Intravenous vegetation of methicillin-resistant Staphylococcus aureus induced by central venous catheter in a patient with implantable cardioverter-defibrillator: a case report

A 54-year-old woman with an implantable cardioverter-defibrillator was admitted because of convulsion. Previously, she had suffered methicillin-resistant Staphylococcus aureus (MRSA) sepsis induced by a central venous catheter. Despite removal of the central venous catheter and administration of vancomycin, fever and increased C-reactive protein level persisted. MRSA had probably infected the implantable cardioverter-defibrillator system. Gallium scintigraphy showed accumulation at the right subclaviculan area, although local inflammatory signs were absent. Intravascular ultrasonography demonstrated intravenous vegetation at the bifurcation of the right subclavian vein and right internal jugular vein. Antibiotic therapy was not curative, so she underwent extirpation of the intravenous vegetation, which cured the systemic inflammation. Intravascular ultrasonography was useful to differentiate central venous catheter-related infection from implantable cardioverter defibrillator-related infection.     

Lightwand intubation is associated with less hemodynamic changes than fibreoptic intubation in normotensive, but not in hypertensive patients over the age of 60

PURPOSE: To compare the effects of the lightwand and fibreoptic techniques for intubation, neither of which require laryngoscopy, on hemodynamic responses associated with tracheal intubation in normotensive and hypertensive elderly patients. METHODS: Eighty-eight normotensive and hypertensive patients aged more than 60 yr were randomly allocated to either the lightwand (LN and LH group, n=22 in both) or the fibreoptic group (FN and FH group, n=22 in both). All intubations were performed after induction of anesthesia with fentanyl and propofol and muscle relaxation with vecuronium. Systolic and mean arterial pressures (SAP and MAP) and heart rate (HR) were recorded, and rate-pressure product (RPP) and the change from "before intubation" to "immediately after intubation" of each variable (triangle upMAP triangle up,HR and triangle upRPP) were calculated. RESULTS: In normotensive patients, significantly smaller triangle upMAP, triangle upHR and triangle upRPP were observed in the LN group than in the FN group (P <0.05). In hypertensive patients, no significant differences between the LH group and the FH group were found in triangle upMAP or triangle upHR, while values of mean RPP in both groups were less than 20,000. CONCLUSION: We conclude that the lightwand technique significantly attenuates hemodynamic changes following intubation in comparison with fibreoptic intubation in normotensive patients over the age of 60. Hemodynamic changes following intubation using the lightwand technique and the fibreoptic technique in hypertensive elderly patients are similar. However, both techniques are useful for intubation in hypertensive elderly patients in terms of RPP.     

Effects of a novel selective agonist for prostaglandin receptor subtype EP4 on hyperalgesia and inflammation in monoarthritic model

BACKGROUND: Cytokines have crucial role in the development and maintenance of inflammation and pain in arthritis. Activation of prostaglandin receptor subtype EP(4) suppresses cytokine production in immune cells. The purpose of this study was to evaluate whether a novel EP(4) agonist would be able to suppress thermal and mechanical hyperalgesia and paw swelling in acute and chronic phases in rat monoarthritic model. METHODS: Monoarthritis was induced by an injection of complete Freund's adjuvant (CFA) intracapsularly into the tibiotarsal joint of the rats. Withdrawal latencies to thermal stimulation on the hind paw, withdrawal thresholds to mechanical stimulation, paw volume, and ankle diameter were measured 24 h and 4 weeks after the CFA injection. A novel selective EP(4) receptor agonist, ONO-AE1-329 (10, 25, or 50 microg) or saline was administered intracapsularly into the joint. RESULTS: Withdrawal latencies and withdrawal thresholds were significantly (P < 0.05) shortened and decreased, respectively, on the arthritic side but not on the contralateral side 24 h and 4 weeks after the CFA injection. In addition, significant (P < 0.05) increases in paw volume and ankle diameter on the arthritic side were observed. Intracapsularly administered ONO-AE1-329 showed significant (P < 0.05) inhibition of thermal and mechanical hyperalgesia and significant (P < 0.05) decrease in paw volume and ankle diameter in a dose-dependent manner at 24 h and 4 weeks after CFA. CONCLUSION: Intracapsular administration of EP(4) receptor agonist effectively inhibited mechanical and thermal hyperalgesia and inflammatory reactions in acute and chronic monoarthritis. An EP(4) agonist would be a potential strategy for inflammatory pain in arthritis.     

Expression of a human SOCS protein, HSOCP-1, in peripheral blood eosinophils from patients with atopic dermatitis

To identify new genes related to atopic dermatitis (AD), we screened for differentially expressed genes in peripheral blood eosinophils derived from AD patients and healthy volunteers. RNA was prepared from peripheral blood eosinophils obtained from both AD patients and healthy volunteers, and the expression of various genes was monitored using fluorescent differential display and real-time RT-PCR. One of the expressed sequence tags (ESTs) was expressed at a significantly higher level in AD patients than in healthy volunteers. A full-length cDNA was identified that encoded a human suppressor of cytokine signaling (SOCS) protein, HSOCP-1, also named hASB-8. The expression of HSOCP-1 was increased in cultured peripheral blood eosinophils after IL-4 stimulation, and overexpression of HSOCP-1 caused cell death in an eosinophil cell line, AML14.3D10. p34(SEI-1) was identified as a HSOCP-1-interacting protein by a yeast two-hybrid system. It is a protein that also interacts with the cyclin-dependent kinase inhibitor p16(INK4), suggesting that HSOCP-1 is involved in cell cycle control and apoptosis.     

Laparoscopic surgery for an esophageal duplication cyst using a near‐infrared indocyanine green fluorescence system: A case report

We herein describe a case of laparoscopic surgery for an esophageal duplication cyst using a near‐infrared indocyanine green fluorescence system. A 64‐year‐old woman with a cystic tumor adjacent to the esophagogastric junction was referred to our hospital for treatment. Esophagogastroduodenoscopy and abdominal CT revealed a 70‐mm submucosal tumor derived from the abdominal esophagus. We performed laparoscopic resection and then evaluated the tissue perfusion of the abdominal esophagus by using a near‐infrared indocyanine green fluorescence system. A Dor fundoplication was performed to prevent postoperative gastroesophageal reflux disease and reinforce the mucosal layer defect. The postoperative course was uneventful, and pathological evaluation confirmed that the tumor was an esophageal duplication cyst. The patient did not develop recurrence in the 24 months after surgery. We have demonstrated that laparoscopic resection of an esophageal duplication cyst may be performed effectively with intraoperative assessment of tissue perfusion using a near‐infrared indocyanine green fluorescence system.     

Endovascular Treatment of Acute Stroke with Major Vessel Occlusion before Approval of Mechanical Thrombectomy Devices in Japan: Japanese Registry of Neuroendovascular Therapy (JR-NET) and JR-NET 2

The aim of this study was to clarify the general status and historical transition of endovascular therapy (EVT) of acute stroke with major vessel occlusion before approval of mechanical thrombectomy devices in Japan from January 2005 to December 2009. We extracted 1,409 acute ischemic stroke patients receiving EVT (513 women, 69.8 ± 11.8 years) from two nationwide registry studies, the Japanese Registry of Neuroendovascular Therapy (JR-NET) and JR-NET 2. The median baseline National Institutes of Health Stroke Scale (NIHSS) score was 18, and 81.3% of the patients received EVT within 6 hours after symptom onset. The culprit occluded arteries were the internal carotid artery (ICA) in 21.2%, middle cerebral artery (MCA) in 53.0%, and basilar artery (BA) in 20.6%. Intravenous thrombolysis was administered to 6.7% of the patients, and EVT mainly consisted of intra-arterial thrombolysis and percutaneous balloon angioplasty/balloon clot disruption. The final recanalization rate was 82.5%, and the clinical outcome was favorable in 35.8% and fatal in 11.6% at 30 days after onset or at discharge. There was no significant change in neurological severity at baseline throughout the study period, but the onset-to-treatment time became longer and the proportion of ICA or BA occlusion increased annually. Although the final recanalization rate was similar throughout the study period, the incidence of a favorable outcome tended to decreased annually from 41.0% to 29.0%. These results could be considered as baseline data that can be used to validate the beneficial effects of novel EVT devices in Japan.     

Anesthetic management of a patient with Maffucci syndrome for removal of a pituitary adenoma

Maffucci syndrome is a rare syndrome characterized by multiple enchondromas and hemangiomas seen in various tissues and organs. We report anesthetic management of a 33-year-old man with multiple hemangiomas due to Maffucci syndrome undergoing removal of a pituitary adenoma. The preoperative examination revealed multiple hemangiomas in the head, neck, right upper and lower extremities, the tongue and the pharynx. In the operating room, we observed the locations of hemangiomas in the tongue and pharynx in detail using a fiberoptic bronchoscope before induction of anesthesia. Since there was a risk of rupture of a large hemangioma by using a laryngoscope, we planned fiberoptic bronchoscope-guided tracheal intubation without using a laryngoscope. After intravenous administration of propofol and rocuronium, a fiberoptic bronchoscope was orally introduced into the trachea and then the trachea was intubated with a flexible spiral endotracheal tube, preventing contact of the fiber or endotracheal tube with the hemangiomas. In addition, hemangiomas on the body surface were wrapped up with soft dressing to prevent rupture. Surgery was uneventfully completed. The trachea was carefully extubated, and bleeding from hemangiomas was not observed. Since patients with Maffucci syndrome have multiple hemangiomas, it is important to check for the presence of a hemangioma in the upper airway in anesthetic management.     

Prediction of surgical site infection in spine surgery from tests of nasal MRSA colonization and drain tip culture

Purpose

MRSA is an organism that is a possible risk factor for postoperative SSI. The purpose of the study was to examine relationships among surgical site infection (SSI) after spinal surgery, nasal methicillin-resistant staphylococcus aureus (MRSA) colonization, and wound drain culture results.

Methods

The subjects were 132 patients who underwent spinal instrumentation surgery. A preoperative nasal swab was used to check for the presence of MRSA colonization, and a wound drain tip culture was performed for detection of SSI. Data from culture studies using nasal samples and those from the distal tip of the wound drain were used for analysis.

Results

Five patients (3.8%) had nasal MRSA, 17 (13%) had positive drain tip cultures, 15 (11%) had SSIs, and 10 (8%) had SSIs with MRSA. Patients with nasal MRSA had a higher rate of detection of bacteria in the drain tip culture (40 vs. 19%, p = 0.065), and the SSI rate was significantly higher in patients with a positive drain tip culture (33 vs. 10%, p = 0.012). The total SSI rate differed significantly between patients with and without nasal MRSA (40 vs. 10%, p = 0.039); however, the SSI with MRSA rate did not differ significantly between these groups.

Conclusion

MRSA carriers were not necessarily associated with MRSA infection, but were related to a positive drain tip culture and SSI, which might be due to endogenous skin bacteria. Therefore, possible SSI should be considered in patients with nasal MRSA colonization or bacteria detected in a drain tip culture.