Randomized clinical trial of duct-to-mucosa versus invagination pancreaticojejunostomy after pancreatoduodenectomy.

BACKGROUND: The postoperative pancreatic fistula (POPF) rate for duct-to-mucosa and invagination anastomosis after pancreatoduodenectomy is still debated. The aim of this RCT was to investigate the POPF rate for duct-to-mucosa versus invagination pancreaticojejunostomy. METHODS: Patients were stratified by pancreatic texture and diameter of the main pancreatic duct and randomized to the duct-to-mucosa or invagination group. The primary endpoint was the rate of clinically relevant POPF (defined as grade B or C). Secondary endpoints were suture material cost for pancreaticojejunostomy, drain insertion duration and duration of postoperative hospital stay. RESULTS: Some 120 patients undergoing pancreatoduodenectomy were included following consent. Clinically relevant POPF developed in six of 59 patients (10 per cent) in the invagination group and in 14 of 61 patients (23 per cent) in the duct-to-mucosa group (P = 0·077). Duration of drain insertion (6 versus 7 days respectively; P = 0·027) and postoperative hospital stay (19 versus 24 days; P = 0·015) were shorter in the invagination group. Subgroup analysis for 61 patients with a soft pancreas revealed a lower rate of clinically relevant POPF in the invagination group (10 per cent versus 42 per cent in the duct-to-mucosa group; P = 0·010). Among 20 patients with a clinically relevant POPF, the six patients in the invagination group had a shorter duration of drain insertion (38·5 days versus 49 days for 14 patients in the duct-to-mucosa group; P = 0·028) and postoperative hospital stay (42 versus 54·5 days respectively; P = 0·028). CONCLUSION: This study did not demonstrate a superiority of invagination over duct-to-mucosa pancreaticojejunostomy in the risk of POPF. However, in high-risk patients with a soft pancreas, invagination may reduce the risk of clinically relevant POPF compared with duct-to-mucosa. Registration number: UMIN000005890 (http://www.umin.ac.jp).

Down-regulation of the two-component system and cell-wall biosynthesis-related genes was associated with the reversion to daptomycin susceptibility in daptomycin non-susceptible methicillin-resistant Staphylococcus aureus.

Daptomycin (DAP) is widely used in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infection. The emergence of DAP non-susceptible MRSA strains during therapy is a major concern in clinical settings. Recent studies revealed that MRSA spontaneously reverts to a subsequent methicillin-susceptible S. aureus (MSSA) strain. However, it is not clear whether DAP non-susceptible MRSA has the ability to revert to a susceptible strain. We obtained an MRSA strain pair, DAP non-susceptible strain and subsequent DAP susceptible strain, from a patient. To understand the underlying mechanism by which DAP non-susceptible MRSA reverts to a susceptible strain, we performed genetic and phenotypic analysis in the strain pair. Although whole-genome analysis revealed four missense mutations, including L826F in mprF, in both strains, the net cell-surface charge was similar between the DAP non-susceptible and susceptible strains. However, the thickness of the cell wall was higher in the DAP non-susceptible strain, which was decreased to the same level as the control after reversion to the DAP susceptible strain. Moreover, the non-susceptible strain showed higher mRNA expression of the two-component system (TCS), such as VraSR, yycG and GraS, with the up-regulated transcription levels of cell-wall biosynthesis-related genes. The expression levels of those genes were decreased after reversion to the susceptible strain. These results indicated that DAP non-susceptibility due to up-regulation of the TCS and cell-wall biosynthesis-related genes may be reversible by the discontinuation of DAP, leading to reversion to the DAP susceptible phenotype.

Hydrogen nanobubble at normal hydrogen electrode.

Electrochemically formed hydrogen nanobubbles at a platinum rotating disk electrode (RDE) were detected by re-oxidation charge. The dissolution time course of the hydrogen nanobubbles was measured by AFM tapping topography under open-circuit conditions at stationary platinum and gold single-crystal electrodes. The bubble dissolution at platinum was much faster than that at gold because two types of diffusion, bulk and surface diffusion, proceeded at the platinum surface, whereas surface diffusion was prohibited at the gold electrode. These findings indicated that the electrochemical reaction of normal hydrogen electrode partly proceeded heterogeneously on the three-phase boundary around the hydrogen nanobubble.

Multiplex PCR using internal transcribed spacer 1 and 2 regions for rapid detection and identification of yeast strains.

Multiplex PCR amplification followed by either agarose gel electrophoresis (PCR-AGE) or microchip electrophoresis (PCR-ME) was used to test a total of 120 fungal strains. The internal transcribed spacer 1 (ITS1) and ITS2 regions and the 5.8S ribosomal DNA (rDNA) region of the fungi were amplified by using universal primers ITS1 and ITS4. The ITS2 region was simultaneously amplified by using universal primers ITS3 and ITS4. Since Trichosporon asahi and T. asteroides showed similar lengths for two amplicons, 29 different gel patterns were demonstrated for 30 yeast species tested on the basis of differences in the lengths of one or two amplicons. Of 75 yeast isolates from clinical materials, 5 isolates (6.8%) which were incompletely identified or not identified by the phenotypic method were identified with our PCR-based method (2 isolates as Candida guilliermondii, 2 as C. krusei, and 1 as C. zeylanoides). No differences in discriminating power or sensitivity were observed between the PCR-AGE method and the PCR-ME method. These methods, prospectively applied to 24 yeast-positive blood culture bottles (16 patients), resulted in the correct detection of 24 yeast strains. In conclusion, multiplex PCR followed by electrophoresis seems to be a promising tool for the rapid identification of common and uncommon yeast strains from culture colonies and from yeast-positive blood culture bottles (5.5 h for the PCR-AGE method and 3 h for the PCR-ME method).

The conformational study of chitin and chitosan oligomers in solution.

The inter-residual dihedral angles phi and phip of chitin and chitosan oligomers were determined from experimental 3J(C-H) constants and ROESY cross peaks.

[Clinical evaluation of serum 1,5AG levels in patients with liver cirrhosis].

We measured serum 1,5 anhydroglucitol (1,5AG) levels by HPLC in 32 patients with liver cirrhosis, 32 with diabetes mellitus and 61 normal subjects. Serum 1,5AG was significantly lower in patients with diabetes mellitus and liver cirrhosis compared with that in normal subjects. Serum levels of type IV collagen were higher in patients with liver cirrhosis than in those without liver cirrhosis. A negative correlation was observed between serum 1,5AG and type IV collagen in patients with liver cirrhosis (r = -0.37, p < 0.05), but not in patients with diabetes mellitus. These data suggest that serum 1,5AG levels reflect the degree of liver cirrhosis.

[Nine cases of spontaneous hemopneumothorax with massive bleeding].

We experienced nine cases of spontaneous hemopneumothorax. All the patients were male and six of those had received emergent operations because of massive intrathoracic bleeding. In six of the nine cases we found the bleeding from the ruptured string like tissues between parietal pleura and the apex of the upper lobe. Those string like tissues contained vessels and were suspected to have ruptured when the lung collapsed. In other three cases the bleeding was controlled conservatively but operations were performed because of continuous air leakage and the bleeding were found from the bullous apical tissues of the lung adhered to the thoracic wall. Histopathologically those bullous tissues and string like tissues were revealed grannuromatous and chronic pleuritis rich in microvessels. Early thoracotomy for spontaneous hemopneumothorax was recommended in case of massive intrathoracic bleeding.

[Infection control systems in the United States: its history and problems].

The purpose of this study is to review recent literature regarding the role of the infection control nurse in the United States. Recent relevant literature, published between 1982 and 1995, was selected by using a computerized literature search, cumulative index to nursing and allied health literature (CINAHL). Four major points in the development of infection control practitioners (ICPs) were identified from the literature review: (1) Since the late 1960s the number of ICPs had increased continuously, through the Center for Disease control training programs, and through training programs developed by members of the Association for Professionals in Infection Control and Epidemiology (APIC) at the national, regional and local chapter levels. (2) The ICPs became certified upon receiving satisfactory results on the infection of 2 years of work in the field of infection control, and then are authorized to use the title "CIC". The certification was valid for five years and is renewed after the ICP passed a re-examination. (3) Six duties of the ICP were identified: management, prevention, surveillance, identification, education, and research. (4) The cost of health care was constantly restructuring the health care delivery system in the United States. The ICPs also were influenced by these changes. New challenges facing ICPs today were, a) the integration of resources to be shared by infection control and quality assurance, b) the change of role from specialist to generalist, c) the expansion of their roles in the area of epidemiology.

[Estimation of anti-thyroid peroxidase autoantibody (TPOAb) and anti-thyroglobulin autoantibody (TgAb) in patients with various thyroid disease--comparison between histopathological findings and serological results in patients with Hashimoto's thyroiditis].

We compared and evaluated titers of AMC (anti-microsome antibody), and ATG (anti-thyroglobulin antibody) by passive gelatin-agglutination and by radioimmunoassay in 170 sera from 129 patients with various thyroid diseases and 41 normal subjects. The results of conventional ATG and TgAb by RIA correlated (r = 0.731) and those of conventional AMC and TPOAb correlated well (r = 0.907), with discrepancies mostly limited to sera with low antibody titers. Five patients with Hashimoto's thyroiditis showed positive results in AMC, whilst negative in TPOAb. These sera had positive ATG autoantibody and preincubation with thyroglobulin inhibited the agglutination reaction of AMC tests, suggesting ATG producing false positive results in AMC assay. The prevalences of positive TgAb rates were higher than (p < 0.001) ATG in patients with Hashimoto's disease (96.6% vs 50.0%) and Graves' disease (76.9% vs 46.1%). However, the prevalences of positive TPOAb were not different from AMC (Hashimoto's disease 75.9% vs 81.0%: Graves' disease 80.8% vs 76.9%). In patients with Hashimoto's thyroiditis, our study demonstrates the results of TgAb by RIA reflects the pathological findings and the diagnostic sensitivity increases by using in combination with TPOAb.

[A case of miliary tuberculosis with skull tuberculosis].

A 47-year old woman was admitted to our hospital with complaints of headache and right occipital swelling. Brain CT scan showed right occipital bone defect with a sequestrum and soft tissue swelling. T1 weighted MRI enhanced by GD-DTPA revealed several nodules. A right occipital craniotomy was performed. Subcutaneous pus and a well-circumscribed yellowish, firm mass which existed under the bone defect was extirpated. Pathologically, this mass was considered to be a tuberculoma and intracranial nodules were suspected to be cerebral tuberculosis. Anti-tuberculous therapy was started. Since her admission fecal occult blood continued and endoscopic examination with biopsy revealed sigmoid colon cancer. Sigmoidectomy was performed and she has been well during 1 year post-operative follow up. Although tuberculous disease are decreasing in number in our country, we must take into account of the existence of skull tuberculosis.

[Two cases of empyema treated with rectus abdominis myocutaneous flap and muscle flap].

A rectus abdominis myocutaneous flap (RAM flap) has often been useful in breast reconstructions after the surgical therapy for breast cancer, or in other plastic surgeries. However, there have been few reports concerning about its applications for intrathoracic diseases. In this paper, we report two cases of recurrent empyema treated with RAM flap and muscle flap from rectus abdominis. One case is 75-year-old male with right-empyema and bronchial fistula after the thoracoplasty due to lung tuberculosis. The bronchial fistula was successfully closed with muscle flap from the right rectus abdominis. The other is 33-year-old male with left empyema and cutaneous fistula after the hemothorax due to traffic accident. He contracted with MRSA in his thoracic cavity. We resected the fistula and reconstructed his left chest wall with left RAM flap. The muscle flap from rectus abdominis or RAM flap has been very effective for the therapy of bronchial fistula after lung tuberculosis, and for the reconstruction of chest wall.

[A case of pulmonary tuberculosis presenting with infected bulla].

A case of pulmonary tuberculosis manifested as infected bulla complicating with tuberculous pneumonia is reported. A 63-year-old male visited our hospital because of chest X-ray abnormality detected by his home doctor. He complained of pyrexia and productive cough. Chest X-ray showed large bulla with air-fluid level, associated with surrounding infiltration at right upper lobe. On the diagnosis of infected bulla empirical antibiotic therapy was started on out-patient basis and continued after admission, but chest X-ray findings worsened, although subjective symptoms were once relieved. Surgical intervention was recommended, but after short interval pulmonary infiltrates rapidly worsened and expanded to other lobes. Sputum was reexamined and Mycobacterium, later proved as Mycobacterium tuberculosis with DNA probe method, was detected in the sputum specimen. Anti-mycobacterial drugs were administered and subjective symptoms, laboratory, and chest X-ray findings improved. Infected bulla caused by Mycobacterium tuberculosis is rare, but when it is resistant to common empirical therapy, Mycobacterium tuberculosis should be considered as one of its causative agents.

[A case of generalized disseminated atypical mycobacteriosis caused by M. avium complex with a giant gravitation abscess].

A case of generalized disseminated atypical mycobacteriosis caused by M. avium complex (MAC) was reported. The case was a female of 52 years of age. She was admitted to our hospital due to high fever and polyarthralgia. Her chest X-ray and CT scan revealed infiltrative shadows in the right S2b and S4 segments, and multiple accumulation shadows were seen on osteoscintigraphy. Pus aspirated from a lesion of the right fifth rib were acid-fast bacilli positive by smear (Gaffky v). The administration of four drugs, INH, RFP, EB and SM, was introduced, then corticosteroid was added, and the case became afebrile. Later, acid-fast bacilli were also isolated from bronchial washing and aspirated specimen from bone marrow, and all of them were identified as MAC. Based on these findings, the case was diagnosed as generalized disseminated mycobacteriosis. After several months remission, tenderness over the fifth lumbar vertebra deteriorated, and MRI scan on lumbar vertebrae showed high-intensity area both on T1-weighted and T2-weighted images. MAC was isolated from the pus of the fifth lumbar vertebra. Lumbar lesions deteriorated gradually, and a giant gravitation abscess which involved right ilium was revealed by CT scan of the pelvis. In spite of vigorous treatment including chemotherapy, aspiration of pus and drainage, general condition of the case deteriorated, and the case finally died of renal insufficiency.

[Successful surgery for pulmonary aspergillosis progressing to subacute process].

A 59-year-old woman with diabetes and rheumatoid arthritis was given prednisolone following the diagnosis of rheumatoid lung disease. She developed fever and bloody sputum, and chest X-ray showed a massive shadow in the right lower lung field. Chest CT revealed a giant massive shadow with unclear margin in the right posterior lower lobe. With enhancement, a round low density area appeared in the shadow. Aspergillus hyphae were detected from a bronchial brushing specimen. Pulmonary aspergillosis was diagnosed administration of anti-fungal agents was commenced but the improvement was not satisfactory. Surgical resection, which may be curative, was subsequently performed. The resected lung contained an aspergillus ball formation within an enlarged bronchus, that is, a bronchial aspergilloma, surrounded by widespread inflammatory cell infiltration. Most pulmonary aspergillomas are of the "colonization type", but in our case progression to subacute process occurred according to the extent of our patient's immunological reaction. For the treatment of localized pulmonary aspergillosis, our results suggest that surgery is recommended.

[Evaluation of type IV collagen in patients with various thyroid disease].

Serum level of type IV collagen was measured in 104 patients with various thyroid disease, and the relationship between its level and thyroid hormone level was examined. The type IV collagen was measured by the method of one step sandwich enzyme immunoassay (EIA) using two distinct monoclonal antibodies recognized triple-helical (TH) domain and 7-S domain, respectively. The serum level of type IV collagen was significantly high in the hyperthyroid patients compared with that in normal controls, and a significant positive correlation was found between its value and thyroid hormone levels (T3, T4, FT3, FT4). The elevated level of type IV collagen in hyperthyroid patients was decreased to normal level, when they became to euthyroid after antithyroid drug therapy for hyperthyroidism. The serum level of type IV collagen was in normal range in hypothyroid patients, but the value was increased to high normal range after T4-replacement therapy for hypothyroidism. This evidence indicates that the serum level of type IV collagen is closely related to thyroid hormone level in patient with various thyroid disease. Type IV collagen concentration might be one of the useful variables for evaluating the thyroid function, although its mechanism is not elucidated.

[Study of washout rate in patients with chronic renal failure by dipyridamole 201Tl myocardial scintigraphy--comparison with hypertrophic cardiomyopathy].

Fourteen patients with chronic renal failure (CRF) were studied by dipyridamole 201Tl myocardial scintigraphy. In this study, patients with coronary heart disease were excluded by clinical findings. 201Tl SPECT was performed at 8 min after injection of dipyridamole (0.56 mg/kg) and at a 3-hr delayed interval, and washout rates (WR) were calculated. Because UCG showed left ventricular hypertrophy (thickness; 13 +/ 2 mm) in CRF, the WR values were compared with those of hypertrophic cardiomyopathy (HCM) (n = 9). In CRF, an average WR was 54.2 +/- 6.8% and was significantly higher than that in normal (46.2 +/- 9.1%, p < 0.05, n = 9), though WR in HCM was significantly low (26.9 +/- 11.4%, p < 0.01). Hematocrit value was 24.5 +/- 3.2% in CRF and was significantly lower than that in normal (37.8 +/- 3.6%, p < 0.001). On the other hands, hemoconcentration was observed in HCM (hematocrit; 44.6 +/- 3.6%, p < 0.001). WR in CRF, HCM and normal had significant correlation with hematocrit values (r = -0.796, p < 0.001). These results suggest that anemia or hemoconcentration may affect coronary blood flow and WR, and this should be considered when diagnosing coronary heart disease in CRF or HCM.

[Therapeutic efficacy of imipenem/cilastatin sodium on respiratory tract infections in lung cancer patients].

Imipenem/cilastatin sodium (IPM/CS) was used to treat respiratory tract infections (RTI) in 54 patients with lung cancer. Out of the 54 patients studied, 53 were evaluable for the utility of IPM/CS; 42 had pneumonia, 9 had obstructive pneumonia, 1 had a lung abscess and 1 had acute bronchitis. The efficacy rate was 71.7%. Seventeen causative organisms were isolated from 14 patients. They included Staphylococcus aureus 5 strains, Staphylococcus epidermidis 4 strains, Staphylococcus sp. 2 strains, Enterococcus faecalis 1 strain, Pseudomonas aeruginosa 2 strains, Pseudomonas fluorescens 2 strains, Acinetobacter sp. 1 strain, and the eradication rate was 81.8%. Clinical adverse effects (nausea and vomiting) were observed in 1 patient. Abnormalities in laboratory test results were observed in 3 patients. They disappeared or returned to normal values after completion of therapy or discontinuation of IPM/CS administration. IPM/CS appears to be a useful antibiotic for RTI in patients with lung cancer.

ECG-gated cardiac scan and echocardiographic assessments of left ventricular hypertrophy: reversal by 6-month treatment with diltiazem.

Serial changes of left ventricular (LV) mass and LV function were evaluated in nine patients with essential hypertension and LV hypertrophy (LVH) after administration of diltiazem (180 mg/day). LV mass and LV function were determined at baseline and at 6 months of therapy by electrocardiogram-gated cardiac CT (ECG-gated CCT) scanning and two-dimensional-guided M-mode echocardiography. At baseline measurements, ECG-gated cardiac scanning clearly showed LVH in two patients in whom no LVH was observed by echocardiography. The systolic and diastolic blood pressures were reduced significantly after 6 months of drug therapy (189-156 mm Hg; p less than 0.01, 111-96 mm Hg; p less than 0.01, respectively). Sequential ECG-gated cardiac scanning revealed a marked reduction in thickness of the interventricular septum (IVS), LV anterior wall (AW), and LV posterior wall (PW) (15.0-12.1 mm; p less than 0.01, 12.5-9.7 mm; p less than 0.01, 10.7-8.3 mm; p less than 0.05, respectively). Simultaneous echocardiographic measurements revealed a reduction in LV mass in six of these patients and a significant reduction in thickness of the IVS (12.1-11.0 mm; p less than 0.05). ECG-gated cardiac scanning demonstrated significant reductions in the thickness of the LVAW, which are difficult to detect by echocardiography. Diltiazem had no effect on the ejection fraction (EF) measured by both methods. In conclusion, ECG-gated cardiac scanning allowed more accurate diagnosis and quantitation of LVH than conventional echocardiography, and LVH in patients with essential hypertension could be reversed by the administration of diltiazem.

[Echo guided percutaneous needle biopsy for diagnosis of thoracic lesions].

Echo guided percutaneous needle biopsy was performed in 32 cases with thoracic lesions. A definitive diagnosis was made histopathologically in 11 (100%) of 11 malignancies, 4 (67%) of 6 benign tumors and 7 (47%) of 15 inflammatory lesions. Furthermore, using cytological specimens, definitive diagnosis was successfully made in 10 (91%) of 11 malignancies and 1 (17%) of 6 benign tumors. Such highly accurate diagnostic rates were due to 1) the accurate puncture of the lesions under real time sonographic guidance, 2) repeated biopsy in case in which sample was inadequate for cytological diagnosis, and 3) aggressive application of needle biopsy for histopathological diagnosis. Following this procedure, three patients suffered from a minor pneumothorax. To prevent pneumothorax, great care is necessary, especially in high risk cases, such as with a pneumatic pattern and thin lesion. One patient suffered from minor hemoptysis but recovered without any medication. No complications were noticed in cases of extrapulmonary lesions. We conclude that echo guided percutaneous needle biopsy is not only a complementary method for biopsy of mediastinal, peripheral pulmonary and chest wall lesions, but due to its simplicity and convenience, it should be a routine method for biopsy of thoracic lesions.