SCCmec typing of PVL-positive community-acquired Staphylococcus aureus (CA-MRSA) at a Japanese hospital.

The epidemiology of Panton-Valentine leukocidin (PVL)-positive MRSA in community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) was examined. Three hundred and forty-two CA-MRSA strains that were susceptible to imipenem and cefazolin were isolated from 1107 samples (intravenous catheter, blood, sputum, urine, skin, wound, and pharynx) from outpatients at Showa University Hospital in Japan between September 2009 and March 2017. The PVL gene was detected in 46 of 342 CA-MRSA strains, accounting for 13.5%. The type of SCCmec was determined by detection of each SCCmec-specific region, class complex, and ccr. SCCmec type IV comprised 33 strains, type V comprised 5 strains, type VII comprised 4 strains, and the unclassified type comprised 4 strains. Among the type IV strains, subtype IVa was dominant, comprising 23 of 33 strains, and the remaining 10 strains were of varying subtypes. The SCCmec type III-specific region, CZ049, was amplified in 2 type V strains, 4 type VII strains, and 4 unclassified strains. In 4 unclassified strains, CZ049 and ccr5 were detected, but neither the SCCmec-specific region nor class complex was detected. The PVL-positive rate was lower than that in Western countries. The SCCmec types of PVL-positive CA-MRSA strains were found to vary, indicating a diverse spreading route.

[Usefulness of the authorized acquisition of ISO 15189 in registered clinical laboratories].

More than 10 years have passed since the ISO 15189 international standardization program on the quality and competence of the medical laboratories was introduced in 2003. Currently, the number of facilities that have committed themselves to providing a higher level of medical service by incorporating a quality management system (QMS) and acquiring accreditation has grown to over 70. QMS is defined as "setting up a policy and goals pertaining to quality, and adopting an appropriate system," and is a scheme that includes all factors both managerial and technical that can affect test results. A number of registered clinical laboratories have received the aforementioned accreditation, but, in the process of implementing the QMS, some problems have been identified. Here, we report on the change (transition) of Quality Control to Quality Management System, the usefulness of external audits by the official inspection body for accreditation, and the problems that I have encountered over the last ten years.

MLST analysis of multiple antimicrobial resistant Acinetobacter baumannii.

Multi-locus sequencing typing (MLST) of Acinetobacter baumannii, isolated at Showa University Hospital, was performed between November 2010 and March 2011. A. baumannii was isolated from 15 patients. Among the 15 isolates, the STs of three isolates were able to be determined, ST76, ST92, and ST146, and belonged to Clonal Complex (CC) 92, the global epidemic clone among carbapenem resistant A. baumannii. The other 12 strains were not applicable to the MLST classification. The ST76 strain was resistant to carbapenems, aminoglycosides, and fluoroquinolones. The ST92 strain was resistant to aminoglycosides and fluoroquinolones. The ST146 strain was resistant to fluoroquinolones. The other 12 strains were susceptible to either of the drugs. Neither the metallo beta lactamase gene (IMP type or VIM2) nor the OXA23 gene was detected in carbapenem resistant A. baumannii. These results indicate that A. baumannii of CC92 has spread as the drug resistant strain in Japan. Monitoring A. baumannii using molecular epidemiology is necessary.

Analysis of EGFR, KRAS and P53 mutations in lung cancer using cells in the curette lavage fluid obtained by bronchoscopy.

Histopathological samples are commonly used for molecular testing to detect both oncogenes and tumor-suppressor genes in lung cancer. The purpose of this study was to determine the efficacy of using curette lavage fluid for molecular testing to detect EGFR, KRAS and P53 mutations in lung cancer patients. Samples were obtained from 77 lung cancer patients by bronchoscopy at the time of diagnosis, collected by scraping the site of the primary tumor lesion with a curette. DNA was extracted from cells in the curette lavage fluid, and PCRs were performed to amplify mutation hot spot regions in the EGFR, KRAS and P53 genes. The PCR products were direct-sequenced to detect mutations of each gene. The reference sequence of each gene was obtained from GenBank. Overall, 27% (21 of 77) were found with EGFR mutations, 1% (1 of 77) with KRAS mutations, and 36% (28 of 77) with P53 mutations. KRAS mutations were not detected in patients harboring mutations in either EGFR or P53. P53 mutations were identified in 38% (8 of 21) of the patients with EGFR mutations, all of who had advanced lung cancer. Of these patients, a 62-year-old female current smoker was given EGFR-TKI as third-line therapy, with no improvement in clinical symptoms or results of radiographic examination. Multivariate analysis indicated that P53 mutation rates in advanced-stage lung cancer were significantly higher than those in early-stage lung cancer (P=.017). In contrast, EGFR mutation rates were not significantly associated with staging. L747S in EGFR, described as a mutation associated with secondary resistance to EGFR-TKI, was detected in three patients who had never received EGFR-TKI, including one SCLC patient. It is possible to analyze EGFR, KRAS and P53 mutations using curette lavage fluid collected from lung cancer patients. This is useful when sufficient amounts of tumor samples cannot be obtained. Data from the current study suggest that EGFR mutations in concert with P53 mutations accelerate cancer development and lead to evolution of therapeutic resistance.

Effects of original crystalloid cardioplegia followed by additional blood cardioplegia: treatments for prolonged cardiac arrest.

PURPOSE: The efficacy of combination treatment of original cold crystalloid cardioplegia (SHA solution; St. Thomas + Histidine + ATP + oxygen) and additional blood cardioplegia was studied in patients who required cardiac arrest time of 120 minutes or longer. METHODS: One hundred and thirty-six patients were included in this study. Patients were divided into two groups according to the cardiac arrest time: S group (cardiac arrest time: 120-149 minutes, n = 81); L group (150-180 minutes, n = 55). Just after cross-clamping of the ascending aorta, 800 ml of SHA solution was infused in an antegrade fashion. Cold-blood cardioplegia was initiated after two hours of cardiac arrest. RESULTS: Six (4%) of the 136 patients died after surgery, 3 in each group. Two critical patients with ischemic cardiomyopathy died of cardiac failure after coronary artery bypass grafting (CABG), and 4 died of noncardiac morbidity. The mean value of postoperative maximum creatine phosphokinase-MB (CPK-MB) in dead patients was 47 IU/L in the S group and 75 IU/L in the L group. The peak CPK-MB values exceeded 100 IU/L in one out of 6 patients who died after surgery. CONCLUSIONS: Combination treatment using original SHA solution and additional blood cardioplegia was effective in patients who required prolonged cardiac arrest.

Papillary muscle head approximation for the treatment of mitral valve regurgitation combined with aortic valve disease.

We initiated an original papillary muscle head approximation procedure, commonly known as Sandwich plasty, for the treatment of ischemic mitral regurgitation (MR). In this study, we evaluated the appropriateness of this procedure for functional MR associated with aortic valve disease. Fifteen patients who had undergone Sandwich plasty combined with aortic valve surgery were included in this study. The mean age of the patients was 69 years. Predominant aortic valve diseases were regurgitation in 8 patients and stenosis in 7 patients. Aortic valve replacement was performed in 14 patients and David surgery in one. The mitral valve was approached through the aortic annulus in 9 patients (the transaortic group). Six other patients with mitral valve annulus of 30 mm or larger underwent concomitant mitral ring-annuloplasty through a left atrial incision (the LA group). The tenting height of the mitral valve and left ventricle diastolic diameter significantly decreased after surgery in both groups. After surgery, residual moderate or mild MR was detected in two patients in the transaortic group. In the LA group, residual mitral regurgitation was not detected. In the follow-up study, prominent MR occurred in two patients in the transaortic group. The MR free rate two years after surgery was 83% in the total patient population. Sandwich plasty was simple and effective in the treatment of functional mitral regurgitation combined with aortic valve surgery. A transaortic approach is effective in obviating a separate left atriotomy and reducing operation time.

Original papillary muscle sandwich plasty for ischemic mitral regurgitation.

BACKGROUND: Mitral valve plasty for functional ischemic mitral regurgitation (MR) is still a controversial procedure. METHODS AND RESULTS: The present study was a review of 23 patients who underwent an original technique known as "papillary muscle sandwich plasty" in which the mitral valve is approached via either the left atrium or left ventricle. The heads of the papillary muscles of the anterior leaflet and leaflets are plicated using Teflon-pledgeted 3-0 Ticron sutures in both the anterolateral and posteromedial commissural portions. Postoperative residual mild MR occurred in 1 patient (4%), but moderate or severe MR was not observed. In the follow-up study, prominent MR occurred in 1 patients and the MR-free rate at 2 years after surgery was 93%. Late cardiac death was significantly (P<0.05) fewer in patients without prominent MR than that in patients with MR. CONCLUSIONS: "Sandwich plasty" is an effective technique for patients requiring left ventricular plasty and may improve the prognosis of ischemic heart failure.

Septal-superior exposure in mitral valve surgery with radiofrequency ablation.

BACKGROUND: We review the results of surgical radiofrequency ablation of both atria in patients of mitral valve disease approached by septal-superior exposure and discuss the availability of this approach. METHODS: Eighteen patients with a mean age of 65 years were included in this study. Thirteen patients had mitral valve regurgitation predominantly and five had mitral valve stenosis. Eleven patients underwent mitral valve plasty and valve replacement was carried out in seven. All ablation lesions were created on both atria using radiofrequency energy delivered by a unipolar malleable radiofrequency ablation catheter with seven electrodes at a minimum temperature of 80-85 degrees C for a period of 2 min. RESULTS: At the time of discharge, 14 patients were showed normal sinus rhythm and one patient remained in AF. The other three patients were free from atrial fibrillation; however, they received dual-mode, dual-pacing, dual-sensing pacemaker implantation because of bradycardia during the early postoperative phase. At a mean time of 7 months after surgery, all patients were free from atrial fibrillation; 13 patients showed normal sinus rhythm and five patients received dual-mode, dual-pacing, dual-sensing pacemakers. CONCLUSION: Septal-superior exposure provides an excellent operative view both for mitral valve surgery and for radiofrequency ablation. However, this exposure has not been considered a first-line approach because of the high rate of pacemaker implantation.

Progression of abdominal aortic aneurysm after endovascular stent-grafting in a patient with Behçet's disease: report of a case.

A 53-year-old man with Behçet's disease was admitted to our hospital for investigation of back and lower abdominal pain. Computed tomography (CT) showed a projecting saccular aneurysm below the right renal artery. We placed a stent-graft just below the right renal artery, successfully excluding the abdominal aortic aneurysm (AAA). His C-reactive protein level and white blood cell count remained elevated after stent-grafting. About 5 months later, he was readmitted with recurrent back and lower abdominal pain and CT showed progression of the AAA. Thus, we performed straight grafting using a woven Dacron graft just below the right renal artery. The patient had an uneventful postoperative course. We discuss the controversial issue of treating AAA in patients with Behçet's disease, focusing on the indications and timing of surgery.

Beraprost sodium-induced hypotension in two patients after cardiac surgery.

Two episodes of hypotension caused by oral beraprost sodium administration following cardiac surgery are described. The first case was a 67-year-old female who underwent concomitant surgery for mitral valve replacement, tricuspid annuloplasty, and a radiofrequency maze procedure for atrial fibrillation. The second case was a 45-year-old female who underwent 4-vessel coronary artery bypass grafting associated with endarterectomy in the right coronary artery. Beraprost sodium was administered for the treatment of residual pulmonary hypertension in the first case, and was initiated as an antiplatelet agent following coronary endarterectomy in the second case. Hypotension occurred at approximately one hour after beraprost sodium administration in both cases. Careful observation to prevent this adverse effect is critical after the administration of beraprost sodium, especially in patients who have undergone cardiac surgery.