Catheter-related gas-forming suppurative thrombophlebitis.

Catheter-related suppurative thrombophlebitis (CRST) is a complication of catheter-related bloodstream infection (CRBSI). The microbiology of CRST is similar with the microbiology of CRBSI, but Clostridium perfringens that causes gas gangrene is a rare pathogen of CRBSI and CRST. We present a case of catheter-related gas-forming suppurative thrombophlebitis due to Clostridium perfringens infection. Gas-forming thrombus around the catheter can be useful findings for the early diagnosis of catheter-related clostridial thrombophlebitis.

Clinical course of Capnocytophaga canimorsus bacteremia from acute onset to life crisis.

Capnocytophaga canimorsus bacteremia can present without signs of sepsis just after onset. For patients with fever, discerning the history of an animal bite is crucial. If it is positive for a dog bite, antibiotic treatment should be started.

Reconstructed Dynamics of the Imaging Photoplethysmogram.

Human photoplethysmogram (PPG) is one of the signals widely applied for health monitoring. Development of the new techniques made possible evolution of traditional contact PPG which was measured at red and near-infrared light (NIR) to the contactless, imaging PPG (iPPG) that can be recorded at various light wavelengths, including ambient visible light. However, despite the numerous advantages of iPPG its applications demonstrated so far are quite limited. The NIR PPG was previously found to be useful for various applications in the area of physiological and mental health monitoring by utilizing advanced methods of nonlinear time-series analysis applied on its reconstructed dynamics. The main purpose of this study is to demonstrate data-driven approach with time-delay-reconstructed attractor obtained from the iPPG. The results of this study demonstrated that the iPPG dynamics can be reconstructed with fine data resolution, and its time-delay-reconstructed trajectory is almost deterministic, though contains noise. The obtained results might be useful for further applied studies on the iPPG.

Antimicrobial stewardship without infectious disease physician for patients with candidemia: A before and after study.

BACKGROUND: Little is known about the effects of antimicrobial stewardship team (AST) without infectious disease physician (IDP) on clinical outcome in patients with candidemia. METHODS: We conducted a before and after study involving patients with hospital-acquired candidemia at a tertiary hospital without IDPs. The AST consisted of physicians, pharmacists, nurse, microbiologist, and administrative staff. A candidemia care bundle was developed based on the Infectious Disease Society of America (IDSA) guideline. The non-IDP AST provided recommendations to the attending physicians whose patients developed candidemia during hospitalization. The primary outcome was 30-day all-cause mortality, while the secondary outcomes were adherence to the IDSA guidelines regarding the management of candidemia. Data of up to 3 years of preintervention and 3 years of intervention period were analyzed. RESULTS: By 30 days, 11 of 46 patients (23.9%) in the intervention group and 7 of 30 patients (23.3%) in the preintervention group died (adjusted hazard ratio for the intervention group: 0.68 [95% CI 0.24-1.91]). The non-IDP AST was associated with appropriate empirical antifungal therapy (100% vs 60.0%; proportion ratio 1.67 [95% CI 1.24-2.23]), appropriate duration of treatment (84.7% vs 43.3%; 1.96 [1.28-3.00]), removal of central venous catheters (94.4% vs 70.8%; 1.33 [1.02-1.74]), and ophthalmological examination (93.5% vs 63.3%; 1.48 [1.12-1.96]). CONCLUSIONS: Although we found no significant difference in 30-day mortality, the non-IDP AST was associated with improved adherence to guidelines for management of candidemia.

Extracorporeal cardiopulmonary resuscitation for blunt cardiac rupture.

Extracorporeal cardiopulmonary resuscitation (ECPR) followed by operating room sternotomy, rather than resuscitative thoracotomy, might be life-saving for patients with blunt cardiac rupture and cardiac arrest who do not have multiple severe traumatic injuries. A 49-year-old man was injured in a vehicle crash and transferred to the emergency department. On admission, he was hemodynamically stable, but a plain chest radiograph revealed a widened mediastinum, and echocardiography revealed hemopericardium. A computed tomography scan revealed hemopericardium and mediastinal hematoma, without other severe traumatic injuries. However, the patient's pulse was lost soon after he was transferred to the intensive care unit, and cardiopulmonary resuscitation was initiated. We initiated ECPR using femorofemoral veno-arterial extracorporeal membrane oxygenation (ECMO) with heparin administration, which achieved hemodynamic stability. He was transferred to the operating room for sternotomy and cardiac repair. Right ventricular rupture and pericardial sac laceration were identified intraoperatively, and cardiac repair was performed. After repairing the cardiac rupture, the cardiac output recovered spontaneously, and ECMO was discontinued intraoperatively. The patient recovered fully and was discharged from the hospital on postoperative day 7. In this patient, ECPR rapidly restored brain perfusion and provided enough time to perform operating room sternotomy, allowing for good surgical exposure of the heart. Moreover, open cardiac massage was unnecessary. ECPR with sternotomy and cardiac repair is advisable for patients with blunt cardiac rupture and cardiac arrest who do not have severe multiple traumatic injuries.

Airway and circulatory collapse due to retropharyngeal hematoma after blunt vertebral artery injury.

Retropharyngeal hematoma following blunt cervical spine injury is a known cause of airway obstruction, but it is not known to cause hemorrhagic shock. We report the case of a massive retropharyngeal hematoma caused by a blunt vertebral artery transection leading simultaneously to airway obstruction and hemorrhagic shock. An 83-year-old woman was injured in a motorcycle accident. In the field, the patient exhibited paradoxical breathing with no breath sounds, and her blood pressure could not be measured. Therefore, emergency intubation and fluid resuscitation were initiated and the patient was transferred to the emergency department. Computed tomography angiography revealed a massive retropharyngeal hematoma with contrast extravasation from the right vertebral artery, which caused airway obstruction and hemorrhagic shock. The right vertebral artery was transected at the C5 level, which was associated with C4/C5 dislocation. Vertebral artery transection was successfully treated by endovascular embolization, which was followed by complication of asymptomatic posterior circulation stroke. Blunt vertebral artery transection can cause massive retropharyngeal hematoma, which can rapidly expand and lead to hemorrhagic shock in addition to airway obstruction. In cases of massive retropharyngeal hematoma with hemorrhagic shock following blunt cervical spine injury, blunt vertebral artery transection should be suspected. If blunt vertebral artery transection is detected and hemorrhagic shock is persistent, endovascular embolization should be performed immediately in addition to emergency intubation.

Toward the rational use of standardized infection ratios to benchmark surgical site infections.

BACKGROUND: The National Healthcare Safety Network transitioned from surgical site infection (SSI) rates to the standardized infection ratio (SIR) calculated by statistical models that included perioperative factors (surgical approach and surgery duration). Rationally, however, only patient-related variables should be included in the SIR model. METHODS: Logistic regression was performed to predict expected SSI rate in 2 models that included or excluded perioperative factors. Observed and expected SSI rates were used to calculate the SIR for each participating hospital. The difference of SIR in each model was then evaluated. RESULTS: Surveillance data were collected from a total of 1,530 colon surgery patients and 185 SSIs. C-index in the model with perioperative factors was statistically greater than that in the model including patient-related factors only (0.701 vs 0.621, respectively, P < .001). At one particular hospital, for which the percentage of open surgery was lowest (33.2%), SIR estimates changed considerably from 0.92 (95% confidence interval: 0.84-1.00) for the model with perioperative variables to 0.79 (0.75-0.85) for the model without perioperative variables. In another hospital with a high percentage of open surgery (88.6%), the estimate of SIR was decreased by 12.1% in the model without perioperative variables. CONCLUSION: Because surgical approach and duration of surgery each serve as a partial proxy of the operative process or the competence of surgical teams, these factors should not be considered predictive variables.

Long-distance relay transportation of a patient with twin-twin transfusion syndrome requiring early delivery by Doctor-Helicopters.

In Japan, there has recently been a severe shortage of physicians in regional core hospitals, limiting the acceptance of emergency patients. Searching for available medical institutions over an extended area beyond the regular regional medical area should increase the possibility of finding medical institutions capable of accepting patients. Physician staffed helicopter ambulance system, so called the Doctor-Helicopter service is highly effective in saving patients life, since emergency doctors start to treat patients at the scene. It may be also useful to transport the critically ill patients for a long distance. A 29 year old female diagnosed twin fetus with twin-twin transfusion syndrome needs urgent delivery at about 29 weeks of gestation. The patients had to be transported to the perinatal care center which is 160 km from the hospital to where the patient was admitted because of a lack of NICU. During transportation, the maternal vital signs were stable without cervical dilatation. After arrived at the perinatal center, the patient underwent Caesarian section. Both babies had respiratory distress syndrome and admitted to NICU. With increasing cases in which medical institutions cannot accept peripartum emergency patients, it needs to search for medical institutions over an extended area and transport patients by Doctor-Helicopter.

A compact, automated cell culture system for clinical scale cell expansion from primary tissues.

Despite the growing number of clinically practical automated cell culture systems, demand is also increasing for more compact platforms with greater capabilities to prepare primary cells directly from patient tissue. Here we report the development of an automated cell culture system that is also compact. The machinery consisted of a supply unit, an incubation unit, and a collection unit, which fit within a 70 cm x 60 cm x 86 cm space. The compact size was enabled by our concept of using a single culture vessel from the primary culture steps to final cell harvest instead of scaling up with multiple culture vessels. Human fibroblasts and bone marrow stromal cells (BMSCs) were successfully cultured with this system over 19 days without contamination. From three pieces of gingival tissue (2 mm x 2 mm) or from 10 mL of bone marrow aspirate, the system could produce more than 2.0x10(7) cells and up to 3.0x10(7) cells for fibroblasts and BMSCs, respectively. The BMSCs produced by this system were capable of ectopic bone formation after transplantation into the subcutaneous space of nude mice. Our prototype system will provide a foundation for minimizing automatic culture machinery with clinically relevant cell yields while also expanding the automation capabilities to include primary tissue culture.

Recovery process of sciatic nerve defect with novel bioabsorbable collagen tubes packed with collagen filaments in dogs.

Autologous nerve graft is the most commonly applied treatment for the patients with peripheral nerve defect, while application is limited because of tissue availability and unfavorable donor site morbidity. To overcome this problem, peripheral nerve regeneration using a nerve conduit has been studied. Especially, nerve conduit using biodegradable materials has been considered promising. In this study, a potential of collagen nerve conduit has been studied with special reference to the regenerating process of a peripheral nerve. Twelve adult female Beagle dogs weighting 10-12 kg were used. The peroneal nerve was cut to make a 30-mm defect. The nerve defect was bridged by the collagen artificial nerve conduit. Comprehensive functional, electrophysiological, morphometrical, and histological analyses were performed until one year after operation. The wet weight of tibialis anterior muscles was only 32.4% of the healthy side at 24 weeks, which was recovered to 77.4% at 52 weeks after denervation. Electrophysiological evaluation of tibialis anterior muscle belly showed polyphasic wave at 52 weeks after implantation, which was almost half amplitude as compared with that of control. The diameters of myelinated nerve fibers thickened day by day, and the average diameter was 5.16 microm at PFN, 3.91 microm at CG, and 3.75 microm at DFN, and average thickness of myelin sheath was 0.94 microm at PFN, 0.46 microm at CG, and 0.55 microm at DFN after 52 weeks. The distribution of myelinated nerve fiber size in the 52 weeks group was distinctly bimodal with the major peak at approximately 2-4 microm and the minor peak at 10-12 microm. These findings were consistent with the distribution of the normal nerve fiber. This study proves the feasibility of the collagen artificial nerve conduit for promoting nerve regeneration, raises new possibilities of seeking alternatives to autograft for nerve repair. The results from this study showed detailed process of morphological, electrophysiological, and functional recovery of the regenerated nerve, which would provide scientific background for this novel therapy.

Composite implantation of mesenchymal stem cells with endothelial progenitor cells enhances tissue-engineered bone formation.

For successful tissue engineering, neovascularization of the implanted tissue is critical. Factors generated by endothelial cells are also considered crucial for the process of osteogenesis. The direct effects of supplementing tissue engineered constructs with cultured endothelial progenitor cells (EPCs) for enhancing bone regeneration have not been reported. In this study, we investigated the potential of EPCs to facilitate neovascularization in implants and evaluated their influence on bone regeneration. The influence of EPC soluble factors on osteogenic differentiation of mesenchymal stem cells (MSCs) was tested by adding EPC culture supernatant to MSC culture medium. To evaluate the influence of EPCs on MSC osteogenesis, canine MSCs-derived osteogenic cells and EPCs were seeded independently onto collagen fiber mesh scaffolds and co-transplanted to nude mice subcutaneously. Results from coimplant experiments were compared to implanted cells absent of EPCs 12 weeks after implantation. Factors from the culture supernatant of EPCs did not influence MSC differentiation. Coimplanted EPCs increased neovascularization and the capillary score was 1.6-fold higher as compared to the MSC only group (p < 0.05). Bone area was also greater in the MSC + EPC group (p < 0.05) and the bone thickness was 1.3-fold greater in the MSC + EPC group than the MSC only group (p < 0.05). These results suggest that soluble factors generated by EPCs may not facilitate the osteogenic differentiation of MSCs; however, newly formed vasculature may enhance regeneration of tissue-engineered bone.

Cryopreservation of cultured periosteum: effect of different cryoprotectants and pre-incubation protocols on cell viability and osteogenic potential.

Evidence has accumulated that periosteal cells have a great potential to regenerate bone. We have demonstrated that cultured periosteum (CP) in membrane form is an effective device to regenerate alveolar bone. To increase the availability of CP in a clinical environment, an effective cryopreservation protocol for CP has been developed. In this study, three different cryoprotectants (Me(2)SO, glycerol, and ethylene glycol) were used. The effect on cell viability of pre-incubation temperature, pre-incubation time, and agitation during incubation was investigated. Samples were stored at -196 degrees C for 10 days. Cell viability was assessed by a colorimetric cell viability assay using a tetrazolium salt, and the assay results were confirmed by confocal laser scanning microscopy after staining with a combination of calcein AM and ethidium homodimer-1. The activity of the cells after thawing was assessed by alkaline phosphatase assay. To assess the osteogenic potential of cryopreserved CP, the CP was grafted to calvarial defects in athymic rats. The greatest cell viability was obtained in the group equilibrated at 37 degrees C for 30 min with Me(2)SO, under agitation, showing 63.3 +/- 10.5% recovery. After cryopreservation, the cell growth of surviving cells was identical when Me(2)SO was used as a cryoprotectant. Alkaline phosphatase (ALP) activity was maintained in the groups cryopreserved with Me(2)SO and glycerol. The transplantation experiment showed that the calvarial defects were completely closed by grafting cryopreserved CP, which demonstrates that the osteogenic property of CP was well maintained. An efficient cryopreservation protocol for CP has been developed and this will provide a convenient and effective treatment option for bone regeneration in clinics.

Ultrasound enhances transforming growth factor beta-mediated chondrocyte differentiation of human mesenchymal stem cells.

In clinical studies and animal models, low-intensity ultrasound (US) promotes fracture repair and increases mechanical strength. US also promotes cartilage healing by increasing glycosaminoglycan synthesis of chondrocytes. As mesenchymal stem cells (MSCs) have the ability to differentiate into chondrocytes, US may promote their differentiation. Here, we evaluated the effects of US on the differentiation of MSCs toward chondrocytes and cartilage matrix formation. When human MSCs cultured in pellets were treated with transforming growth factor beta (TGF-beta, 10 ng/mL), they differentiated into chondrocytes as assessed by alcian blue staining and immunostaining for aggrecan, but nontreated cell pellets did not. Furthermore, when low-intensity US was applied for 20 min every day to the TGF-beta-treated cell pellets, chondrocyte differentiation was enhanced. Biochemically, aggrecan deposition was increased by 2.9- and 8.7-fold by treatment with TGF-beta alone, and with both TGF-beta and US, respectively. In contrast, cell proliferation and total protein amount appeared unaffected by these treatments. These results indicate that low-intensity US enhances TGF-beta-mediated chondrocyte differentiation of MSCs in pellet culture and that application of US may facilitate larger preparations of chondrocytes and the formation of mature cartilage tissue.

The effect of the long-term cultivation on telomere length and morphology of cultured epidermis.

BACKGROUND: Cultured epidermis has been successfully used in clinical treatment such as burns and pigmentary disorders. Although the generation of wide cultured epidermis for clinical use may require repeated passages, especially for allografts, the effects of long-term cultivation on its quality and cell viability are not well known. OBJECTIVES: To investigate the changes in morphology, telomere length, and telomerase activity during the passages of cultured epidermis and keratinocytes up to the passage limit, and to examine the usefulness of telomere length as a performance criterion for cultured epidermis. METHODS: The keratinocytes obtained from five patients were used to generate cultured epidermis. At the early passage and after cultivation up to the passage limit, morphology, telomere length and telomerase activity were investigated by using microscopes, southern blot analysis and telomeric repeat amplification protocol assay, respectively. RESULTS: The cultured cells started to show morphological changes when each passage was close to its limit and the cell sheets assumed an irregular stratification with various sizes of cytoplasm and nuclei. At the passage limit, the telomere length had decreased approximately 80-85%, and the average telomerase activity had declined under serum-free culture conditions. CONCLUSION: The results of this study showed the morphological change and telomere length reduction by long-term cultivation on cultured epidermis. Although the reduction in telomere length and telomerase activity may not be the major cause of the senescence, they could provide a useful information for the quality of the cultured epidermis.

Protective effect of colored rice over white rice on Fenton reaction-based renal lipid peroxidation in rats.

Rice has been one of the most important grains. While polished white rice is favored, colored strains of rice, red, or black, have been maintained for religious purposes in Japan. We studied whether feeding of unpolished colored rice instead of white rice ameliorates oxidative renal tubular damage in rats induced by ferric nitrilotriacetate. Whereas renal lipid peroxidation was exacerbated in white rice-fed group in comparison with standard chow group, this exacerbation was not observed in red or black rice-fed groups. These changes were dependent on the proportion of colored rice to standard chow in the diet. Cyanidin 3-O-beta-D-glucoside was detectable neither in the serum nor kidney after one week of colored rice diet, but serum protocatechuic acid was significantly increased after black rice diet. There was a generalized decrease in the renal glutathione peroxidase activity in rice diet groups. Renal enzymatic activities of superoxide dismutase, glutathione S-transferase and NAD(P)H quinone reductase were not associated with the levels of lipid peroxidation. However, renal catalase activity was significantly increased in black rice-fed groups. These may partly explain the antioxidative effect. Furthermore, colored strains of rice are rich in proteins. Thus, our data warrants further investigation of the antioxidative effect of colored rice.

Tissue-engineered bone using mesenchymal stem cells and a biodegradable scaffold.

Bone marrow has been shown to contain a population of rare cells capable of differentiating to the cells that form various tissues. These cells, referred to as mesenchymal stem cells (MSCs), are capable of forming bone when implanted ectopically in an appropriate scaffold. The aim of this study was to investigate the potential of a new beta-tricalcium phosphate (beta-TCP) as a scaffold and to compare the osteogenic potential between beta-TCP and hydroxyapatite (HA). The beta-TCP and HA loaded with MSCs were implanted in subcutaneous sites and harvested at 1, 2, 4, and 8 weeks after implantation for biochemical and histological analysis. Biochemically, in both beta-TCP and HA composites, the alkaline phosphatase activity in the composites could be detected and was maintained at a high level for 8 weeks. In the histological analysis, active bone formation could be found in both the beta-TCP and HA composites. These findings suggest that beta-TCP could play a role as a scaffold as well as HA. The fabricated synthetic bone using biodegradable beta-TCP as a scaffold in vivo is useful for reconstructing bone, because the scaffold material is absorbed several months after implantation.