Topical administration of HSV gD-IL-2 DNA is highly protective against murine herpetic stromal keratitis.

PURPOSE: To evaluate the immunopreventive effect of eyedrops that contain gD-IL-2 DNA (a chimeric gene of the glycoprotein D gene of herpes simplex virus type I (HSV-1) and human interleukin-2 (IL-2) on murine herpetic keratitis. METHODS: A plasmid containing gD-IL-2 (pHDLneo1) was constructed. The eyedrops containing 90 microg/10 microL of the DNA was instilled bilaterally into the conjunctival sacs of BALB/c mice on days 0 and 7. Three weeks after the last administration, neutralizing antibody, delayed-type hypersensitivity (DTH), and 51Cr-release from infected targeted cells by lymphocytes from the cervical lymph nodes and spleen were determined. Immunized mice were challenged with HSV-1, after which the clinical signs of the corneal epithelia and stroma were scored. RESULTS: Specific neutralizing antibody was raised and prominent DTH reaction was elicited from immunized mice. Lymphocytes obtained from the local lymph nodes and spleen vigorously potentiated the cytotoxic activity against the virus-infected cells. Clinically, the development of stromal keratitis was completely inhibited, but prevention or reduction of HSV-1 epithelial lesions was not demonstrated statistically. CONCLUSION: Topical immunization with a DNA vaccine encoding gD-IL-2 totally prevented the development of herpetic stromal keratitis. This procedure is a simple and convenient method for possible clinical application in the future.     

A secure taping technique for a liver hanging maneuver using a surgical probe

A liver hanging maneuver is currently being applied for various types of hepatectomies. The most difficult and important step of this technique is to encircle the liver with tape that is passed between the liver and the inferior vena cava, using a blind dissection. This report describes a secure technique for taping utilizing a surgical probe.     

Clinical significance of urinary FDP-E measured by latex photometric immunoassay (LPIA) in the renal disease

It is well known that urinary FDP is one of the parameters of intrarenal coagulation in renal disease. The measurement of urinary FDP, however, is not satisfactory enough, since it is not a quantitative and sensitive method. Latex photometric immunoassay has recently been developed as a quantitative and more sensitive method. Since fibrinogen reacts with FDP-E less than FDP, the measurement of urinary FDP-E is much better than that of urinary FDP in order to determine the presence of intrarenal coagulation and fibrinolysis of patients with renal diseases. The aim of this study is to clarify the clinical significance of urinary FDP-E measured by LPIA in the renal disease. The results were as follows: (1) Urinary FDP-E correlate with urinary protein, FDP, FDP-D, fibrinopeptide A (FPA), but not serum FDP-E. (2) The diseases which showed higher amounts of urinary FDP-E were diabetic nephropathy, amyloidosis and chronic glomerulonephritis. On the other hand, the diseases which showed smaller amounts of urinary FDP-E were minimal change, toxemia of pregnancy and lupus nephritis. All patients with higher amounts of urinary FDP-E showed marked renal dysfunction. But all the patients with the marked renal dysfunction did not always show higher amounts of urinary FDP-E. The urinary FDP-E showed a positive correlation to 1/serum creatinine. These results suggested that the measurement of urinary FDP-E is a useful method in determining the presence and degree of intrarenal coagulation and fibrinolysis in renal diseases.     

Long-term Efficacy of Percutaneous Transhepatic Choledochoscopic Y AG Laser Therapy for Malignant Biliary Obstruction

Abstract: The long-term effect of percutaneous transhepatic choledochoscopic YAG laser therapy for malignant biliary tract obstruction was evaluated. Ten consecutive patients underwent laser therapy to alleviate the obstruction. All patients were followed up for 8 months or more (range: 8–33 month, average: 15). Cholangiography was performed when re-elevation of the alkaline phosphatase level was observed during the regular checkup. Choledochoscopy was performed when any sign of recurrence was observed on cholangiography. Sufficient re-opening of the bile duct was obtained in every case, without complications. Indwelling of the internal drainage tube was perfomed in 5 patients, the remaining 5 having “tube free” internal drainage. Five patients showed no rise in alkaline phosphatase levels during their 8- to-13 month follow-up period. Re-elevation of the alkaline phosphatase level was observed 9 times in 5 patients, mostly from internal drainage tube occlusion. The cholangiogram performed on each occasion revealed a patent bile duct without any sign of recurrence (6/9), slight narrowing (2/9) or tumorous obstruction (1/9). Cholangitis was complicated 6 times in 3 patients, mostly from internal drainage tube occlusion. Choledochoscopy was performed in the 3 patients suspected of tumor recurrence on cholangiogram. In 2 of them, no signs of recurrence were noted endoscopically or histologically, but the tumor was revealed to have recurred only at the part previously treated, in the remaining. Thus, choledochoscopic I'AG laser therapy can locally control the malignant biliary tract obstruction for a long period of time. “tube free” internal drainage may serve as a means to prevent cholangitis, which is one of the complications frequently occurring with conventional stent therapy.     

Surgical-site infection surveillance at a small-scale community hospital

Surveillance of surgical-site infection (SSI) is becoming more important given the current situation of increasing antibiotic resistance by microorganisms. It may be difficult to carry out SSI surveillance at small-scale community hospitals because of small staff numbers. We examined whether SSI surveillance could be carried out with a system we devised. Furthermore, we investigated the SSI rateat our small-scale community hospital (179 beds) in aJapanese city (populations, 330 000). Between June andDecember 2003, operations were performed on 210patients. Procedures were identified as clean (n = 85),clean-contaminated (n = 108), contaminated (n = 14), or dirty-infected (n = 3). A 7-month prospective survey ofSSI was conducted. SSIs were classified according to the Centers for Disease Control and Prevention criteria and identified using bedside surveillance and post-discharge follow-up. SSI developed following 16 procedures (7.6%). All patients who developed SSI had received antibiotic prophylaxis. Among the 16 patients with SSI, operations were clean (n = 1), clean-contaminated (n = 8), contaminated(n = 5), or dirty-infected (n = 2). Enterobacteriaceae were the most frequently isolated microorganisms, followed by Pseudomonas aeruginosa. SSI surveillance is just as important at small community hospitals as it is at larger hospitals, and SSI surveillance is relatively simple to institute at small-scale community hospitals with the selective use of investigation items.     

Reliability of cardiac output measurements using LiDCOrapid™ and FloTrac/Vigileo™ across broad ranges of cardiac output values

Knowing a patient’s cardiac output (CO) could contribute to a safe, optimized hemodynamic control during surgery. Precise CO measurements can serve as a guide for resuscitation therapy, catecholamine use, differential diagnosis, and intervention during a hemodynamic crisis. Despite its invasiveness and intermittent nature, the thermodilution technique via a pulmonary artery catheter (PAC) remains the clinical gold standard for CO measurements. LiDCOrapid? (LiDCO, London, UK) and FloTrac/Vigileo? (Edwards Lifesciences, Irvine, CA) are less invasive continuous CO monitors that use arterial waveform analysis. Their calculations are based on arterial waveform characteristics and do not require calibration. Here, we evaluated LiDCOrapid? and FloTrac/Vigileo? during off-pump coronary artery bypass graft (OPCAB) and living-donor liver transplantation (LDLT) surgery. This observational, single-center study included 21 patients (11 OPCAB and 10 LDLT). We performed simultaneous measurements of CO at fixed sampling points during surgery using both devices (LiDCOrapid? version 1.04-b222 and FloTrac/Vigileo? version 3.02). The thermodilution technique via a PAC was used to obtain the benchmark data. LiDCOrapid? and FloTrac/Vigileo? were used in an uncalibrated fashion. We analyzed the measured cardiac index using a Bland–Altman analysis (the method of variance estimates recovery), a polar plot method (half-moon method), a 4-quadrant plot and compared the widths of the limits of agreement (LOA) using an F test. One OPCAB patient was excluded because of the use of an intra-aortic balloon pumping during surgery, and 20 patients (10 OPCAB and 10 LDLT) were ultimately analyzed. We obtained 149 triplet measurements with a wide range of cardiac index. For the FloTrac/Vigileo?, the bias and percentage error were ?0.44 L/min/m² and 74.4 %. For the LiDCOrapid?, the bias and percentage error were ?0.38 L/min/m² and 53.5 %. The polar plot method showed an angular bias (FloTrac/Vigileo? vs. LiDCOrapid?: 6.6° vs. 5.8°, respectively) and radial limits of agreement (?63.9 to 77.1 vs. ?41.6 to 53.1). A 4-quadrant plot was used to obtain concordance rates (FloTrac/Vigileo? vs. PAC and LiDCOrapid? vs. PAC: 84.0 and 92.4 %, respectively). We could compare CO measurement devices across broad ranges of CO and SVR using LDLT and OPCAB surgical patients. An F test revealed no significant difference in the widths of the LoA for both devices when sample sizes capable of detecting a more than two-fold difference were used. We found that both devices tended to underestimate the calculated CIs when the CIs were relatively high. These proportional bias produced large percentage errors in the present study.     

Evaluation of the BD Phoenix Automated Microbiology System SMIC/ID panel for identification and antimicrobial susceptibility testing of Streptococcus spp

The BD Phoenix Automated Microbiology System SMIC/ID panel was evaluated for identification and antimicrobial susceptibility testing (AST) of various streptococci. A group of 97 consecutive clinical isolates of Streptococcus pneumoniae, 23 Streptococcus pyogenes, 24 Streptococcus agalactiae, and 34 viridans streptococci were collected and comparisons made with routine manual methods used in the clinical microbiology laboratory. Overall, in 162 (91%) of 178 isolates, Phoenix identification results demonstrated agreement. For AST results for the 162 isolates that demonstrated identification concordance, the overall essential agreement rate was 98.5%; the category agreement was 94.9%; and the very major error, major error, and minor error rates were 0%, 0.15%, and 5.8%, respectively. Although relatively high minor error rates were observed with S. pneumoniae and beta-lactams, 79.2% of the 77 minor errors were the result of a single log(2) dilution difference. The Phoenix SMIC/ID panel performed favorably and demonstrated the advantages of automation and simple methodology.     

General anesthesia in a patient with Parkes Weber syndrome with high-output cardiac failure due to multiple arteriovenous fistulas complicated by severe aortic regurgitation

Parkes Weber syndrome is a rare disease characterized by overgrowth of an extremity linked to the presence of an arteriovenous malformation with multiple arteriovenous fistulas (AVFs). We report a patient with Parkes Weber syndrome with high-output cardiac failure due to multiple AVFs complicated by severe aortic regurgitation (AR) who required surgical treatment for AVFs. Division of the left deep femoral artery and banding of the left superficial femoral artery were performed. Such procedures can cause aggravation of AR and left ventricular failure due to the sudden increase in cardiac afterload. Pulmonary artery pressure, mixed venous oxygen saturation and cardiac index monitored by a thermodilution catheter, and a transesophageal echocardiography were useful in evaluating the effect of the surgical procedure and resultant acute increase in cardiac afterload on cardiac output and left ventricular function.     

Placement of a plastic biliary stent tube with primary closure of the common bile duct after laparoscopic common bile duct exploration

Laparoscopic common bile duct exploration (LCBDE) is one of the standard surgical procedures for treating choledocholithiasis. Several methods of biliary drainage following LCBDE have been advocated to prevent bile leakage. We report herein a surgical procedure using a plastic biliary stent tube following LCBDE for biliary drainage. Our method is technically simple, feasible and an ideal procedure for biliary drainage with LCBDE.