Displaced Intra-Articular Calcaneal Fractures: Evaluation of Clinical and Radiological Outcome Following Open Reduction and Internal Fixation with Locking Branched Calcaneal Plate.

Background An introduction of the World Health Organization Surgical Safety Checklist (WHO SSC) is essential to promote surgical safety. Objective To obtain country-specific information regarding the checklist in a leading medical institution in Nepal. Method The present research was a cross-sectional study with a survey conducted among healthcare professionals working in the operation theatre at the Tribhuvan University Teaching Hospital (TUTH) in Kathmandu, Nepal. A questionnaire was distributed to 150 healthcare professionals working in the operating theatre. Responses to the questionnaire were analysed descriptively and regression analyses used to identify factors associated with awareness of the checklist. Result In total, 127 healthcare professionals participated in the study, of whom 118 (92.9%) had been aware of the WHO SSC. A substantial proportion of participants (108, 91.5%) were not satisfied with the prevailing practice whereby the checklist was not routinely used during surgery. Lack of appropriate training was the most prevalent barrier to the checklist use (72, 67.9%), followed by unwillingness of staff to use the checklist (54, 50.9%), and lack of experience (42, 39.7%). The mean score on the survey was 6.0 out of 10. Regarding the results of the regression model on survey scores, surgeons had higher scores compared to nurses (unadjusted coefficient 0.80, 95% CI 0.20-1.40). Conclusion Most of the healthcare professionals were aware of the WHO SSC, however multiple barriers to the checklist use were identified. It is important to establish an effective use of WHO SSC in the operation theatre.

Mycobacterium avium genotype is associated with the therapeutic response to lung infection.

Factors that can interfere with the successful treatment of Mycobacterium avium lung infection have been inadequately studied. To identify a potent predictor of therapeutic responses of M. avium lung infection, we analyzed variable number tandem repeats (VNTR) at 16 minisatellite loci of M. avium clinical isolates. Associations between the VNTR profiling data and a therapeutic response were evaluated in 59 subjects with M. avium lung infection. M. avium lung infection of 30 subjects in whom clarithromycin-containing regimens produced microbiological and radiographic improvement was defined as responsive disease, while that of the remaining 29 subjects was defined as refractory disease. In phylogenetic analysis using the genotypic distance aggregated from 16-dimensional VNTR data, 59 M. avium isolates were divided into three clusters, which showed a nearly significant association with therapeutic responses (p 0.06). We then subjected the raw 16-dimensional VNTR data directly to principal component analysis, and identified the genetic features that were significantly associated with the therapeutic response (p <0.05). By further analysis of logistic regression with a stepwise variable-selection, we constructed the highest likelihood multivariate model, adjusted for age, to predict a therapeutic response, using VNTR data from only four minisatellite loci. In conclusion, we identified four mycobacterial minisatellite loci that together were associated with the therapeutic response of M. avium lung infections.

Clinical evaluation of the QuantiFERON-TB Gold test in patients with non-tuberculous mycobacterial disease.

OBJECTIVE: To evaluate the clinical usefulness of the QuantiFERON TB-2G (QFT-2G) test in patients with non-tuberculous mycobacterial (NTM) disease without a previous history of tuberculosis (TB). METHODS: The study consisted of 214 patients with NTM disease who satisfied the diagnostic guidelines of the American Thoracic Society. RESULTS: The causative microorganism was Mycobacterium avium in 83 patients, M. intracellulare in 80, M. kansasii in 33, M. marinum in 12, M. szulgai in 3, M. abscessus in 2 and M. chelonei in 1. The positive response rate of QFT-2G test result was 2% in 163 patients with M. avium-intracellulare complex (MAIC) disease, 52% in 33 with M. kansasii disease, 58% in 12 with M. marinum disease, 33% in 3 with M. szulgai disease, 0% in two with M. abscessus disease and 0% in one with M. chelonei disease. The positivity of the QFT-2G test was 52% in patients with NTM disease, thought to be because NTM possesses common M. tuberculosis-specific antigens. CONCLUSIONS: Although QFT-2G may be a useful diagnostic method to differentiate TB from MAIC disease, there are several problems to be resolved before it can be used as a diagnostic method for NTM disease (M. kansasii disease), including the determination of the positive cut-off level for QFT-2G test.

Indeterminate results of QuantiFERON TB-2G test performed in routine clinical practice.

The present authors assessed risk factors that can promote indeterminate results of QuantiFERON TB-2G (QFT-2G; Cellestis Ltd, Carnegie, Australia) tests. The subjects were 704 patients with suspected tuberculosis (TB) and latent TB infection between January 2005 and December 2007. The QFT-2G test and the tuberculin skin test (TST) were performed for all subjects. If the results of the QFT-2G test were indeterminate, the test was repeated within 1 month. In total, 72 (10.2%) patients showed indeterminate results on the QFT-2G test. Indeterminate results were due to positive control failure in 68 (88.9%) patients and negative control failure in four patients. The results of the TST were negative for 64 patients showing indeterminate results, the remaining eight patients showed a positive response to the TST. Indeterminate results were significantly associated with elderly and immunocompromised patients. Lymphocytopaenia and hypoalbuminaemia were significantly associated with indeterminate laboratory findings. When the QFT-2G test was repeated for all patients showing indeterminate results, 12 (16.7%) patients demonstrated determinate results on the subsequent test. Indeterminate results of the QuantiFERON TB-2G test under routine clinical practice are not infrequent. When scoring QuantiFERON TB-2G test results for elderly and immunocompromised patients, one must be careful because the possibility of obtaining determinate results may be low even if the test is repeated.

Clinical evaluation of QuantiFERON TB-2G test for immunocompromised patients.

The usefulness of the tuberculin skin test (TST) and the QuantiFERON TB-2G (QFT-TB) test were compared in immunocompromised patients. The subjects consisted of 252 immunocompromised patients who were clinically suspected of tuberculosis (TB) infection between April 2005 and December 2006. Regarding the underlying diseases, 74 subjects had malignant diseases, 72 were undergoing immunosuppressive treatment, 52 had diabetes mellitus, 50 had chronic renal failure and four had HIV infection. While the positive rate of the QFT-TB test for the diagnosis of TB infection (TB disease or latent TB infection) was 78.1%, that of TST for TB infection was 50.0%. The QFT-TB test was significantly better than TST. However, 32 (13%) patients had an indeterminate QFT-TB result. Indeterminate findings were significantly more frequent in patients receiving immunosuppressive treatment (28%), especially with lymphocytopaenia in the peripheral blood, than in those who had other underlying diseases. While TST-positive and QFT-TB test-negative results were recognised in immunocompromised patients with bacille Calmette-Guérin vaccination or nontuberculous mycobacterial disease, TST-negative and QFT-TB test-positive results were recognised in immunocompromised patients with a past history of TB infection. It was concluded that the QuantiFERON TB-2G test is a more useful diagnostic method for tuberculosis infection than tuberculin skin test for immunocompromised patients suspected of tuberculosis disease. However, because the results of the QuantiFERON TB-2G test show an indeterminate response for patients receiving immunosuppressive treatment, especially for those with lymphocytopaenia due to severe underlying diseases, care must be taken in the interpretation of the QuantiFERON TB-2G test for these patients.

Cystic adenomyosis with florid glandular differentiation mimicking ovarian malignancy.

We report a case of cystic adenomyosis, presenting as a huge exophytic cystic mass with florid glandular differentiation. MR findings of the mass mimicked ovarian carcinoma associated with endometriosis. The presence of signal voids bridging the uterus and tumour should suggest a mass of uterine origin. Hyperintense protuberance in a hypointense loculus on T(2) weighted images may suggest benign disease. However, surgical exploration and resection is still required to exclude an ovarian malignancy.

[Occurrence of BOOP outside radiation field after radiation therapy for small cell lung cancer].

We report a case of bronchiolitis obliterans organizing pneumonia (BOOP) that occurred outside the radiation field after radiation therapy for small cell lung cancer. A 74-year-old woman received chemotherapy and a total of 60 Gy of radiation therapy to the right hilum and mediastinum for small cell carcinoma of the suprahilar area of the right lung. Radiation pneumonitis developed within the radiation port 3 months after the completion of radiation therapy. She complained of cough and was admitted 7 months after completion of the radiation therapy. Chest radiography and computed tomography demonstrated peripheral alveolar opacities outside the radiation field on the side contralateral to that receiving the radiation therapy. Bronchoalveolar lavage showed that the total cell count was increased, with a markedly increased percentage of lymphocytes. Transbronchial lung biopsy revealed a histologic pattern consistent with BOOP. Treatment with corticosteroids resulted in rapid improvement of the symptoms and complete resolution of the radiographic abnormalities of the left lung. Although some cases of BOOP following radiation therapy for breast cancer have been reported, none of BOOP after radiation therapy for lung cancer have appeared in the literature.

Thin-section CT features of intrapulmonary lymph nodes.

PURPOSE: The objective of this study was to evaluate CT findings of pathologically proven intrapulmonary lymph nodes (IPLNs) and discuss the utility of thin-section CT and contrast-enhanced CT. METHOD: CT findings of 18 nodules in 14 patients with pathologically proven IPLNs were reviewed. CT scanning of the whole lung was performed contiguously with slice thickness of 10 mm. In addition, a helical scan with slice thickness of 2 mm was performed in nine patients, focusing on the nodule. Contrast-enhanced helical CT was performed in four patients, and the utility of thin section CT and contrast-enhanced CT was investigated. RESULTS: One patient had three nodules, 2 patients had two nodules, and the remaining 11 patients had a solitary nodule. All nodules were located below the level of the carina and within 15 mm of the pleura. In one case, conventional CT revealed the nodule 20 mm away from the pleura; however, the nodule attached to the major fissure was clearly revealed on thin-section CT. The size of the nodules was < or =15 mm, and the shape was round (n = 8), oval (n = 9), or lobulated (n = 1) with sharp border. One nodule demonstrated a spiculated border due to a surrounding pulmonary fibrosis on conventional CT; however, thin-section CT showed precisely a sharp border. The lobulated shape of one case histopathologically reflected a hilus of lymph node. On contrast-enhanced helical CT, all four nodules were enhanced and the degree enhancement was 36-85 HU (median 66.6 HU). CONCLUSION: In current times, IPLNs are not uncommon lesions. We should consider IPLN in the differential diagnosis of solitary or multiple pulmonary nodules in the peripheral field and below the level of the carina. Thin-section CT showed precisely the border or relation between IPLNs and the surrounding structure. It was difficult to distinguish between IPLNs and malignant nodules from the degree of enhancement on contrast-enhanced CT. On thin-section and contrast-enhanced CT, the findings of IPLNs are not necessarily specific. Therefore, strict observation on CT is necessary; in certain cases that are increasing in size, video-assisted thoracic surgery should be considered because of their location.

Clinical analysis of community-acquired pneumonia in the elderly.

OBJECTIVE: To evaluate the clinical features, etiology, and outcome of patients over 65 years old hospitalized for community-acquired pneumonia. PATIENTS: Eighty-four patients (50 males, 34 females) hospitalized for community-acquired pneumonia in Kawasaki Medical School Kawasaki Hospital between April 1998 and March 2000. RESULTS: Most of the patients had respiratory symptoms or signs, but over one-third also had atypical symptoms of pneumonia such as dyspnea, consciousness disturbance, and gastrointestinal symptoms. The causative microorganisms were identified in 48% of these patients. Streptococcus pneumoniae (13%), respiratory viruses (13%), Haemophilus influenzae (8%) and Mycobacterium tuberculosis (8%) were frequently identified, but Mycoplasma pneumoniae was less frequently noted in the elderly. Double infection was recognized in 19 % and a combination of some virus and bacteria in 13%. Treatment consisted of the administration of second or third generation cephalosporin antibiotics intravenously, because antibiotics had already been preadministered in 39%. The prognosis was poor (mortality rate 9%) for the elderly with community-acquired pneumonia despite mechanical ventilation in 8%. CONCLUSIONS: Although the range of microorganisms causing community-acquired pneumonia differed slightly from that in previous reports; namely, lower frequency of Chlamydia pneumoniae and Legionella pneumophila, it is suggested that the initial antibiotic treatment should always cover S. pneumoniae and H. influenzae. In addition, since a prevalence of virus infections related to the increase in community-acquired pneumonia in the elderly was found in this study, the routine use of influenza vaccine and pneumococcal vaccines in the elderly is recommended to reduce the high mortality rate.

[Clinical analysis of community-acquired pneumonia and pulmonary tuberculosis in the elderly and advances in treatment].

We treated 510 elderly case (over 65 years old) among 1,017 patients with community-acquired pneumonia and 60 similar cases among 112 patients with pulmonary tuberculosis in Kawasaki Medical School Kawasaki Hospital during approximately the past 15 years. These were compared with non-elderly cases (below 65 years old). In the elderly cases with community-acquired pneumonia, atypical clinical symptoms or physical signs were frequent and the mortality rate was high because of severe underlying diseases, and poor general and nutritional conditions. Regarding a prospective study of 84 elderly cases with community-acquired pneumonia during the past two years, S. pneumoniae, Respiratory virus, Gram-negative bacilli, H. influenzae, M. Tuberculosis were frequently isolated. In addition, mixed viral and bacterial infections, which were frequently noted during the winter, were significantly related to the increased frequency of community-acquired pneumonia. In treating elderly cases with community-acquired pneumonia, immunization therapy (e.g., influenza vaccine), second cephalosporin and/or macrolide antimicrobial agents for outpatients with mild pneumonia, and carbapenem and/or macrolide antimicrobial agents for hospitalized patients with moderate or severe pneumonia were most effective. The number of elderly cases with pulmonary tuberculosis has recently increased and the recognition of 10 cases was delayed because of a low percentage of positive smears, but no resistance to antituberculosis drugs have been observed. Regarding the treatment of pulmonary tuberculosis, fluoroquinolone and rifamycin derivative antibiotics have been developed as antituberculosis drugs with strong antituberculous activity. However, due to the high percentage of adverse effects in elderly patients, careful treatment with desensitization therapy for antituberculosis drugs is considered important.

Breast conservation for huge-sized locally advanced breast cancer: a case report.

A 35-year-old woman with locally advanced stage IIIB breast cancer (medullary carcinoma) 12 cm in diameter underwent neoadjuvant chemotherapy consisting of three courses of intraarterial infusion [adriamycin (ADR), mitomycin (MMC), cisplatin (CDDP), 5-fluorouracil (5FU)] and four cycles of systemic chemotherapy (ADR, epirubicin, cyclophosphamide, MMC, CDDP) for three months. The tumor markedly diminished after the first course of intraarterial infusion chemotherapy, with a 3-cm tumor remaining after the completion of preoperative administration. Pathologically complete response was noted in specimens resected following breast conservation surgery. Postoperative radiotherapy was added and adjuvant chemohormonal therapy was continued for two years. The patient is alive without recurrence and has been able to conserve the breast for the past eight years, neoadjuvant chemotherapy including intraarterial infusion enabled breast conservation treatment even for huge-sized locally advanced breast cancer.

[Clinical analysis of patients with community-acquired pneumonia caused by a mixed infection of polymicrobial agents--including a comparative study of an infectious group with monomicrobial agents and an infectious group with unknown agents].

We clinically analyzed 83 patients with community-acquired pneumonia caused by a mixed infection of polymicrobial agents who we have treated during the past 15 years. A comparative study among three groups; an infectious group with polymicrobial agents (83 cases), an infectious group with monomicrobial agents (335 cases), and an infectious group with unknown agents (599 cases) was performed. The results were as follows; (1) The highest percentage of patients were elderly and bedridden. (2) Striking atypical pneumonic symptoms, including dyspnea, consciousness disturbance, gastrointestinal symptoms and hypotension (shock) were present. (3) Laboratory findings of poor nutritional conditions, including decreases in serum protein, albumin, and cholineesterase, and hypoxia remarkably increased. (4) The prognosis was poor because the mortality rate (15.7%) was higher. (5) There were two polymicrobial agents for 75 patients and three agents for 8 patients. The coupling of polymicrobial agents was most frequent in five patients with Haemophilus influenzae + MSSA and five with H. influenzae + respiratory virus. These results suggest that the patients with community-acquired pneumonia caused by a mixed infection of polymicrobial agents had clinical features and causative microorganisms resembling those of elderly patients with community-acquired pneumonia. We recommended that treatment with antibiotics for them was adequate if the treatment resemble that of elderly patients.

[Clinical analysis of patients with community-acquired pneumonia requiring hospitalization classified by age group].

We classified 1017 patients with community-acquired pneumonia requiring hospitalization experienced in Kawasaki Medical School Kawasaki Hospital during the past 15 years into five age groups (< or = 54 years old, 55-64 years old, 65-74 years old, 75-84 years old, > or = 85 years old). With particular emphasis on the elderly patients, we then compared the clinical and microbiological findings in the five groups. The results were as follows; (1) Half of patients in the over 85 years old group were bed-ridden. (2) The proportion receiving antibiotics before hospitalization decreased with age. (3) There were striking atypical pneumonic symptoms, such as dyspnea and consciousness disturbance in the two age groups over 75 years old. (4) Hypotension (shock) increased with age. (5) Markers of nutritional conditions, such as serum protein, albumin, cholinesterase, and hypoxia remarkably increased in the two age groups over 75 years old. (6) There were no significant differences in the isolation rate of etiological microorganisms. (7) The number of polymicrobial agents in the < or = 54 years old group was lower than that in the other age groups. (8) Mycoplasma pneumoniae was most significantly higher in < or = 54 years old group, Haemophilus influenzae in patients 55-64 years old, and Streptococcus pneumoniae in both 65-74 and 75-84 years old groups. (9) The isolation rate of MSSA, gram-negative bacilli such as Klebsiella pneumoniae, Pseudomonas aeruginosa, respiratory viruses increased with age. (10) The amount of sepsis increased with age. (11) The prognosis was poor in the two groups over 75 years old because the mortality rate (over 10%) was higher that for the other age groups.

[A case of rheumatoid lung disease in which lung involvement preceded arthritis].

A 75-year-old man was admitted because of dyspnea on exertion and diffuse pulmonary interstitial shadows. An open lung biopsy revealed unclassified interstitial pneumonia. The abnormal shadow subsided spontaneously. Three years later, however, rheumatoid arthritis developed with a simultaneous relapse of interstitial pneumonitis, which was alleviated by steroid therapy. We report here the rheumatoid lung disease that preceded the onset of arthritis, together with a review of the literature.

Intraarterial infusion chemotherapy and radiotherapy with or without surgery for patients with locally advanced or recurrent breast cancer.

We analyzed response, side effects, and local control rates of a multimodal treatment consisting of intraarterial infusion chemotherapy (IAIC) and radiotherapy with or without surgery for patients with locally advanced or recurred breast cancer. Thirty-three patients, clinically diagnosed as stage IIB in 1, IIIA in 2, IIIB in 12, IV in 18, were treated from 1991 to 1998. Twenty-five were primary and eight were recurrent cases after surgery. IAIC started as initial treatment up to three times maximum. In most cases, doxorubicin 50 mg, cisplatin 50 mg, and mitomycin 10 mg were infused in the subclavian and/or internal mammary artery. After IAIC, patients in primary cases underwent radical mastectomy or breast conservation surgery, after radiotherapy at a total dose of 50 Gy/25 fractions/5 weeks with a boost of 10 Gy. In recurrent cases, a full dose of radiotherapy was delivered. Clinical objective and complete response rates were 78% and 9% after IAIC. Despite a high rate of residual positive margin (67%) or clinically residual carcinoma, local recurrence developed only in 2 patients (6%) and local control rates at 5 years were calculated as 89%. Bone marrow suppression was frequent, and skin vesiculation (15%) and ulceration (9%) were experienced after IAIC. Skin ulcer (6%), brachial plexus neuropathy (3%), and radiation pneumonitis (3%) occurred as late toxicity. IAIC was effective as an induction treatment and radiotherapy played a role of local control for patients with locally advanced or recurrent breast cancer.

Gynecologic malignancies accompanied by benign hormone-dependent diseases.

OBJECTIVE: To investigate the correlation between benign gynecologic diseases and hormone-dependent malignancies such as endometrial carcinoma in postmenopausal women. DESIGN: We retrospectively analyzed the prevalence of myoma uteri and adenomyosis uteri in 136 cases of endometrial carcinomas. We used 222 uterine prolapse cases as controls. RESULTS: The results showed that 21.6% and 9.9% of healthy postmenopausal women (control) had myoma uteri and adenomyosis uteri, respectively, after the cessation of menses. However, postmenopausal women with endometrial carcinomas had a 1.5- to 2-fold higher prevalence, respectively, for myoma uteri and adenomyosis uteri as compared with the postmenopausal control women. CONCLUSION: There was a higher prevalence of myoma uteri and adenomyosis uteri in postmenopausal patients with endometrial carcinomas than in the control population.

Fibrous tumor of the breast in a postmenopausal woman receiving estrogen.

Fibrous tumor of the breast is a rare, benign stromal proliferation with atrophy of the epithelial component. Almost all patients who develop fibrous tumors are premenopausal. An unusual example of fibrous tumor of the breast is reported in a 62-year-old postmenopausal woman. The mass, first noted 1 year previously, progressively enlarged over the year. The patient noted a history of taking exogenous estrogens for 10 years. Intense estrogen administration during the year of enlargement may be associated with accelerated growth of the tumor. In addition, positive nuclear staining for estrogen receptor antibodies in stromal cells was demonstrated by immunohistochemical methods.

[Comparison of community-acquired pneumonia in relation to influenza A and RS virus infections].

We experienced 142 cases with community-acquired pneumonia between April 1998 and March 2000. By measuring the titers of respiratory viruses for these cases, we were able to identify acute phase infections of influenza A virus in 10 cases and RS virus in 6 cases and determined that there was an increase in community-acquired pneumonia during both winter seasons. Thereafter we compared the clinical features of community-acquired pneumonia with regard to these two types of virus infection by dividing the patients into two groups, both of which frequently included in the elderly. In the influenza virus group, such general symptoms as high fever, headache and general fatigue were dominant. Common bacteria were isolated in nine cases with mixed infection; four of them with Streptococcus pneumoniae. In the RS virus group, there were fewer general symptoms and common bacteria were isolated in four cases with mixed infection; three with Haemophilus influenzae. The severity of the illness was greater in the Influenza virus group; i.e.) three cases required mechanical ventilation and two of these three cases died. In the RS virus group, on the other hand, the prognosis was good because no mechanical ventilation was required and there were no deaths. Influenza vaccination is especially important for the elderly, because the epidemiology of the influenza virus groups showed none had a history of influenza vaccination in this study.