Multiple Blood Culture Sampling, Proper Antimicrobial Choice, and Adequate Dose in Definitive Therapy Supported by the Antimicrobial Stewardship Team Could Decrease 30-Day Sepsis Mortality Rates.

Objective: This study aimed to identify factors that should be focused on by the antimicrobial stewardship team for treating patients with sepsis, by investigating the mortality of patients with sepsis within 30 days and the mortality-related factors in our hospital over a 10-year period from the perspective of appropriate antimicrobial use. Methods: Factors associated with 30-day mortality were investigated using hierarchical multiple logistic regression in 1406 patients with pathogen-identified sepsis in Hirosaki University Hospital. These factors were clinical data, microbiological data, antimicrobials used in empiric and definitive therapies, presence/absence of ineffective use, underdosing as evaluated using Monte Carlo simulation, and practice of de-escalation. Results: The ineffective use of antimicrobials in empiric therapy and the underdosing and ineffective use in definitive therapy were significantly associated with 30-day mortality (odds ratio [OR] = 2.70, 3.72, and 3.65, respectively). Multiple blood culture sampling was inversely associated with these inappropriate antimicrobial uses. Every year, the 30-day mortality rate has been decreasing, in line with the increase in multiple blood culture sampling and de-escalation; the inappropriate use of antimicrobials has also decreased. Conclusion: Multiple blood culture sampling, proper choice of antimicrobial, and using an adequate dose in definitive therapy could decrease the 30-day mortality rate in patients with sepsis and these factors could be supported by the antimicrobial stewardship team.

Role of G-protein-coupled estrogen receptor in the pathogenesis of chronic asthma.

BACKGROUND AND AIM: G protein-coupled estrogen receptor (GPER) is an estrogen receptor located on the plasma membrane. We previously reported that the administration of G-1, a GPER-specific agonist, suppressed development of acute ovalbumin (OVA)-induced asthma in a mouse model. Herein, we evaluate the involvement of GPER in a mouse model of chronic OVA asthma. METHODS: G-1 or saline was administered subcutaneously to BALB/c mice with chronic OVA asthma, and pathological and immunological evaluation was performed. In addition, Foxp3-expressing CD4-positive T-cells in the spleen and ILC2 in the lungs were measured using flow cytometry. RESULTS: We observed a significant decrease in the number of inflammatory cells in the bronchoalveolar lavage fluid (BALF) in the G-1 treated group. In the airways, inflammatory cell accumulation, Th2 cytokines (IL-4, IL-5, IL-13, and eotaxin) and epithelial cytokine TSLP were suppressed, while in the BALF, anti-inflammatory cytokines (IL-10 and TGF-ß) were increased. Furthermore, in splenic mononuclear cells, Foxp3-expressing CD4-positive T-cells were increased in the G-1 group, whereas treatment with G-1 did not change the percentage of ILC2 in the lungs. CONCLUSION: G-1 administration suppressed allergic airway inflammation in mice with chronic OVA asthma. GPER may be a potential therapeutic target for chronic allergic asthma.

Serum 3-Hydroxybutyrate is Expected to Serve as One of the Supportive Diagnostic Markers of Persistent Idiopathic Dentoalveolar Pain (PDAP).

Background: Persistent idiopathic dentoalveolar pain (PDAP), previously referred to as atypical odontalgia, is a chronic dental pain that occurs without signs of pathology. PDAP is considered a diagnosis of exclusion, and its definition is currently under refinement and remains ambiguous. The metabolite known as 3-hydroxybutyrate (3HB) has garnered significant interest as a potential indicator for both depression and chronic psychogenic pain. We investigated the characteristics of patients with PDAP and hypothesized that serum 3HB could support the diagnosis of PDAP. Subjects and Methods: Forty-one patients with PDAP and 167 patients with odontogenic toothache were investigated regarding depression and anxiety scales in addition to the general dental evaluation. Blood tests including high-sensitivity CRP, HbA1c, and 3HB were performed for all patients. Associations between PDAP and patients' varying characteristics were investigated using hierarchical multivariate logistic regression analyses. Results: There were more females, current smokers, patients with orofacial pain (such as temporomandibular joint pain, glossalgia, and headache), and people with elevated 3HB levels among patients with PDAP than among control participants. Multivariate logistic regression analyses predicting patients with PDAP identified the female sex (odds ratio [OR]: 4.16), current smoking (OR: 14.9), glossalgia (OR: 19.8) a high CES-D score (≥16) (OR: 5.98), and elevated serum 3HB (≥80 µmol/L) (OR: 18.4) factors significantly associated with PDAP. Conclusion: Our results demonstrated that serum 3HB levels could be elevated in patients with PDAP compared to other types of odontogenic pain, although 3HB was not specific to PDAP. Based on our findings, five factors - female sex, current smoking, depressive tendencies, chronic orofacial pains, and high serum 3HB levels - could be useful for diagnosing PDAP.

Chorioamnionitis and maternal sepsis caused by AmpC ß-lactamase-producing Escherichia coli infection: A case report.

INTRODUCTION: Multidrug resistant bacteria have increasingly become a concern regarding infection treatment. The clinical course of chorioamnionitis (CAM) caused by multidrug-resistant bacteria is not well understood. PRESENTATION OF CASE: We report a case of CAM caused by AmpC-type ß-lactamase (AmpC)-producing Escherichia coli (E. coli), a multidrug-resistant bacterium. A 35-year-old primipara was hospitalized with preterm membrane rupture at 36 weeks of gestation and was started on oral ampicillin. On the fourth day after admission, the patient was diagnosed with CAM owing to high fever development and uterine tenderness; therefore, an emergency cesarean section was performed. AmpC-producing E. coli were detected in blood and amniotic fluid cultures. Post-operation, the patient received treatment for septic shock and was discharged on the 15th post-operative day. DISCUSSION: The patient initially had no symptoms of infection but later experienced fever and uterine pain. She underwent an emergency cesarean section, and both mother and baby were successfully treated with broad-spectrum antibiotics. CAM associated with multidrug-resistant bacteria is more challenging to manage compared to infections in other parts of the body, as it occurs in unique environments such as the uterus, during pregnancy, and in the presence of compromised immunity. CONCLUSION: The development of new diagnostic criteria and effective biomarkers is needed to improve early detection, and adherence to standard precautions can help prevent the acquisition of multidrug-resistant bacteria in healthcare settings.

Interhospital transmission of vancomycin-resistant Enterococcus faecium in Aomori, Japan.

BACKGROUND: Spread of vancomycin-resistant Enterococcus (VRE) is a global concern as a significant cause of healthcare-associated infections. A series of VRE faecium (VREf) outbreaks caused by clonal propagation due to interhospital transmission occurred in six general hospitals in Aomori prefecture, Japan. METHODS: The number of patients with VREf was obtained from thirty seven hospitals participating in the local network of Aomori prefecture. Thirteen hospitals performed active screening tests for VRE. Whole genome sequencing analysis was performed. RESULTS: The total number of cases with VREf amounted to 500 in fourteen hospitals in Aomori from Jan 2018 to April 2021. It took more than three years for the frequency of detection of VRE to return to pre-outbreak levels. The duration and size of outbreaks differed between hospitals according to the countermeasures available at each hospital. Whole genome sequencing analysis indicated vanA-type VREf ST1421 for most samples from six hospitals. CONCLUSIONS: This was the first multi-jurisdictional outbreak of VREf sequence type 1421 in Japan. In addition to strict infection control measures, continuous monitoring of VRE detection in local medical regions and smooth and immediate communication among hospitals are required to prevent VREf outbreaks.

Clinical characteristics and treatment outcomes of carbapenem-resistant Enterobacterales infections in Japan.

OBJECTIVES: The dissemination of difficult-to-treat carbapenem-resistant Enterobacterales (CRE) is of great concern. We clarified the risk factors underlying CRE infection mortality in Japan. METHODS: We conducted a retrospective, multicentre, observational cohort study of patients with CRE infections at 28 university hospitals from September 2014 to December 2016, using the Japanese National Surveillance criteria. Clinical information, including patient background, type of infection, antibiotic treatment, and treatment outcome, was collected. The carbapenemase genotype was determined using PCR sequencing. Multivariate analysis was performed to identify the risk factors for 28-day mortality. RESULTS: Among the 179 patients enrolled, 65 patients (36.3%) had bloodstream infections, with 37 (20.7%) infections occurring due to carbapenemase-producing Enterobacterales (CPE); all carbapenemases were of IMP-type (IMP-1: 32, IMP-6: 5). Two-thirds of CPE were identified as Enterobacter cloacae complex. Combination therapy was administered only in 46 patients (25.7%), and the 28-day mortality rate was 14.3%. Univariate analysis showed that solid metastatic cancer, Charlson Comorbidity Index ≥3, bloodstream infection, pneumonia, or empyema, central venous catheters, mechanical ventilation, and prior use of quinolones were significant risk factors for mortality. Multivariate analysis revealed that mechanical ventilation (OR: 6.71 [1.42-31.6], P = 0.016), solid metastatic cancers (OR: 5.63 [1.38-23.0], P = 0.016), and bloodstream infections (OR: 3.49 [1.02-12.0], P = 0.046) were independent risk factors for 28-day mortality. CONCLUSION: The significant risk factors for 28-day mortality in patients with CRE infections in Japan are mechanical ventilation, solid metastatic cancers, and bloodstream infections.

Impact of polymorphisms of pharmacokinetics-related genes and the inflammatory response on the metabolism of voriconazole.

The effects of inflammatory responses and polymorphisms of the genes encoding cytochrome P450 (CYP) (CYP2C19 and CYP3A5), flavin-containing monooxygenase 3 (FMO3), pregnane X receptor (NR1I2), constitutive androstane receptor (NR1I3), and CYP oxidoreductase (POR) on the ratio of voriconazole (VRCZ) N-oxide to VRCZ (VNO/VRCZ) and steady-state trough concentrations (C0h ) of VRCZ were investigated. A total of 56 blood samples were collected from 36 Japanese patients. Results of multiple linear regression analyses demonstrated that the presence of the extensive metabolizer CYP2C19 genotype, the dose per administration, and the presence of the NR1I2 rs3814057 C/C genotype were independent factors influencing the VNO/VRCZ ratio in patients with CRP levels of less than 40 mg/L (standardized regression coefficients (SRC) = 0.448, -0.301, and 0.390, respectively; all p < .05). With regard to the concentration of VRCZ itself, in addition to the above factors, the presence of the NR1I2 rs7643645 G/G and rs3814055 T/T genotypes were found to be independent factors influencing the VRCZ C0h in these patients (SRC = -0.430, 0.424, -0.326, 0.406 and -0.455, respectively; all p < .05). On the contrary, in patients with CRP levels of at least 40 mg/L, no independent factors were found to affect VNO/VRCZ and VRCZ C0h . Inflammatory responses, and CYP2C19 and NR1I2 polymorphisms may be useful information for the individualization of VRCZ dosages.

Serum 3-Hydroxybutyrate in Patients with Psychogenic Somatoform Symptoms May Be a Predictor of the Effectiveness of Sertraline and Venlafaxine.

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) are often used to treat outpatients with psychogenic somatoform symptoms but prove ineffective in some cases. The metabolite 3-hydroxybutyrate (3HB) is currently attracting attention as a marker of the severity of depression. We investigated whether serum 3HB levels in patients with psychogenic somatoform symptoms can predict the effectiveness of sertraline and venlafaxine. PATIENTS AND METHODS: Physical and psychiatric problems were assessed in 132 outpatients, and symptomatic response and serum 3HB concentrations were examined before and after treatment with sertraline (50 mg/day) or venlafaxine (75 mg/day). RESULTS: In 30.3% of patients with psychogenic symptoms, serum 3HB was above the upper limit of normal (<80 µmol/L). According to multiple logistic regression analysis, only episodes of suicidal ideation showed a significant positive association with elevated 3HB (odds ratio 10.2; 95% confidence interval (CI) 2.46-42.2). The sensitivity of 3HB for the effectiveness of sertraline or venlafaxine for psychosomatic symptoms was 44.6%, but specificity was 93.9%. Hierarchical multiple logistic regression analysis identified 3HB as a better predictor of the effectiveness of medication (odds ratio 10.0; 95% CI, 2.49-40.3) than episodes of suicidal ideation. CONCLUSION: The present findings suggest that high serum 3HB levels in patients with psychogenic somatoform symptoms may be associated with suicidal ideation and the effectiveness of sertraline and venlafaxine at low to intermediate doses. The 3HB level may be a good predictor of the effectiveness of medication. Examination of serum 3HB levels may lead to earlier and more appropriate administration of sertraline and venlafaxine.

Clinical relevance of procalcitonin values in bacteremia.

INTRODUCTION: The aim of this study was to investigate procalcitonin levels according to the causative pathogens of bacteremia. The relationships between the clinical outcomes and procalcitonin levels were also studied. METHODS: From among 452 patients, 507 cases of positive blood culture were included in the present study. Procalcitonin levels were studied according to the pathogen types. The prevalence of septic shock and the mortality rates were also studied in four groups stratified by the procalcitonin levels (groups 1, 2, 3, and 4 had procalcitonin levels of <0.5 ng/mL, 0.5 ≤ 2.0 ng/mL, 2.0 < 10 ng/mL, and ≥10 ng/mL, respectively). RESULTS: The procalcitonin levels were significantly higher in bacteremia cases with Gram-negative rods (19.50 ng/mL), such as Escherichia coli (32.5 ng/mL), than those with Gram-positive rods (8.45 ng/mL) or Gram-positive cocci (9.21 ng/mL) (p < 0.01). The 28-day mortality rates in groups 1, 2, 3, and 4 were 6.0%, 12.0%, 14.9%, and 19.8%, respectively. The procalcitonin levels of samples taken before or on the same day of blood cultures were significantly lower than those taken one day after blood cultures. Multiple logistic regression analysis showed that C-reactive protein and procalcitonin ≥10 ng/mL were independently associated with a higher risk of mortality within 28 days. CONCLUSIONS: The PCT levels were higher in cases of bacteremia caused by GNR than those caused by GPR or GPC. The 28-day mortality rate increased as the PCT levels increased. Clinical importance of early evaluations and appropriate interpretation of procalcitonin levels for bacteremia were indicated.

Impact of Geographical Variations on the Prevalence of Multidrug-Resistant Organisms in Japan.

Emergence and spread of multidrug-resistant organisms (MDRO) is an urgent social and public health problem. Here, we carried out an epidemiological survey to clarify the geographical characteristics and factors influencing the prevalence of MDRO. Data on the prevalence of MDRO in 47 prefectures in Japan were extracted from the Japanese Nosocomial Infection Surveillance, a nationwide database for infection control. Potential factors for MDRO were analyzed using data selected from the pharmacological, medical service, infection control, environmental, social, and food-related categories, based on the characteristics of each organism and the correlations between them and MDRO prevalence. Statistical data for potential factors were obtained from public domains. The use of antibiotics was found to be correlated with the prevalence of penicillin-resistant Streptococcus pneumoniae, 3rd-generation cephalosporin- and fluoroquinolone-resistant Escherichia coli, and methicillin-resistant Staphylococcus aureus. Negative correlation between the consumption of food such as kelp and fermented soybeans that facilitate the growth of lactic acid bacteria and the prevalence of 3rd-generation cephalosporin- and fluoroquinolone-resistant E. coli suggested an association between the intestinal microflora and MDRO colonization. In addition to the use of antibiotics, lifestyle, food culture, and social factors such as tobacco smoking, average atmospheric temperature, prevalence of three-generation households, ratio of elderly population, average duration of tourist stay, chicken and fermented soybean consumption, and the competency of healthcare services may also affect MDRO prevalence.

Impact on Antifungal Susceptibility Patterns of Previous vs. Revised Clinical and Laboratory Standards Institute Breakpoints for Candida Species Isolated from Candidemia: Experience of Two Tertiary Care Institutions in Japan.

BACKGROUND: Candidemia has a high mortality rate. Identifying prognostic factors of candidemia, based on each regional data, is essential for better management. The Clinical and Laboratory Standards Institute (CLSI) recently revised Candida species-specific breakpoints (R-BP) for antifungal agents. Few studies have investigated the detection performance of resistance in Candida species by comparing the R-BP and previous species non-specific CLSI breakpoint (P-BP) among patients with candidemia. The primary objective was to investigate the impact of the R-BP on the antifungal susceptibility patterns of Candida species, while the secondary objective was to identify the prognostic factors of candidemia. METHODS: A total of 193 Candida species isolated from 187 patients with candidemia between January 2007 and December 2016 were examined. Susceptibility based on CLSI M27-A3 was defined as the P-BP and based on species-specific CLSI M59 or M60 breakpoint was defined as the R-BP. Multivariate Cox's hazard analysis was performed to identify prognostic factors within 30 days of the diagnosis of candidemia. RESULTS: A significant difference was observed in the susceptibility rate to fluconazole (FLCZ) (P-BP; 93.0% vs. R-BP; 79.4%) and to voriconazole (VRCZ) (P-BP; 97.2% vs. R-BP; 91.0%). The susceptibilities of C. parapsilosis, C. glabrata, and C. tropicalis to azole antifungal agents were markedly lower with the R-BP. Based on the R-BP, anti-fungal therapy was regarded as inappropriate for approximately 10% of the patients. The 30-day mortality rate was 29.4%. In a multivariate Cox's hazard analysis, age, lung disease, C. albicans, and the absence of antifungal therapy were associated with a high mortality rate, whereas serum albumin, C. parapsilosis, surgical wards, the removal of central venous catheter (CVC), and follow-up blood culture tests to confirm the clearance of Candida species were associated with a lower mortality rate. CONCLUSIONS: Early initiation of antifungal therapy, removal of CVC, and follow-up blood culture tests are essential for improving the outcome. The R-BP efficiently detected non-susceptible strains to FLCZ and VRCZ, particularly in non-albicans Candida species. The present results support the importance of antifungal susceptibility tests and interpretations based on the R-BP among patients with candidemia.

Analysis for risk factors of 12-month neurological worsening in patients with surgically treated small-to-moderate size unruptured intracranial aneurysms.

The risk associated with surgical treatment for small-to-moderate size unruptured intracranial aneurysms (SMUIAs, defined as <15 mm) has not been well characterized. Authors aimed to investigate risk factors for poor outcome in surgical treatment of SMUIAs. The data of prospectively collected 801 consecutive patients harboring 971 surgically treated SMUIAs was evaluated. Neurological worsening (NW) was defined as an increase in 1 or more modified Rankin Scale at 12-month. Clinical and radiological characteristics were compared. Neurological worsening was observed in 45 (4.6%). In multivariate analysis, only perforator territory infarction (PTI) on postoperative diffusion-weighted imaging (odds ratio (OR), 13; 95% confidence interval (CI), 4.9-32, p < 0.0001), and aneurysm locations (paraclinoid (OR, 6.9; 95% CI, 3.1-15, p < 0.0001), basilar artery (OR, 4.5; 95% CI, 1.5-14, p = 0.008), vertebral artery (OR, 11; 95% CI, 3.3-34, p < 0.0001)) were related to neurological worsening. Multivariate analysis showed that statin use (OR, 12; 95% CI, 3.8-39, p < 0.0001) and aneurysm locations (internal carotid artery-posterior communicating artery (OR, 3.9; 95% CI, 1.8-8.2, p < 0.0001) and basilar artery (OR, 6.3; 95% CI, 2.3-17, p = 0.008)), and aneurysm size >10 mm (OR, 5.3; 95% CI, 1.8-15, p = 0.003) were related to PTI. Although all SMUIAs should be carefully considered whether to be treated, those with statins, specific locations, and larger sizes should perhaps be more meticulously contemplated, and neurosurgeons should continue to avoid PTI.

Morphological parameters as factors of 12-month neurological worsening in surgical treatment of patients with unruptured saccular intracranial aneurysms: importance of size ratio.

OBJECTIVE: It is well known that larger aneurysm size is a risk factor for poor outcome after surgical treatment of unruptured saccular intracranial aneurysms (USIAs). However, the authors have occasionally observed poor outcome in the surgical treatment of small USIAs and hypothesized that size ratio has a negative impact on outcome. The aim of this paper was to investigate the influence of size ratio on outcome in the surgical treatment of USIAs. METHODS: Prospectively collected clinical and radiological data of 683 consecutive patients harboring 683 surgically treated USIAs were evaluated. Dome-to-neck ratio was defined as the ratio of the maximum width of the aneurysm to the average neck diameter. The aspect ratio was defined as the ratio of the maximum perpendicular height of the aneurysm to the average neck diameter of the aneurysm. The size ratio was calculated by dividing the maximum aneurysm diameter (height or width, mm) by the average parent artery diameter (mm). Neurological worsening was defined as an increase in modified Rankin Scale score of 1 or more points at 12 months. Clinical and radiological variables were compared between patients with and without neurological worsening. RESULTS: The median patient age was 64 years (IQR 56-71 years), and 528 (77%) patients were female. The median maximum size, dome-to-neck ratio, aspect ratio, and size ratio were 4.7 mm (IQR 3.6-6.7 mm), 1.2 (IQR 1.0-1.4), 1.0 (IQR 0.76-1.3), and 1.9 (IQR 1.4-2.8), respectively. The size ratio was significantly correlated with maximum size (r = 0.83, p < 0.0001), dome-to-neck ratio (r = 0.69, p < 0.0001), and aspect ratio (r = 0.74, p < 0.0001). Multivariate logistic regression analysis showed that the specific USIA location (paraclinoid segment of the internal carotid artery: OR 6.2, 95% CI 2.6-15, p < 0.0001; and basilar artery: OR 8.4, 95% CI 2.8-25, p < 0.0001), size ratio (OR 1.3, 95% CI 1.1-1.6, p = 0.021), and postoperative ischemic lesion (OR 9.4, 95% CI 4.4-19, p < 0.0001) were associated with neurological worsening (n = 52, 7.6%), and other characteristics showed no significant differences. CONCLUSIONS: The present study showed that size ratio, and not other morphological parameters, was a risk factor for 12-month neurological worsening in surgically treated patients with USIAs. The size ratio should be further studied in a large, prospective observational cohort to predict neurological worsening in the surgical treatment of USIAs.

Anti-E Detected in a 7-Month-Old Infant with Acute Lymphoblastic Leukemia after Transfusion.

BACKGROUND: Only a few cases of infantile anti-red blood cell alloantibody production have been reported. METHODS: A 7-month-old girl with acute lymphoid leukemia developed anti-E alloantibody 13 days after transfusion of E-positive red blood cells. Antibody screening was performed before and at 2, 6, 13, 18, 27, 34, and 49 days after red blood cell transfusion. Identification test, direct immunoglobulin test, acid elution, and dithiothreitol test were also performed. RESULTS: Anti-E alloantibody was detected in the blood 13 days after the first transfusion. The detected antibody was IgM and it decreased below detectable levels within 49 days after the first transfusion. CONCLUSIONS: Follow-up testing for the presence of post-transfusion alloantibody at appropriate times is important, even in infants.

Evaluation of Microsurgery for Managing Giant or Complex Cerebral Aneurysms: A Retrospective Study.

OBJECTIVE: Surgical or endovascular treatment for giant or complex aneurysms is challenging. The aims of this study were to evaluate clinical outcomes and factors affecting the prognosis of giant or complex aneurysms and to better establish the role of microsurgery in the management strategy. METHODS: One hundred fifty-nine patients with surgically treated complex aneurysms were included. Thirty-two patients (20.1%) had giant aneurysms (≥25 mm) and 57 (35.8%) had large aneurysms (≥15 mm). Poor outcome was defined as modified Rankin Scale scores of 3-6. RESULTS: The mean aneurysm size was 17.0 mm (range, 1.6-47.5 mm). One hundred and sixteen aneurysms (80.0%) were in the anterior circulation and 43 (27.0%) were in the posterior circulation. One hundred and thirty-eight (86.8%) aneurysms were completely occluded without residual aneurysms. Nineteen (11.9%) had minor aneurysm remnants; 2 (1.3%) had incomplete occlusion. Two patients (1.3%) with giant basilar artery (BA) trunk aneurysms experienced rupture of the treated aneurysm and died. Bypass surgery was combined with microsurgery in 148 patients (93.1%). Perforating artery infarction was observed postoperatively in 42 patients (26.4%), and poor outcome was observed in 29 (18.2%). Male sex (P = 0.016; adjusted odds ratio [OR], 4.524 [1.949-10.500]), perforating artery infarction (P < 0.001; adjusted OR, 13.625 [5.329-34.837]), and BA aneurysm location (P = 0.003; adjusted OR, 56.333 [6.830-464.657]) were significantly related to poor outcome. The aneurysm size (P = 0.017; adjusted OR, 1.064 [1.021-1.107]), C1 aneurysm location (P = 0.042; adjusted OR, 2.591 [0.986-6.811]), and BA aneurysm location (P = 0.033; adjusted OR, 12.956 [3.197-52.505]) were significantly related to perforating artery infarction. CONCLUSIONS: Microsurgery with bypass is effective for many different complex aneurysms, except BA aneurysms.

Impacts of a Size Ratio on Outcome in Patients with Surgically Treated Unruptured Nondissecting Anterior Cerebral Artery Aneurysms.

BACKGROUND: Anterior cerebral artery aneurysms (ACAs) are characterized by higher rupture rate and small size at rupture. It was shown that the aneurysm/vessel size ratio, and not the absolute size, might predict the risk of rupture in small unruptured intracranial aneurysms. The present study aimed to investigate the relationship between a size ratio and outcome in patients with unruptured nondissecting ACA aneurysms (UNDAs). METHODS: A total of 187 consecutive patients with 12 A1 (6.2%), 149 anterior communicating artery (77%), and 33 distal ACA (17%) aneurysms were retrospectively evaluated. The size ratio was defined as (size of aneurysm)/(size of parent artery). Neurologic worsening (NW) was defined as an increase in score of 1 or more on the modified Rankin Scale (mRS). RESULTS: The mean age of the patient population was 63 ± 11 years and 132 UNDAs (68%) were seen in women. Complete, partial neck clipping, and aneurysm trapping were archived in 188 (97%), 2 (1.0%), and 4 (2.1%) UNDAs, respectively. An excellent outcome (mRS score 0) at 12 months was archived in 177 (93%) UNDAs overall and 177 (95%) in UNDAs with preoperative mRS score of 0 (n = 186). Postoperative ischemic lesions (odds ratio, 193; 95% confidence interval, 17-2205; P < 0.0001) and the size ratio >3.0 (odds ratio, 11; 95% confidence interval, 1.2-105; P = 0.031) were related to 12-month NW on multivariate analysis. The aneurysm size was not related to 12-month NW. CONCLUSIONS: The present study showed that the size ratio, and not the absolute size, was related to 12-month NW in surgically treated UNDAs.

Subarachnoid hemorrhage after surgical treatment of unruptured intracranial aneurysms.

OBJECTIVE Only a few previous studies have investigated subarachnoid hemorrhage (SAH) after surgical treatment in patients with unruptured intracranial aneurysms (UIAs). Given the improvement in long-term outcomes of embolization, more extensive data are needed concerning the true rupture rates after microsurgery in order to provide reliable information for treatment decisions. The purpose of this study was to investigate the incidence of and risk factors for postoperative SAH in patients with surgically treated UIAs. METHODS Data from 702 consecutive patients harboring 852 surgically treated UIAs were evaluated. Surgical treatments included neck clipping (complete or incomplete), coating/wrapping, trapping, proximal occlusion, and bypass surgery. Clippable UIAs were defined as UIAs treated by complete neck clipping. The annual incidence of postoperative SAH and risk factors for SAH were studied using Kaplan-Meier survival analysis and Cox proportional hazards regression models. RESULTS The patients' median age was 64 years (interquartile range [IQR] 56-71 years). Of 852 UIAs, 767 were clippable and 85 were not. The mean duration of follow-up was 731 days (SD 380 days). During 1708 aneurysm years, there were 4 episodes of SAH, giving an overall average annual incidence rate of 0.23% (95% CI 0.12%-0.59%) and an average annual incidence rate of 0.065% (95% CI 0.0017%-0.37%) for clippable UIAs (1 episode of SAH, 1552 aneurysm-years). Basilar artery location (adjusted hazard ratio [HR] 23, 95% CI 2.0-255, p = 0.0012) and unclippable UIA status (adjusted HR 15, 95% CI 1.1-215, p = 0.046) were significantly related to postoperative SAH. An excellent outcome (modified Rankin Scale score of 0 or 1) was achieved in 816 (95.7%) of 852 cases overall and in 748 (98%) of 767 clippable UIAs at 12 months. CONCLUSIONS In this large case series, microsurgical treatment of UIAs was found to be safe and effective. Aneurysm location and unclippable morphologies were related to postoperative SAH in patients with surgically treated UIAs.

Evaluating effectiveness of infection control efforts in hospitals using information in microbiological laboratory databases.

Purpose: To analyze the quality of infection control activities, bacteriological data relevant to infection control was evaluated through the microbiological data warehouse networking hospitals in two medical regions. Methods: Data regarding bacterial test results of 19 hospitals were extracted from two microbiological laboratory information data bases. The rate of MRSA among total S. aureus was used as a general indicator of infection control activities. The occupancy rate of nasal or pharyngeal swabs among MRSA-positive bacteriological samples was used as an indicator of attention paid for infection control in intensive care wards. The number of blood culture sets per examined patient was utilized as an indicator for life-long vocational education on updated medical practice relevant to infectious diseases. Results: The rate of MRSA was significantly higher in secondary private hospitals. The occupancy rate of nasal or pharyngeal swabs was significantly higher in tertiary hospitals. The average number of blood culture set per examined patient were 1.55, 1.54 and 1.39 in tertiary, secondary public and secondary private hospitals, respectively; however, there were no statistical differences between groups. Conclusions: Data bases of microbiological test results shared by hospital laboratories are useful for evaluating regional infection control activities.

Posterior Inferior Cerebellar Artery Thrombosed Aneurysm Associated with Persistent Primitive Hypoglossal Artery Successfully Treated with Condylar Fossa Approach.

A 68-year-old woman presented with generalized seizure due to the left internal carotid artery (ICA) aneurysmal compression of the ipsilateral medial temporal lobe. Computed tomography angiography (CTA) revealed multiple aneurysms of the right persistent primitive hypoglossal artery (PPHA), the right ICA, and the right anterior cerebral artery (ACA). The right PPHA originated from the ICA at the level of the C1 and C2 vertebral bodies and passed through the hypoglossal canal (HC). The PPHA aneurysm was large and thrombosed, which was located at the bifurcation of the right PPHA and the right posterior inferior cerebellar artery (PICA), projecting medially to compress the medulla oblongata. Since this patient had no neurological deficits, sequential imaging studies were performed to follow this lesion, which showed gradual growth of the PPHA aneurysm with further compression of the brain stem. Although the patient remained neurologically intact, considering the growing tendency clipping of the aneurysm was performed. Drilling of the condylar fossa was necessary to expose the proximal portion of the PPHA inside the HC. The key of this surgery was the preoperative imaging studies to fully understand the anatomical structures. The PPHA was fully exposed from the dura to the corner its turning inferiorly without damaging the occipital condylar facet. Utilizing this technique, the neck ligation of the aneurysm was safely achieved without any surgical complications.

Preventing Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage with Aggressive Cisternal Clot Removal and Nicardipine.

BACKGROUND: A subarachnoid clot is the strongest predictor of cerebral vasospasm. Our purpose was to analyze the relationship between the number of postoperative cisternal clots and cerebral vasospasm and to assess the efficacy of surgical clot removal. METHODS: The subjects were 158 patients with aneurysmal subarachnoid hemorrhage. All patients underwent clipping with cisternal clot removal. The preoperative and postoperative number of clots was analyzed semiquantitatively using computed tomography, and cerebral vasospasm and its severity were analyzed using magnetic resonance angiography in a blind fashion. Factors related to cerebral vasospasm and poor outcome were analyzed retrospectively. Poor outcome was defined as modified Rankin Scale (mRS) score of 3 or greater. RESULTS: Symptomatic cerebral vasospasm (SCV) was observed in 6 patients (3.8%). Angiographic vasospasm (AVS) was observed in 38 patients (24.1%). One year after the operation, 82.9% of patients had an mRS score of 0-2. The postoperative number of clots was significantly (P < 0.005) related to SCV (adjusted odds ratio [OR], 6.447; 95% confidence interval [CI], 2.063-20.146), AVS (OR, 2.634; 95% CI, 1.467-4.728), and poor outcome (OR, 2.103; 95% CI, 1.104-4.007). Poor outcome was also related to age over 65 (OR, 6.658; 95% CI, 2.389-18.559) and World Federation of Neurosurgical Societies scale grade (OR, 1.732; 95% CI, 1.248-2.403). CONCLUSIONS: Surgically removing as many clots as possible in the acute stage can decrease SCV and reduce AVS severity. Irrigation should be performed on all approachable cisterns.