, with ability to distinguish LV filling abnormalities.

Effect of age on carotid arterial intima-media thickness in childhood.

To investigate relationships between carotid arterial intima-media thickness (IMT) and age in childhood, we performed high-resolution carotid arterial ultrasonography in 60 healthy children (27 boys, 33 girls; age range, 5-14 years) determined by screening to have no dyslipidemia or hypertension. No plaque formation was found, and irregularity of IMT (root mean square roughness of IMT) did not correlate with age. Mean IMT increased in a linear manner with age [IMT in millimeters = (0.009 x age in years) + 0.35] ( r = 0.39, P = 0.002). This correlation remained significant after adjustment for gender, parental smoking, systolic and diastolic blood pressure, body mass index, and serum concentrations of low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides. None of these known cardiovascular disease risk factors in adults had a significant relationship with age-adjusted IMT in children. While circumferential wall stress and diastolic blood pressure were not correlated with age, mean IMT and lumen diameter showed significant positive relationships with circulating blood volume, which was calculated as the function of height and weight. These data suggested that age-dependent physiologic thickening of arterial walls begins in childhood.

Preload-dependent variation of the propagation velocity in patients with congestive heart failure.

BACKGROUND: Although color Doppler M-mode propagation velocity (Vp) is preload-independent, the variation in Vp with the temporal variation of preload in the clinical setting has not been evaluated. Because left ventricular filling pressure changes dramatically with treatment of congestive heart failure (CHF), we hypothesized that preload-dependent variations in Vp occur with treatment of CHF. METHODS: We performed Doppler echocardiographic and hemodynamic evaluation in 24 patients with CHF (15 men, 62 +/- 10 years) at initial presentation (baseline study) and after CHF had improved with therapy (second study). RESULTS: The interval between the baseline and the second study was 48.6 +/- 21.5 hours. Vp decreased between the baseline study (41 +/- 5 cm/s) and the second study (28 +/- 5 cm/s, P <.0001). Only the change in pulmonary capillary wedge pressure (-8.3 +/- 3.3 mm Hg) between the baseline and second study was an independent predictor of the change in Vp (-12.5 +/- 5.9 cm/s) by stepwise linear regression (r = 0.68, P =.0002). CONCLUSIONS: Vp decreases significantly with decreases in pulmonary capillary wedge pressure with the treatment of CHF. The preload-dependent variation should be taken into account in the assessment of Vp in patients with CHF.

Peripartum cardiomyopathy and biventricular thrombi.

Peripartum cardiomyopathy is a rare cardiac disorder characterized by the development of heart failure in the last month of pregnancy or up to 5 months postpartum in women without other determinable causes of cardiac failure. Intracardiac thrombi have been found at autopsy in some patients with this condition and have been demonstrated in the left or right ventricles on 2-dimensional echocardiography. A 23-year-old woman presented with peripartum cardiomyopathy and biventricular thrombi on echocardiography. The thrombi were spherical, pedunculate, shaggy and irregular in configuration, and freely mobile, suggesting that they were fresh. She was treated with conventional heart failure therapy and anticoagulants. Four days later, the apical thrombi within both ventricles had disappeared and there was no evidence of embolism on physical examination. The hypercoagulable state of the peripartum period and the severe biventricular dysfunction most likely led to the formation of biventricular thrombi.

[A case of colon cancer with multiple liver metastases and lymph nodes metastases successfully treated by 5'-deoxy-5-fluorouridine].

In a 79-year-old man with ascending colon cancer, multiple liver metastases were detected by computer tomography. The patient underwent right hemicolectomy. Paraaortic lymph nodes metastases were found intraoperatively. After surgery, 5'-deoxy-5-fluorouridine (5'-DFUR) was administered orally at 600 mg daily. Abdominal CT showed disappearance of the liver metastases 6 months after operation. At a follow-up exam 24 months after the beginning of the chemotherapy, the patient remained in remission and reported no side effects. We consider oral administration of 5'-DFUR to be a useful treatment for advanced colon cancer.