Introduction : The purpose of this study was to clarify the antimicrobial susceptibility of Haemophilus influenzae in central Tokyo over a ten-year period.
Methods : We investigated the susceptibility of Haemophilus influenzae isolated in Tokyo Saiseikai Central Hospital for 10 years from 2004 through 2013.
Results : Significant increases in the proportion of strains resistant to ampicillin, ampicillin / sulbactam and cefditoren pivoxil were noted for some years in comparison to the first year studied. There were no significant changes in the susceptibility to levofloxacin and clarithromycin. The proportion of strains resistant to ampicillin and cefditoren pivoxil showed statistically significant increases during the study period. The proportion of the strains resistant to ampicillin / sulbactam isolated from children was greater than from adults for every year studied. Levofloxacin resistant strains were isolated only from adults. The proportion of strains resistant to clarithromycin were about 1% in Japanese national surveillance data, but the proportions in this study were over 9%.
Conclusion : Over a ten-year period in central Tokyo, Haemophilus influenzae strains resistant to ampicillin and cefditoren pivoxil increased. Strains resistant to clarithromycin occurred at a higher rate than nationally.

PURPOSE: Comatose elderly patients with acute neurological illness have a great risk of deep vein thrombosis (DVT). In this study, the incidence of DVT and the effectiveness of early initiation of treatment were evaluated in those patients. MATERIALS AND METHODS: Total 323 patients were admitted to our ward due to neurological diseases in one year, and 43 patients, whose Glasgow Coma Scale was < or =11 and who was older than > or =60 years, were included in this study. D-dimer was measured on admission and day 7, and lower-extremity ultrasonography was performed on day 7. When DVT was positive, heparin treatment was initiated, and further evaluation of pulmonary embolism (PE) was conducted. Vena cava filter protection was inserted in PE-positive patients. Incidence of DVT and PE, alteration of D-dimer value, and effect of heparin treatment were analyzed. RESULTS: DVT was positive in 19 (44.2%) patients, and PE was in 4 (9.3%). D-dimer was significantly higher in DVT-positive group on day 7 (p<0.01). No DVT were identified in patients with ischemic disease, while 66.7% of intracerebral hemorrhage and 53.3% of brain contusion patients were DVT positive. Surgery was a definite risk factor for DVT, with an odds ratio of 5.25. DVT and PE disappeared by treatment in all cases, and no patients were succumbed to the thrombosis. CONCLUSION: Patients with hemorrhagic diseases or who undergo operation possess high risk of DVT, and initiation of heparin treatment in 7 days after admission is an effective prophylaxis for DVT in comatose elderly patients without causing bleeding.
Acute Disease ; Aged ; Anticoagulants/adverse effects/therapeutic use ; Antifibrinolytic Agents/therapeutic use ; *Coma ; Female ; Fibrin Fibrinogen Degradation Products/therapeutic use ; Hemorrhage/*epidemiology ; Heparin/adverse effects/therapeutic use ; Humans ; Incidence ; Japan/epidemiology ; Lower Extremity ; Male ; Middle Aged ; Nervous System Diseases/epidemiology ; Neurosurgical Procedures/*adverse effects ; Pulmonary Embolism/*complications/epidemiology/prevention & control ; Risk Factors ; Venous Thrombosis/epidemiology/*etiology/prevention & control

A 78-year-old woman who had undergone an axillobifemoral artery bypass with a prosthetic graft for Leriche syndrome presented 1 month later with cough and fever. A clinical examination revealed obvious redness in the right groin. Routine laboratory tests uncovered inflammation and methicillin-sensitive-Staphylococcus aureus was cultured from blood samples. Mitral valve vegetations were identified by echocardiography, and after a diagnosis of infective endocarditis, specific intravenous antibiotics were immediately administered. One month later, CT revealed a large pseudoaneurysm of the posterior left ventricular wall that had not been present at the time of admission. Transesophageal echocardiography and magnetic resonance imaging showed an aneurysmal cavity arising from the wall just below the posterior mitral valve leaflet. The patient agreed to undergo cardiac surgery due to the high likelihood that the pseudoaneurysm would rupture. The mitral annulus and leaflet were normal at surgery. We resected the posterior leaflet, closed the cavity using a Xenomedica patch, and reconstructed the leaflet. We did not remove the pseudoaneurysm using an extracardiac approach because the likelihood of damaging the coronary arteries and the coronary sinus was quite high. The postoperative course was uneventful. At follow-up 1 year later, the patient was afebrile and both CT and echocardiography showed that the cavity was completely filled by the thrombus. The imaging findings were useful in determining the surgical approach.

Background: The technique of pancreatoduodenectomy (PD) has evolved, and artery first’ approach was considered for the intraoperative early determination of resectability for borderline resectable cases before the ‘point of no return’ and avoidance of blood congestion resulted in the reduction of blood loss. Also, active application of energy device was useful for the reduced operative time and blood loss. Recently, 3D simulation for hepatobiliary pancreatic surgery has been useful and mandatory. In this presentation, we introduced our recent refinements and advances for PD. ‘Artery first’ approach and vessel sealing system for PD: ‘Artery first’ approach were considered as six different methods as follows; 1) Superior approach, 2) Anterior approach, 3) Posterior approach, 4) Left posterior approach, 5) Right/ medial uncinate approach and 6) Mesenteric approach. A while ago, we preferably applied the mesenteric approach to PD, and also the combination of this approach with vessel sealing system (VSS) significantly reduced intraoperative blood loss (Mesenteric approach with VSS, n=21 vs. non-‘Artery first’ approach without VSS, n=78; 320±174ml vs. 486±263ml, p<0.01). Modified de-rotation method as complete ‘Artery first’ approach: Most recently, for further refinement of operative procedure, we refined a right/medial uncinate and posterior approach as modified de-rotation method. Point of view in this method was the complete clockwise rotation of small intestinal mesentery including ascending colon, in order to linearize from duodenum to jejunum and look at the direct front of superior mesenteric artery (SMA), vein (SMV) and some branched jejunal vessels originated from SMA and SMV (Fig.). Thereby, in the posterior view, the easy dissection of all pancreatic branch originated from SMA can be done. This modified de-rotation method was possible to achieve the complete ‘Artery first’ approach. Preoperative 3D simulation of arterial and venous anatomy: Until now, we applied 3D volumetery software (SYNAPSE VINCENT®) as preoperative simulation for hepatic resection. And recently, for evaluation of the position relationship between arteries and veins surround pancreas head, we adopted this software before PD. As first step, arteries and veins are automatically identified, and small vessels are manually traced on the axial CT view. After that, 3D arterial and venous simulations are combined. Grasp of detailed vessel anatomy and its relationship using preoperative 3D simulation enable to safely perform PD, even in young surgeons (operative time; young 512±49 vs. senior 445±41 min, p<0.01), (blood loss; young 353±203 vs. senior 246±109 ml, p=0.16). Conclusion: Those refinements and advances are possible to safely and easily perform pancreatoduodenectomy.

Background: The technique of pancreatoduodenectomy (PD) has evolved, andartery first’ approach was considered for the intraoperative early determinationof resectability for borderline resectable cases before the ‘point of no return’and avoidance of blood congestion resulted in the reduction of blood loss. Also,active application of energy device was useful for the reduced operative time andblood loss. Recently, 3D simulation for hepatobiliary pancreatic surgery has beenuseful and mandatory. In this presentation, we introduced our recent refinementsand advances for PD.‘Artery first’ approach and vessel sealing system for PD: ‘Artery first’ approachwere considered as six different methods as follows; 1) Superior approach, 2)Anterior approach, 3) Posterior approach, 4) Left posterior approach, 5) Right/medial uncinate approach and 6) Mesenteric approach. A while ago, wepreferably applied the mesenteric approach to PD, and also the combination ofthis approach with vessel sealing system (VSS) significantly reduced intraoperativeblood loss (Mesenteric approach with VSS, n=21 vs. non-‘Artery first’ approachwithout VSS, n=78; 320±174ml vs. 486±263ml, p<0.01).Modified de-rotation method as complete ‘Artery first’ approach: Most recently,for further refinement of operative procedure, we refined a right/medial uncinateand posterior approach as modified de-rotation method. Point of view in thismethod was the complete clockwise rotation of small intestinal mesenteryincluding ascending colon, in order to linearize from duodenum to jejunumand look at the direct front of superior mesenteric artery (SMA), vein (SMV) andsome branched jejunal vessels originated from SMA and SMV (Fig.). Thereby, inthe posterior view, the easy dissection of all pancreatic branch originated fromSMA can be done. This modified de-rotation method was possible to achieve thecomplete ‘Artery first’ approach.Preoperative 3D simulation of arterial and venous anatomy:Until now, we applied 3D volumetery software (SYNAPSE VINCENT®) aspreoperative simulation for hepatic resection. And recently, for evaluation of theposition relationship between arteries and veins surround pancreas head, weadopted this software before PD. As first step, arteries and veins are automaticallyidentified, and small vessels are manually traced on the axial CT view. Afterthat, 3D arterial and venous simulations are combined. Grasp of detailed vesselanatomy and its relationship using preoperative 3D simulation enable to safelyperform PD, even in young surgeons (operative time; young 512±49 vs. senior445±41 min, p<0.01), (blood loss; young 353±203 vs. senior 246±109 ml,p=0.16).Conclusion: Those refinements and advances are possible to safely and easilyperform pancreatoduodenectomy.

BACKGROUND/AIMS: Our physicians work to expand the possibilities to treat female patients with inflammatory bowel disease (IBD) who wish to become pregnant. Although many drugs, including 5-aminosalicylate (5-ASA), corticosteroids, immunomodulators, and biologics, are used safely during pregnancy, few reports have described the therapeutic regimen throughout pregnancy and the management of patients who relapse during pregnancy precisely. The aim of this study was to assess the management of patients with IBD during pregnancy. METHODS: We identified 19 patients (five with Crohn's disease and 14 with ulcerative colitis [UC]) who became pregnant with a total of 23 pregnancies between May 2005 and May 2015 by reviewing the medical records of Kyoto University Hospital. The following data were collected: the maternal variables, the IBD treatment type, the disease activity, the pregnancy outcome, and the mode of delivery. RESULTS: Among the 19 patients, 18 had become pregnant after being diagnosed with IBD, while one had developed UC newly after pregnancy. Throughout the gestation, all patients were treated with probiotics, 5-ASA, prednisolone, cytapheresis, or infliximab. The relapse rate during pregnancy was 21.7% (5/23 cases). The five patients who experienced a relapse were able to pursue their pregnancy after intensification of their treatments. There were no adverse fetal or neonatal problems, except in one case that required an emergency Caesarean section because of placental dysfunction and in which a very low-birth-weight infant was born preterm. CONCLUSIONS: Our present data confirmed that even if the disease flares up during pregnancy, good pregnancy outcomes can be achieved with an optimal intensification of the patient's treatment.
Adrenal Cortex Hormones ; Asian Continental Ancestry Group* ; Biological Products ; Cesarean Section ; Colitis, Ulcerative ; Crohn Disease ; Cytapheresis ; Emergencies ; Female ; Humans ; Immunologic Factors ; Infant, Low Birth Weight ; Infant, Newborn ; Inflammatory Bowel Diseases* ; Infliximab ; Medical Records ; Mesalamine ; Prednisolone ; Pregnancy ; Pregnancy Outcome ; Probiotics ; Recurrence

Human cytomegalovirus (HCMV) is a member of the herpesvirus family. HCMV infection persists throughout the host lifespan in a latent state following primary infection. The ability of HCMV to escape control by the host immune system and its resulting reactivation suggests the importance of ongoing immune surveillance in the prevention of HCMV reactivation. HCMV is a common cause of opportunistic infection that causes severe and fatal disease in immune-compromised individuals. In inflammatory bowel disease patients, particularly those with ulcerative colitis (UC), HCMV is often reactivated because these patients are frequently treated with immunosuppressive agents. This reactivation exacerbates colitis. Additionally, HCMV infection can induce severe colitis, even in patients with UC who have never been treated with immunosuppressive agents. However, the role of HCMV in colonic inflammation in patients with UC remains unclear. Here, we present previous and current clinical data on the diagnosis and treatment of HCMV infection in UC. Additionally, our experimental data from a newly established mouse model mimicking UC with concomitant CMV infection clearly demonstrate that inflammation could result in the exacerbation of UC disease activity with induction of HCMV reactivation. In summary, optimal control of colonic inflammation should be achieved in UC patients who are refractory to conventional immunosuppressive therapies and are positive for HCMV.
Animals ; Colitis ; Colitis, Ulcerative* ; Colon ; Cytomegalovirus Infections* ; Cytomegalovirus* ; Diagnosis* ; Humans ; Immune System ; Immunosuppressive Agents ; Inflammation* ; Inflammatory Bowel Diseases ; Mice ; Opportunistic Infections ; Tumor Necrosis Factor-alpha ; Ulcer* ; United Nations

The median time of brain metastasis from the diagnosis of breast cancer is approximately 3 years. In this case report, a 69-year-old woman demonstrated cerebellar ataxia. Brain magnetic resonance imaging revealed enhanced lesions in bilateral cerebellar hemispheres. She had undergone surgery, radiation, and chemotherapy for uterine and breast cancer 24 years prior and 16 years prior, respectively. Although she had not received any anticancer treatment for 10 years, no recurrences were identified using whole body scans. A partial tumor resection was performed and the histological diagnosis was an adenocarcinoma from breast cancer. As no extracranial lesions were found, gamma-knife irradiation was performed, without additional systemic chemotherapy. One month posttreatment, the tumors dramatically reduced in size and the patient completely recovered from cerebellar ataxia. Systemic chemotherapy is not always required for brain metastasis from breast cancer with a long interval period, as long as no evidence of extracranial recurrence is detected.
Adenocarcinoma ; Aged ; Brain* ; Breast Neoplasms* ; Breast* ; Cerebellar Ataxia ; Diagnosis ; Drug Therapy ; Female ; Humans ; Magnetic Resonance Imaging ; Neoplasm Metastasis* ; Neoplasm Recurrence, Local ; Prognosis ; Recurrence* ; Whole Body Imaging

Objective: Little is known about the coagulation activity of factor XIII (FXIII) during resuscitation for hemorrhagic shock and the effects of plasma transfusions. We performed a single-center observational study to evaluate the changes in FXIII activity during resuscitation for hemorrhagic shock.Patient and Methods: Twenty-three adult patients with hemorrhagic shock were enrolled in this study. Blood samples were drawn upon arrival (T1), at the time of hemostasis completion (T2), and on day 2 (T3). Baseline and changes in FXIII activity and the proportion of patients with adequate levels of FXIII activity (FXIII activity >70%) were evaluated. The effects of plasma transfusion on these parameters were also investigated.Results: At T1, the median (interquartile range) FXIII activity was 53% (47–85%), which did not increase (T1 vs. T3: 53% [47–85%] vs. 63% [52–70%], P=0.8766). The proportion of patients with adequate FXIII activity decreased throughout the resuscitation period (T1, T2, and T3: 30, 34, and 21%, respectively). Plasma transfusion did not affect FXIII activity (T1 vs. T2, 66.4% [23.4] vs. 70.0% [16.2%], P=0.3956; T2 vs. T3, 72.0% [19.5] vs. 63.5% [8.6%], P=0.1161) or the proportion of adequate levels of FXIII activity at 44% at T2 and 27% at T3.Conclusion: FXIII activity is low during the early phase of a hemorrhagic shock. Even with plasma transfusion, FXIII levels were not adequately maintained throughout resuscitation.

BACKGROUND/AIMS: Early use of biologics in patients with Crohn's disease (CD) improves quality of life. However, the effects of the early use of immunomodulators on long-term outcomes remain unclear. This study aimed to evaluate the effects of immunomodulators in patients with CD. METHODS: Between January 2004 and December 2011, 47 biologic-naive CD patients treated with thiopurines alone for remission maintenance were analyzed. The patients were classified into 2 groups depending on the presence or absence of digestive complications. We evaluated the efficacy of and predictive factors for thiopurine use for remission maintenance. RESULTS: The cumulative relapse rates at 24 and 60 months were 13.7% and 35.4%, respectively. Regarding patient characteristics, there was a significant difference in patient history of surgery between the non-relapse and relapse groups (P=0.021). The cumulative relapse rate was lower in patients without a history of surgery than in those with such a history (27.2% and 52.9% at 60.0 months, respectively). Multivariate analysis suggested that the prevalence of stricturing and penetrating complications is an independent factor for relapse. The cumulative relapse rate in patients without a history of surgery was significantly lower in the non-stricturing and non-penetrating group than in the stricturing and penetrating group (11.8% at 85.0 months vs. 58.5% at 69.0 months; P=0.036). CONCLUSIONS: Thiopurine use might be beneficial for the long-term maintenance of remission in biologic-naive Crohn's disease patients without digestive complications and a history of surgery.
Asian Continental Ancestry Group* ; Biological Products ; Crohn Disease* ; Humans ; Immunologic Factors ; Multivariate Analysis ; Prevalence ; Quality of Life ; Recurrence