Controlling methicillin-resistant Staphylococcus aureus by stepwise implementation of preventive strategies in a university hospital: impact of a link-nurse system on the basis of multidisciplinary approaches

BACKGROUND: Current approaches in the control of methicillin-resistant Staphylococcus aureus (MRSA) in the large tertiary referral hospital have not been universally successful. METHODS: The trend of MRSA rates and their relationship with stepwise implementation of preventive strategies in Tokai University Hospital during a 76-month period from September 1998 to December 2004, was retrospectively analyzed with a quasi-experimental design. RESULTS: Implementation of strategies including a feedback process with case and epidemic reporting, an infection control team and office, and a preventive guideline for MRSA did not result in reduction in monthly MRSA rates in the hospital, as analyzed with Shewhart u charts. When infection control link nurses were organized and their activities became full-scale, there appeared significant reduction in arithmetic mean of the monthly rates of MRSA from 6.3% to 5.0% in June 2002. Meanwhile the mean values for monthly counts of new MRSA cases also dropped in 15 of 25 wards/units in June 2002, as analyzed with Exponentially Weighted Moving Average charts. Concurrently, there was a significant increase (17.3%) in the monthly consumption of handwashing liquid plain soap. Thereafter the MRSA rates remained low for 2 years within three standard deviations. CONCLUSIONS: The sustained reduction of MRSA rates in the hospital can be related to introduction of the infection control link-nurse system on the basis of continuous enforcement of basic and multidisciplinary approaches such as hand-hygiene compliance.     

The degree of newly emerging mitral regurgitation during off-pump coronary artery bypass is predicted by preoperative left ventricular function

Purpose During off-pump coronary artery bypass (OPCAB), the displacement of the heart causes mitral regurgitation. We hypothesized that patients with impaired left ventricle (LV) function would be more prone to develop mitral regurgitation, due to further LV end-diastolic pressure elevation and mitral annulus distortion. Therefore, in this study, we examined the relationship between LV function and the severity of mitral regurgitation. Methods We studied 41 patients undergoing elective OPCAB. LV function was evaluated by LV ejection fraction (LVEF), serum brain natriuretic peptide (BNP) levels, the Tei index (myocardial performance index) and mitral inflow propagation velocity (Vp). Results Among all of the anastomoses performed mitral regurgitation was most severe during anastomosis of the left circumflex artery (LCX) territory (P < 0.001). Twenty-five patients (61%) had no to mild mitral regurgitation during anastomosis of the LCX territory (M-MR group) and 16 patients (39%) had moderate to severe mitral regurgitation during anastomosis of the LCX territory (S-MR group). There were significant differences between these groups in preoperative serum BNP levels (median, 26 pg·ml⁻¹ interquartile range [IQR, 14 to 75 pg·ml⁻¹] versus median, 173 pg·ml⁻¹ [IQR, 91 to 296 pg·ml⁻¹]; P < 0.001), Tei index values (median, 0.35; [IQR, 0.27 to 0.41] versus median, 0.53 [IQR, 0.47 to 0.57]; P < 0.001), and Vp (median, 63 cm·s⁻¹; [IQR, 57 to 72 cm·s⁻¹] versus median, 47 cm·s⁻¹; [IQR, 40 to 57 cm·c⁻¹]; P = 0.008), while there was no significant difference in LVEF between the patients in the M-MR group and those in the S-MR group. Conclusion Preoperative LV dysfunction is a predictor of severe mitral regurgitation during OPCAB. When poor LV function is suggested, it is necessary to be prepared for further hemodynamic deterioration caused by mitral regurgitation.     

Postoperative enteroenteric intussusception in patients with Crohn’s disease: Report of two cases

Postoperative enteroenteric intussusception is a rare complication in adult patients with Crohn’s disease. We treated two patients with Crohn’s disease accompanied by an ileal obstruction, each of whom underwent an elective resection. In both, the upper left quadrant of the abdoment became progressively distended following ileocecal resection and each required surgical treatment after diagnosis of postoperative enteroenteric intussusception by abdominal computed tomography scanning, as the intussusception could not be reduced by conservative treatment. There were no Crohn’s lesions found in the intussuscepted specimens, and the condition was thought to have been caused by a segment of thickened and fibrotic intestine that had developed because of long-standing bowel dilatation from obstructive Crohn’s lesions. In one of the patients, the intussusceptum was irreducibly incarcerated and required a resection, whereas it was able to be manually reduced in the other.     

Correlation between emetic effect of phosphodiesterase 4 inhibitors and their occupation of the high-affinity rolipram binding site in Suncus murinus brain

We employed an ex vivo [(3)H]rolipram binding experiment to elucidate the mechanism of emetic activity of phosphodiesterase 4 inhibitors. In Suncus murinus (an insectivore used for evaluation of emesis), emetic potential as well as ability to occupy the high-affinity rolipram binding site in brain membrane fraction in vivo were determined for phosphodiesterase 4 inhibitors. In vitro, [(3)H]rolipram bound to the membrane fraction of S. murinus brain with high affinity and its value was comparable to that for rat brain (K(d)=3.6 nM and 3.5 nM, respectively). The test compounds included denbufylline, rolipram, piclamilast, CDP840 and KF19514, each of which possessed similar affinities for the rolipram binding sites in both S. murinus and rat brain. In S. murinus, these compounds induced emesis via intraperitoneal administration. Their ED(50) values were as follows: denbufylline (1.4 mg/kg), rolipram (0.16 mg/kg), piclamilast (1.8 mg/kg), CDP840 (20 mg/kg), and KF19514 (0.030 mg/kg). In addition, these compounds occupied the high-affinity rolipram binding site in vivo as detected by dose-dependent reduction in capacity of ex vivo [(3)H]rolipram binding in brain membrane fractions. A clear correlation was observed between dose required to induce emesis and that to occupy the high-affinity rolipram binding site for individual phosphodiesterase 4 inhibitors. We conclude that the emetic effect of phosphodiesterase 4 inhibitors is caused at least in part via binding to the high-affinity rolipram binding site in brain in vivo.     

Pathological features of diseases associated with human T-cell leukemia virus type I

In the early 1980s, the first human retrovirus, human T-cell leukemia virus type I (HTLV-I), was isolated and its characterization opened up the new field of human viral oncology. Adult T-cell leukemia/lymphoma (ATLL), which is associated with HTLV-I, is characterized clinically by the appearance of characteristic flower cells, a rapid clinical course, occasional skin lesions, lymphadenopathy and hepatosplenomegaly. Severe opportunistic infections are occasionally accompanied. In addition, HTLV-I infection is associated with autoimmune and reactive disorders, such as HTLV-I-associated myelopathy and uveitis, and is also related to immunodeficient infectious diseases. Pathological findings of ATLL in the lymph nodes, skin, liver and other organs have been described. Common histological features are a diffuse proliferation of atypical lymphoid cells that vary in size and shape. In addition to ATLL, non-neoplastic organopathies have been documented in many organs, such as the central nerve system, lung, skin, lymph nodes and gastrointestinal tract. To clarify the HTLV-I-associated diseases, it is important to understand the pathological variations.     

A case of anaphylactic shock caused by granisetron

A 60-year-old man suffered from inoperable recurrent undifferentiated thyroid cancer and was scheduled to undergo chemotherapy. He had no known allergy to medications. In the first regimen, he was given IV granisetron and betamethasone before IV 120 mg paclitaxel was administered. Five minutes after the paclitaxel infusion, he developed anaphylactic shock of hypotension, dyspnea, and flushing. He was treated by steroid and recovered. In the second regimen one week later, he was scheduled to be treated by other antineoplastic medication instead of paclitaxel for fear of anaphylaxis. Prechemotherapy the same as the first regimen, granisetron and betamethasone, were given,but he developed the same anaphylaxis before the antineoplastic medication was given. He was thus thought to develop anaphylaxis due to the granisetron itself. Anaphylaxis caused by granisetron has not yet been reported, and this experience prompted us to report this case.     

Interdigitating dendritic cell sarcoma/tumor--a case report

We report an extremely rare case of interdigitating dendritic cell sarcoma/tumor (IDCS). A 52-year-old man presented with a 2-week history of fever in January 2002. Physical examination revealed enlarged, painless right axillary lymph nodes, and hepatosplenomegaly. Whole-body computerized tomography showed enlarged lymph nodes in mediastinal, right axillary, abdominal para-aortic, ileum, and inguinal regions. Hepatosplenomegaly was also detected. In addition to abnormal liver function tests, serum levels of soluble interleukin-2 receptor and ferritin were elevated. Excisional biopsy of right axillary lymph node was performed in February 2002. Histological examination showed a diffuse proliferation of medium-to large-sized cells with round or oval nuclei and abundant cytoplasm. Spindle shape cells and Hodgkin-like giant cells were also seen. Immunohistochemically, the tumor cells expressed S-100 protein, CD 68, and CD 45 RO. They were negative for CD 1, CD 3, CD 15, CD 20, CD 21, CD 23, FDC, DRC, and p80. These findings were compatible with the diagnosis of IDCS. The patient was treated with polychemotherapy consisting of doxorubicin,cyclophosphamide, vincristine, and prednisone. However, he developed fungal pneumonia and died of respiratory failure 1 month after the start of treatment.     

Epithelioid hemangioendothelioma presenting with severe myelofibrosis and a high serum hyaluronan level

Epithelioid hemangioendothelioma (EHE) is a rare tumor originating from the vascular endothelium; it has an intermediate malignant potential. EHEs affect all age groups and mostly originate from the soft tissues of the extremities, lungs, and liver. Spinal EHEs, especially those occurring in the bone marrow region, are extremely rare. We report a case of EHE with massive involvement of the liver, vertebrae, and cranial bones that caused severe myelofibrosis (MF) in a 67-yr-old-male patient. Hyaluronan deposits were diffusely observed in the tumor tissue biopsies obtained from both the liver and bone marrow. Furthermore, the serum hyaluronan level increased markedly along with rapid progression of the disease. To the best of our knowledge, this is the first report of MF occurring in an EHE; hyaluronan may have played an important role in the pathogenesis of fibrosis in this case.     

Successful alternative treatment containing vindesine for acute lymphoblastic leukemia with Charcot-Marie-Tooth disease

Peripheral neuropathy is a well-known side effect of vincristine (VCR), a microtubule inhibitor commonly used to treat malignancies. Severe neurological adverse events can occur in patients with Charcot-Marie-Tooth disease (CMT) treated with VCR. Vindesine is also a microtubule inhibitor, which, like VCR, is widely used to treat malignancies. The case of an 11-year-old female patient with CMT type 1A who developed severe peripheral neuropathy induced by VCR given for her acute lymphoblastic leukemia is reported. Alternative treatment containing vindesine instead of VCR led to a successful outcome without a relapse of leukemia or neurological worsening of CMT.