Cross-contamination risk and decontamination during changeover after cell-product processing.

Introduction: During changeover in cell-product processing, it is essential to minimize cross-contamination risks. These risks differ depending on the patient from whom the cells were derived. Human error during manual cell-product processing increases the contamination risk in biosafety cabinets. Here, we evaluate the risk of cross-contamination during manual cell-processing to develop an evidence-based changeover method for biosafety cabinets. Methods: Contaminant coverage was analyzed during simulated medium preparation, cell seeding, and waste liquid decanting by seven operators, classified by skill. Environmental bacteria were surveyed at four participating facilities. Finally, we assessed the effect of conventional UV irradiation in biosafety cabinets on bacteria and fungi that pose a cross-contamination risk. Results: Under simulated conditions, scattered contamination occurred via droplets falling onto the surface from heights of 30 cm, and from bubbles rupturing at this height. Visible traces of contaminants were distributed up to 50 cm from the point of droplet impact, or from the location of the pipette tip when the bubble ruptured. In several facilities, we detected Bacillus subtilis, of which the associated endospores are highly resistant to disinfection. Irradiation at 50 mJ/cm2 effectively eliminated Bacillus subtilis vegetative cells and Aspergillus brasiliensis, which is highly resistant to UV. Bacillus subtilis endospores were eliminated at 100 mJ/cm2. Conclusions: Under these simulated optimal conditions, UV irradiation successfully prevents cross-contamination. Therefore, following cell-product processing, monitoring the UV dose in the biosafety cabinet during cell changeover represents a promising method for reducing cross-contamination.

Charcot Arthropathy of the Shoulder Joint in a Patient with Guillain-Barré Syndrome: A Case Report.

CASE: A 53-year-old woman presented with Charcot arthropathy of the shoulder joint secondary to residual sensory neuropathy of Guillain-Barré syndrome, which was accompanied by swollen shoulder and restricted range of motion of the right shoulder. We performed a reverse shoulder arthroplasty (RSA). The range of motion had improved 15 months postoperatively, and there was no postoperative complication after RSA. CONCLUSION: Clinicians should be aware that Guillain-Barré syndrome can cause Charcot arthropathy of the shoulder joint. RSA is regarded as a useful treatment, although careful follow-up is needed.

SAMD9 mutations cause a novel multisystem disorder, MIRAGE syndrome, and are associated with loss of chromosome 7.

Adrenal hypoplasia is a rare, life-threatening congenital disorder. Here we define a new form of syndromic adrenal hypoplasia, which we propose to term MIRAGE (myelodysplasia, infection, restriction of growth, adrenal hypoplasia, genital phenotypes, and enteropathy) syndrome. By exome sequencing and follow-up studies, we identified 11 patients with adrenal hypoplasia and common extra-adrenal features harboring mutations in SAMD9. Expression of the wild-type SAMD9 protein, a facilitator of endosome fusion, caused mild growth restriction in cultured cells, whereas expression of mutants caused profound growth inhibition. Patient-derived fibroblasts had restricted growth, decreased plasma membrane EGFR expression, increased size of early endosomes, and intracellular accumulation of giant vesicles carrying a late endosome marker. Of interest, two patients developed myelodysplasitc syndrome (MDS) that was accompanied by loss of the chromosome 7 carrying the SAMD9 mutation. Considering the potent growth-restricting activity of the SAMD9 mutants, the loss of chromosome 7 presumably occurred as an adaptation to the growth-restricting condition.

Laparoscopic Total Gastrectomy for Remnant Gastric Cancer Following Distal Gastrectomy with Radical Lymphadenectomy.

BACKGROUND/AIMS: In cases of remnantgastric cancer (RGC) with previous lymphadenectomy, laparoscopic total gastrectomy (LTG) is still uncommon because of the technical difficulties associated with adhesions from previous gastric cancer surgery and variations in anastomotic reconstruction. Here we demonstrate our procedure of LTG for RGC following distal gastrectomy (DG) with radical lymphadenectomy and review its clinical results. METHODOLOGY: From October 2008 to June 2014, we carried out three consecutive LTGs for RGC with previous lymphadenectomy. All cases had a past history of primary gastric cancer that had required open or laparoscopic DG with D2 radical lymphadenectomy. The preoperative TNM statuses of RGC were all cT1N0M0. RESULTS: All patients successfully underwent LTG without open conversion or intraoperative complications. The median operative duration was 360 min; the median blood loss was 45 mL. The median number of retrieved lymph nodes was 23. No complications occurred postoperatively, and the median length of postoperative hospitalization was 20 days. The pathological TNM statuses of the RGC were all T1N0M0. Resection margins were negative in all cases (R0). CONCLUSIONS: Our novel procedure of LTG for RGC following DG with radical lymphadenectomy is technically acceptable, safe, and feasible.

A modified overlap method using a linear stapler for intracorporeal esophagojejunostomy after laparoscopic total gastrectomy.

BACKGROUND/AIMS: Intracorporeal esophagojejunostomy represents the most difficult step during laparoscopic total gastrectomy (LTG). A novel technique for intracorporeal esophagojejunostomy was recently developed and named the "overlap method." However, this procedure is thought to have some technical disadvantages. To facilitate intracorporeal esophagojejunostomy, we developed some modifications for the overlap method. METHODOLOGY: From October 2009 to July 2013, 63 consecutive patients with gastric cancer underwent LTG at our institution. Our modified overlap method was used for 54 patients with the following modifications. First, the esophagus was transected while being rotated by approximately 90 degrees in the clockwise direction. Second, an endoscopic linear stapler was used through the right lower trocar to create a side-to-side esophagojejunostomy. Third, the entry hole of the linear stapler was closed with intracorporeal hand-sewn continuous suturing. This procedure was termed the "modified overlap method." RESULTS: In 53 patients with the exception of one case, the modified overlap method was successfully completed (98.1%). Only one patient developed esophagojejunal anastomotic leakage (1.9%), which recovered well with conservative management. No postoperative anastomotic stricture or bleeding occurred. CONCLUSIONS: Our modified overlap method for intracorporeal esophagojejunostomy provides amazingly satisfactory outcomes. We believe this procedure could become a standard method for intracorporeal esophagojejunostomy after LTG.

Clinical efficacy of macrolide antibiotics against genetically determined macrolide-resistant Mycoplasma pneumoniae pneumonia in paediatric patients.

BACKGROUND AND OBJECTIVE: Since 2000, the prevalence of macrolide-resistant (MR) Mycoplasma pneumoniae has increased among paediatric patients in Japan. To determine the efficacy of macrolides against MR M. pneumoniae pneumonia, microbiological and clinical efficacies were compared during the antibiotic treatment. METHODS: Samples from a total of 30 children with M. pneumoniae pneumonia, as confirmed by PCR and serology, were analyzed. Primers for domain V of 23S rRNA were used, and DNA sequences of the PCR products were compared with the sequence of an M. pneumoniae reference strain. RESULTS: Isolates from 21 patients demonstrated point mutations, and these patients were defined as MR. The remaining nine patients, whose isolates showed no point mutations, were categorized as control (macrolide-sensitive) patients. The number of M. pneumoniae in nasopharyngeal samples from the control group decreased rapidly 48 h after initiation of macrolide treatment and showed a close relationship with clinical outcome. In contrast, the number of M. pneumoniae 48 h after initiation of macrolide treatment were significantly higher in samples from MR patients than in samples from macrolide-sensitive patients. In 15 of 21 MR patients, fever persisted for more than 48 h after the initiation of macrolide treatment. When treatment was changed to minocycline, fever disappeared within 48 h in all these MR patients. There were no differences between MR patients who demonstrated a reduction in fever and those in whom fever persisted after 48 h of macrolide treatment. CONCLUSIONS: The microbiological and clinical efficacies of macrolides for treating patients with MR M. pneumoniae pneumonia were low. These results show that macrolides are clearly less effective in patients with MR M. pneumoniae pneumonia.

Evaluation of serological tests for diagnosis of Bordetella pertussis infection in adolescents and adults.

BACKGROUND AND OBJECTIVE: Bacterial agglutination antibodies against Bordetella pertussis, Yamaguchi and Tohama strains, are frequently measured for serodiagnosis of pertussis infection in Japan. To determine the serological criteria, the comparative titres of bacterial agglutination antibody and anti-pertussis toxin (PT) antibody were evaluated. METHODS: Antibody titres were analysed in 36 definitive (fourfold increase in agglutination antibody) and 137 presumptive (high titre of single-antibody) cases of B. pertussis infection among adolescents and adults, and in a control group of 318 healthy volunteers. RESULTS: When a single Yamaguchi agglutinin titre of ≥ 1:1280 (> three SD above the geometric mean for the control group) was taken as diagnostic, the sensitivity and specificity at 4-5 weeks after onset of cough were 58% and 98%, respectively. Using this criterion, the clinical findings in presumptive cases were almost identical to those in definitive cases. When the two tests were compared using 318 control sera, there was no association between the Tohama agglutinin titre and the anti-PT antibody titre, whereas a weak association between the Yamaguchi agglutinin titre and the anti-PT antibody titre was observed. When the numbers of pertussis cases with high antibody titres in the two tests were compared, 60% of cases with a Yamaguchi agglutinin titre of ≥1:1280 showed an anti-PT antibody titre of ≥100 EU/mL. CONCLUSIONS: These results indicate that the bacterial agglutination test is a method with low sensitivity and specificity for the diagnosis of B. pertussis infection. Therefore, to yield an accurate diagnosis, anti-PT antibody levels should be measured instead of bacterial agglutination antibody.

Outbreak of pertussis in a university laboratory.

OBJECTIVE: Analysis of an outbreak of Bordetella pertussis infection in a university laboratory. To prevent and control the outbreak, we conducted a survey of the laboratory staff and their family members, and we investigated the clinical features of adult pertussis. PATIENTS AND METHODS: During the outbreak, four out of the 10 laboratory staff and five out of 16 family members had a primary complaint of cough. Seven of nine patients were diagnosed as definitive B. pertussis infection using serology and PCR. RESULTS: Clinical findings and laboratory data in adult patients with B. pertussis infection demonstrated non-specific cough and normal WBC and lymphocyte count. The patients who received clarithromycin prior to 14 days after clinical onset demonstrated a shorter duration of cough symptoms than patients who received clarithromycin at 14 days or more after clinical onset (duration of cough after administration of clarithromycin: 17.8 ± 6.48 days versus 35.3 ± 5.38 days; duration of total cough after clinical onset: 24.8 ± 6.65 days versus 56.8 ± 6.50 days). CONCLUSION: The clinical findings of adult pertussis are different from pertussis in children. The efficacy of macrolide therapy clearly differed between the catarrhal phase and paroxysmal phase. Physicians should consider B. pertussis in the differential diagnosis of an outbreak of non-specific respiratory infection even in adult populations.

Community-acquired macrolide-resistant Mycoplasma pneumoniae pneumonia in patients more than 18 years of age.

A macrolide-resistant Mycoplasma pneumoniae strain was isolated from two patients with community-acquired pneumonia. The pneumonia severity score of both patients was mild, and rapid clinical improvement was seen after administration of fluoroquinolone. Clinical features of macrolide-resistant M. pneumoniae pneumonia were identical to those of macrolide-sensitive M. pneumoniae pneumonia. An A-to-G transition at position 2063 and 2064, respectively, in domain V of the 23S rRNA gene was identified. The minimum inhibitory concentration of erythromycin of these isolates was greatly elevated. In Japan, macrolide-resistant M. pneumoniae infections are common in pediatric patients but not in adults. However, physicians should pay attention to macrolide-resistant M. pneumoniae not only in children but also in adults.

Radiographic features of Mycoplasma pneumoniae pneumonia: differential diagnosis and performance timing.

BACKGROUND: The Japanese Respiratory Society guidelines propose a differential diagnosis for atypical pneumonia and bacterial pneumonia using a scoring system for the selection of appropriate antibiotic. In order to improve this scoring system, the guidelines are seeking new specific parameter. The purpose of this study was to clarify the pattern of abnormalities with Mycoplasma pneumoniae pneumonia on chest computed tomography (CT) and whether the radiographic findings could distinguish M. pneumoniae pneumonia from Streptococcus pneumoniae pneumonia. METHODS: A retrospective review was performed of the CT findings of 64 cases and 68 cases where M. pneumoniae and S. pneumoniae, respectively, were the only pathogen identified by the panel of diagnostic tests used. RESULTS: Of the 64 patients with M. pneumoniae pneumonia, bronchial wall thickening was observed most frequently (81%), followed by centrilobular nodules (78%), ground-glass attenuation (78%), and consolidation (61%). Bronchial wall thickening and centrilobular nodules were observed more often in M. pneumoniae patients than in S. pneumoniae patients (p < 0.0001). The presence of bilateral bronchial wall thickening or centrilobular nodules was only seen in patients with M. pneumoniae pneumonia. Using the scoring system of the Japanese Respiratory Society guidelines and chest CT findings, 97% of M. pneumoniae patients were suspected to be M. pneumoniae pneumonia without serology. When comparing the CT findings between early stage and progressed stage in the same patients with severe pneumonia, the radiographic features of early stage M. pneumoniae pneumonia were not observed clearly in the progressed stage. CONCLUSION: The present results indicate that the diagnosis of M. pneumoniae pneumonia would appear to be reliable when found with a combination of bronchial wall thickening and centrilobular nodules in the CT findings. However, these CT findings are not observed in progressed severe M. pneumoniae pneumonia patients.

Lymphoepithelial cyst of the pancreas associated with elevated CA 19-9 levels.

An extremely rare case of a lymphoepithelial cyst associated with persistent elevation of serum carbohydrate antigen (CA) 19-9 levels is described. A 72-year-old man was incidentally found to have a cystic tumor in the uncus of the pancreas and to have a high serum CA 19-9 level. At 2-year follow up, the tumor size had gradually increased and the high CA 19-9 level persisted. Because the malignant potential of the tumor could not be ruled out, a laparotomy was performed. The tumor was excised from the pancreas. On pathological examination, the tumor was proven to be a lymphoepithelial cyst. After the operation, the patient's serum CA 19-9 level decreased to the normal range. Lymphoepithelial cysts of the pancreas are a rare, benign entity. They are true pancreatic cysts, characterized by a mature, keratinizing, squamous lining surrounded by lymphoid tissue. Because the treatment options and the prognosis of these entities are quite different from those of other cystic neoplasms of the pancreas, preoperative differential diagnosis is the main issue. Thus, although they are rare, lymphoepithelial cysts should be considered in the differential diagnosis of cystic tumors of the pancreas.

Surgical resection combined with CHOP chemotherapy plus rituximab for a patient with advanced mesenteric diffuse large B cell lymphoma.

Herein is described a mesenteric diffuse large B cell lymphoma (DLBCL) case with a bulky mass which had achieved a complete remission by the combination therapy of a surgical resection and the CHOP chemotherapy with rituximab. A 78 year old man was referred to the Rakuwakai-Otowa Hospital due to a left lower abdominal tumor. Abdominal CT and MRI showed a bowel-like mass in the left lower abdominal cavity. Abdominal US revealed lymph node swellings at the paraaortic region. By the gastro-duodenoscopy, DLBCL of non-Hodgkin's lymphoma was proven at the 2nd portion of the duodenum. On laparotomy, a mass of 8x8cm in size was found at the mesenterium of the ileum, which directly invaded the ileum and the sigmoid mesocolon. A partial resection of the ileum and the sigmoid colon was performed. After the operation, it was determined to be Stage IV DLBCL and the chemotherapy based on the R-CHOP regimen was performed. The regimen was repeated to the 6th course. During the chemotherapy, he was confirmed to have achieved a complete remission. The present case is a rare case in which a Stage IV mesenteric DLBCL with extensive bulky masses had a favorable prognosis. Stage IV mesenteric DLBCLs with extensive bulky masses are thought to be the indication for the combination therapy of surgical resection and multiagent chemotherapy with rituximab.

The role of prophylactic bilateral oophorectomy at the time of initial diagnosis of a unilateral ovarian metastasis in cases with colorectal adenocarcinoma.

BACKGROUND/AIMS: In cases with a macroscopic unilateral ovarian metastasis of colorectal adenocarcinoma, a clear therapeutic policy regarding a prophylactic bilateral oophorectomy is lacking. METHODOLOGY: Four cases of ovarian metastases of colorectal adenocarcinoma are presented. RESULTS: Case 1 is a 63-year-old with ascending colon carcinoma, Dukes' C, and right oophorectomy due to metachronous ovarian metastasis. Case 2 is a 28-year-old with transverse colon carcinoma, Dukes' D, and right oophorectomy due to synchronous ovarian metastasis. Case 3 is a 40-year-old with rectal carcinoma, Dukes' B, and right oophorectomy due to metachronous ovarian metastasis. Case 4 is a 32-year-old with rectal carcinoma, Dukes' D, and bilateral oophorectomy due to synchronous and metachronous ovarian metastases. Later, in cases 1 and 3, in which a unilateral ovary was preserved, ovarian metastases to the preserved ovary were found and caused severe clinical symptoms. However, by that time their general condition did not permit any additional laparotomy. CONCLUSIONS: Without other extensive metastases, if demonstrable diseases are found in a unilateral ovary, a prophylactic bilateral oophorectomy is recommended.

Synchronous mucosa-associated lymphoid tissue lymphoma and gastrointestinal stromal tumor of the stomach presenting with gastric bleeding.

We report an extraordinarily rare case of synchronous mucosa-associated lymphoid tissue lymphoma and gastrointestinal stromal tumor of the stomach. An 80-year-old man presented with gastric bleeding. Gastroscopy showed an ulcerative lesion and a submucosal tumor at the upper corpus of the stomach. The ulcerative lesion was proven by biopsy to be mucosa-associated lymphoid tissue lymphoma, but the submucosal tumor could not be diagnosed. Due to the repeating episodes of massive gastric bleeding, a total gastrectomy with lymphadenectomy was performed. After the operation, the submucosal tumor was pathologically proven to be a gastrointestinal stromal tumor. In this case, synchronous occurrence of mucosa-associated lymphoid tissue lymphoma and gastrointestinal stromal tumor seems to be coincidental rather than related with the same pathogenic triggering. Surgical resection of the stomach provided an accurate diagnosis and an effective treatment.

Successful sphincter-sparing local excision for mucinous adenocarcinoma associated with chronic fistula in ano using preoperative MRI evaluation.

A 78-year-old man with a 10-year history of ischiorectal abscess was referred to our hospital because purulent drainage from an external opening changed to mucoid drainage. By the brushing cytology of fistula ano, mucinous adenocarcinoma was found. T2-weighted magnetic resonance imaging (MRI) indicated that a mucinous adenocarcinoma was localized within the abscess and the fistula, and was not invasive neoplasm. He underwent a sphincter-sparing local excision of the ischiorectal abscess including the fistula and openings. The pathological findings indicated that mucinous adenocarcinoma arose from anal glands, developed lining the preexisting abscess and fistula wall. Five years after the resection, he remains asymptomatic and free of disease. From the present case, it is advisable that a high index of clinical suspicion in any elderly patient presenting with perirectal abscess and a major impact of the MRI evaluation on the perioperative assessment of perianal diseases should be emphasized.

Successfully-treated mesenteric non-Hodgkin's lymphoma involving hepatic mass--a case report.

A mesenteric diffuse large B-cell lymphoma which also involves the liver is very rare. We describe herein a mesenteric diffuse large B-cell lymphoma with hepatic involvement successfully treated by the combination of surgical resection and multiagent chemotherapy. A 77-year-old man was referred to our hospital because of a right lower abdominal tumor. Abdominal computed tomography showed a mass in the mesenterium at the ileocoecal region and multiple mass in the liver. Gallium scintigram showed focal hot uptake at the ileocoecal region and multiple areas of increased Gallium uptake in the liver. With the diagnosis of a mesenteric tumor with liver metastases, a laparotomy was performed. By an intraoperative pathological examination, non-Hodgkin's lymphoma was suggested. The mesenteric mass was completely resected, but additional operative procedures were not done to the liver. After the operation, the patient was determined to have Stage IVB diffuse large B-cell lymphoma, and chemotherapy based on the CHOP-like regimen was given. After the 8th course of such chemotherapy, he was confirmed to have achieved a complete remission by abdominal computed tomography and Gallium scintigram.The Stage IV mesenteric diffuse large B-cell lymphoma involving the liver seems to be an indication for combination therapy of surgical resection and multiagent chemotherapy.