Outbreak of Streptococcus pyogenes emm89 ST646 in a head and neck surgical oncology ward

Streptococcus pyogenes causes a variety of human infections, and hospital outbreaks with this pathogen have also been reported. The purpose of this study is to describe the clinical characteristics of an outbreak of S. pyogenes involving 15 patients and four healthcare workers (HCWs), as well as the molecular characteristics of the causative isolates. The course and response to the outbreak were reviewed, and information on the characteristics of the patients was extracted retrospectively from the medical records. Whole-genome sequencing of the 16 causative isolates (14 from patients and two from HCWs) was also performed. All 15 patients were postoperative of head and neck cancer with tracheotomy, and 12 had invasive infections, primarily surgical site infections, all of which resolved without causing serious illness. All but the first case was detected more than 7 days after admission. S. pyogenes was detected in two patients after empiric antimicrobial administration was performed on all inpatients and HCWs, and the outbreak was finally contained in approximately 2 months. All isolates detected in patients and HCWs belonged to emm89/clade 3, a hypervirulent clone that has emerged worldwide and was classified as sequence type 646. These isolates had single nucleotide polymorphism (SNP) differences of zero to one, indicating clonal transmission. This study demonstrated an outbreak of S. pyogenes emm89/clade 3 in a ward of patients with head and neck cancer. The global emergence of hypervirulent isolates may increase the risk of outbreaks among high-risk patients.

IMPORTANCE

This study describes an outbreak of Streptococcus pyogenes that occurred in a ward caring for patients with head and neck cancer and tracheostomies. Many cases of invasive infections occurred in a short period, and extensive empiric antimicrobial administration on patients and healthcare workers was performed to control the outbreak. Whole-genome sequencing analysis of the causative strains confirmed that it was a monoclonal transmission of strains belonging to emm89/clade 3. The epidemiology and clinical characteristics of S. pyogenes infections have changed with the replacement of the prevalent clones worldwide. In the 1980s, there was a reemergence of S. pyogenes infections in high-income countries due to the spread of hypervirulent emm1 strains. emm89/clade 3 has recently been spreading worldwide and shares common features with emm1, including increased production of two toxins, NADase, and streptolysin O. The outbreak reported here may reflect the high spreading potential and virulence of emm89/clade 3.

Visualization of the Internal Thoracic Arteries in Giant Cell Arteritis on 18 F-FDG Semiconductor PET/CT

ABSTRACT

A 72-year-old woman presented with the fever and the pain of skull and face for 2 weeks. 18 F-FDG PET/CT equipped with semiconductor detectors revealed strong uptake not only in the temporal, cervical, subclavian arteries, and aorta, but also in the bilateral internal thoracic arteries. The diagnosis of giant cell arteritis was made. Semiconductor PET can visualize small arteries such as the internal thoracic artery. The patients with giant cell arteritis are at a high risk of ischemic heart disease, and inflammatory involvement of the internal thoracic arteries may affect the outcome of coronary artery bypass grafting.

Extent of thyroidectomy and paratracheal lymph node dissection in total pharyngolaryngectomy for pyriform sinus cancer, and recurrence, survival, and postoperative hypoparathyroidism: A multicenter retrospective study

BACKGROUND

Total pharyngolaryngectomy (TPL) is standard treatment for hypopharyngeal cancer. However, extensive thyroidectomy and paratracheal nodal dissection (PTND) can cause hypoparathyroidism. We sought to determine the optimum extent of resection.

METHODS

We analyzed the clinicopathological information of 161 pyriform sinus cancer patients undergoing TPL from 25 Japanese institutions. Rates of recurrence and risk factors for hypoparathyroidism, as well as incidence of pathological contralateral level VI nodal metastasis and stomal recurrence, were investigated.

RESULTS

The extent of thyroidectomy and nodal dissection were not independent risk factors for recurrence. Incidences of contralateral level VI nodal involvement and stomal recurrence were 1.8% and 1.2%, respectively. Patients undergoing hemithyroidectomy/ipsilateral PTND did not develop stomal recurrence and had the lowest incidence of hypoparathyroidism. Prognosis in patients without tracheostomy prior to hemithyroidectomy/ipsilateral PTND was comparable to that with more extensive resections.

CONCLUSIONS

Hemithyroidectomy/ipsilateral PTND may be sufficient for pyriform sinus cancer cases without tracheostomy.

Quantification of bone metabolic activity in the natural course of fractural lesions measured by quantitative SPECT/CT

Objectives

While increased uptake at the bone fractural site gradually decreases over time on bone scans, the rate of change has not been quantitatively evaluated. The purpose of this study was to quantify the extent of bone metabolic changes in fractural lesions on bone SPECT/CT.

Methods

We reviewed bone scans acquired by dedicated SPECT/CT and chose those scans in which quantitative SPECT/CT of the same range was acquired twice or more. We set the region of interest on lesions of bone fracture and degeneration, and measured the maximum standardized uptake value (SUV_max). From the SUV_max of lesions and the interval between scans, a value for 30-day change in SUV_max was calculated as ∆SUV_max30d. The relationship between preSUV_max, SUV_max for the first scan of the comparison, and ∆SUV_max30d was evaluated utilizing a linear least-squares method. Furthermore, we assessed the ability to differentiate between fracture and degeneration using receiver operating characteristics (ROC) analysis and the Mann-Whitney U test. All cases were then categorized into five groups according to preSUV_max. Values of p <0.05 were considered statistically significant.

Results

We investigated 175 scans from 60 patients and analyzed scan combinations for 157 fractural lesions and 266 degenerative lesions. The relationship between preSUV_max of fractural lesions and ∆SUV_max30d was approximated as ∆SUV_max30d =-0.15×preSUV_max +1.35 (R ²=0.60, p<0.0001). Area under the curves for all cases, 30≤ preSUV_max, 20≤ preSUV_max <30, 15≤ preSUV_max <20, 10≤ preSUV_max <15, and preSUV_max <10 were 0.73, 0.89, 0.86, 0.80, 0.91, and 0.59, respectively. Median ∆SUV_max30d was significantly lower at fractural lesions than at degenerative lesions (-0.62 vs -0.04; p <0.0001). As for analyses of groups divided by preSUV_max, all median ∆SUV_max30d for fractural lesions were significantly lower than those of degenerative lesions except for the group with preSUV_max <10.

Conclusion

The increased uptake at the fractural bone lesion observed in the quantitative bone SPECT/CT gradually decreased at the rate of SUV 0.15 per month, which showed a different trend with degenerative change.

Postoperative Complications Following Pharyngolaryngectomy With Total Esophagectomy: Comparison Between Cervical and Anterior Mediastinal Tracheostomy

OBJECTIVES

Pharyngolaryngectomy with total esophagectomy (PLTE) is associated with high morbidity and mortality rates. Cervical tracheostomy (CT) is the first choice of tracheostomy, whereas anterior mediastinal tracheostomy (AMT) is sometimes required due to tumor extension or insufficient blood supply to the tracheal tip. However, the differences in the outcomes between CT and AMT after PLTE remain unclear.

METHODS

We retrospectively reviewed 67 patients who underwent PLTE and compared the clinical features and postoperative complications between patients with CT and AMT. The characteristics and the outcomes were compared between the groups stratified by the causes of AMT.

RESULTS

Of the 67 patients, 42 (62.7%) patients underwent PLTE with CT (CT group), whereas 25 (37.3%) underwent PLTE with AMT (AMT group). The AMT group included more cervicothoracic esophageal cancers and had showed an advanced T stage compared to the CT group (P < .01 and .01, respectively). The incidences of pneumonia and surgical site infection (SSI) were more frequent in the AMT group than in the CT group (P = .03 and .01, respectively). Surgery-related mortality was only observed in the AMT group. In the AMT group, 17 (68.0%) and 8 (32.0%) patients underwent AMT because of tumor extension and insufficient supply to the tracheal tip. The latter cases underwent transthoracic esophagectomy more frequently than former cases (P = .03).

CONCLUSION

AMT after PLTE had more postoperative complications and mortality than CT. In cases that may need AMT, a transthoracic approach is preferable over transhiatal esophagectomy to avoid fatal complications when oncologically permissive.

Satisfied quantitative value can be acquired by short-time bone SPECT/CT using a whole-body cadmium-zinc-telluride gamma camera

The aim of this study was to evaluate the quantitative values of short-time scan (STS) of metastatic lesions compared with a standard scan (SS) when acquired by whole-body bone SPECT/CT with cadmium-zinc-telluride (CZT) detectors. We retrospectively reviewed 13 patients with bone metastases from prostate cancer, who underwent SPECT/CT performed on whole-body CZT gamma cameras. STSs were obtained using 75, 50, 25, 10, and 5% of the list-mode data for SS, respectively. Regions of interest (ROIs) were set on the increased uptake areas diagnosed as metastases. Intraclass correlation coefficients (ICCs) of standardized uptake values (SUVs) for the ROIs were calculated between the SS and each STS, and ICC ≥ 0.8 was set as a perfect correlation. Moreover, the repeatability coefficient (RC) was calculated, and RC ≤ 20% was defined as acceptable. A total of 152 metastatic lesions were included in the analysis. The ICCs between the SS vs. 75%-STS, 50%-STS, 25%-STS, 10%-STS, and 5%-STS were 0.999, 0.997, 0.994, 0.983, and 0.955, respectively. The RCs of the SS vs. 75%-STS, 50%-STS, 25%-STS, 10%-STS, and 5%-STS were 7.9, 12.4, 19.8, 30.8, and 41.3%, respectively. When evaluating the quality of CZT bone SPECT/CT acquired by a standard protocol, 25%-STS may provide adequate quantitative values.

Can the function of the tubarial glands be evaluated using [99mTc]pertechnetate SPECT/CT, [18F]FDG PET/CT, and [11C]methionine PET/CT?

BACKGROUND

The tubarial glands (TGs) are recently reported as newly found salivary gland structures that can be organs at risk predominantly localized in the tori tubarius in the nasopharynx using prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT). The aims of this study were to analyze uptake in the TGs compared with that in the other salivary glands and palatine tonsils using [^99mTc]pertechnetate SPECT/CT, [¹⁸F]FDG PET/CT, and [¹¹C]methionine PET/CT and to confirm whether these three imaging modalities are useful in evaluating the physiological function of the TGs. Twelve and 130 patients, who underwent [^99mTc]pertechnetate SPECT/CT and [¹⁸F]FDG/[¹¹C]methionine PET/CT, respectively, were retrospectively included. [^99mTc]pertechnetate uptake in the tori tubarius was visually assessed and semiquantitatively compared with that in the background, parotid salivary glands (PSGs), submandibular salivary glands (SmSGs), and sublingual salivary glands (SlSGs). Correlations of [¹⁸F]FDG and [¹¹C]methionine uptakes in the tori tubarius with those in the other three salivary glands and palatine tonsils were analyzed.

RESULTS

[^99mTc]pertechnetate uptake in the tori tubarius was invisible and was not significantly higher than that in the background. Both [¹⁸F]FDG and [¹¹C]methionine uptakes in the tori tubarius were correlated with that in the palatine tonsils (r = 0.56, p < 0.0001; r = 0.48, p < 0.0001, respectively). [¹⁸F]FDG uptake in the tori tubarius was not positively correlated with that in the PSGs, SmSGs, and SlSGs (r = - 0.19, p = 0.03; r = - 0.02, p = 0.81; r = 0.12, p = 0.17, respectively). [¹¹C]methionine uptake in the tori tubarius was correlated with that in the SmSGs and SlSGs (r = 0.24, p = 0.01; r = 0.32, p < 0.01, respectively), but not with that in the PSGs (r = 0.16, p = 0.08).

CONCLUSIONS

The TGs were undetectable on [^99mTc]pertechnetate SPECT/CT. Both [¹⁸F]FDG and [¹¹C]methionine uptakes in the tori tubarius were clearly affected by that in the palatine tonsils and was little related to that in the other salivary glands. Therefore, it seems difficult to evaluate the physiological function of the TGs as salivary glands using [^99mTc]pertechnetate SPECT/CT, [¹⁸F]FDG PET/CT, and [¹¹C]methionine PET/CT imaging.

The complete mitochondrial genome sequences of Japanese earthworms Metaphire hilgendorfi and Amynthas yunoshimensis (Clitellata: Megascolecidae)

Many studies have reported the complete mitochondrial genome sequences of Chinese Megascolecidae earthworms, however, there have been no reports on sequences originating from Japanese Megascolecidae earthworms. In this study, we determined complete mitochondrial genome sequences of two Japanese earthworms belonging to the Pheretima complex within the Megascolecidae family. Metaphire hilgendorfi is one of the most common earthworms in Japan and Amynthas yunoshimensis was found to be morphologically similar to M. hilgendorfi. The complete mitochondrial genomes of M. hilgendorfi (15,186 bp; LC573968) and A. yunoshimensis (15,109 bp; LC573969) contained typical 13 protein coding genes, 22 tRNA genes, and 2 rRNA genes. The phylogenetic analysis revealed that these two species were sister species. Therefore, our findings will further contribute to phylogenetic and genetic diversity analyses of Megascolecidae earthworms.

Artificial intelligence-based detection of pharyngeal cancer using convolutional neural networks

OBJECTIVES

The prognosis for pharyngeal cancer is relatively poor. It is usually diagnosed in an advanced stage. Although the recent development of narrow-band imaging (NBI) and increased awareness among endoscopists have enabled detection of superficial pharyngeal cancer, these techniques are still not prevalent worldwide. Nevertheless, artificial intelligence (AI)-based deep learning has led to significant advancements in various medical fields. Here, we demonstrate the diagnostic ability of AI-based detection of pharyngeal cancer from endoscopic images in esophagogastroduodenoscopy.

METHODS

We retrospectively collected 5403 training images of pharyngeal cancer from 202 superficial cancers and 45 advanced cancers from the Cancer Institute Hospital, Tokyo, Japan. Using these images, we developed an AI-based diagnostic system with convolutional neural networks. We prepared 1912 validation images from 35 patients with 40 pharyngeal cancers and 40 patients without pharyngeal cancer to evaluate our system.

RESULTS

Our AI-based diagnostic system correctly detected all pharyngeal cancer lesions (40/40) in the patients with cancer, including three small lesions smaller than 10 mm. For each image, the AI-based system correctly detected pharyngeal cancers in images obtained via NBI with a sensitivity of 85.6%, much higher sensitivity than that for images obtained via white light imaging (70.1%). The novel diagnostic system took only 28 s to analyze 1912 validation images.

CONCLUSIONS

The novel AI-based diagnostic system detected pharyngeal cancer with high sensitivity. It could facilitate early detection, thereby leading to better prognosis and quality of life for patients with pharyngeal cancers in the near future.

Digestive Reconstruction After Pharyngolaryngectomy with Total Esophagectomy

BACKGROUND

Pharyngolaryngectomy with total esophagectomy (PLTE) is often indicated for patients with synchronous head and neck cancer and thoracic esophageal cancer or those with head and neck cancer extending to the upper mediastinum. A long conduit is required for the reconstruction, and the blood flow at the tip of the conduit is not always sufficient. Thus, reconstructive surgery after PLTE remains challenging, and optimal reconstruction methods have not been elucidated to date.

METHODS

This analysis investigated 65 patients who underwent PLTE. The short-term outcomes among the procedures were compared to explore the optimal digestive reconstruction methods.

RESULTS

We used a simple gastric conduit for 7 patients, a gastric conduit with microvascular anastomosis (MVA) for 10 patients, an elongated gastric conduit with an MVA for 20 patients, a gastric conduit combined with a free jejunum transfer (FJT) for 25 patients, and other procedures for 3 patients. Postoperatively, 17 (26.2%) of the patients experienced severe complications, classified as Clavien-Dindo grade 3b or higher, including graft failure for 3 patients (6.2%). Anastomotic leakage was found in six patients (9.2%), and all leakages occurred at the pharyngogastric anastomosis. The reoperation rate was 15.4% (n = 10), and three patients (4.6%) died of massive bleeding from major vessels. The patients who underwent simple gastric conduit more frequently had graft failure (P = 0.04), anastomotic leakage (P < 0.01), and reoperation (P = 0.04) than the patients treated with the other reconstructive methods.

CONCLUSION

Additional procedures such as MVA, gastric tube elongation, and FJT contribute to improving the outcomes of reconstruction after PLTE.

[18F]FMISO PET/CT as a preoperative prognostic factor in patients with pancreatic cancer

Background

While [¹⁸F]fluoromisonidazole (FMISO), a representative PET tracer to detect hypoxia, is reported to be able to prospect the prognosis after treatment for various types of cancers, the relation is unclear for pancreatic cancer. The aim of this study is to assess the feasibility of [¹⁸F]FMISO PET/CT as a preoperative prognostic factor in patients with pancreatic cancer.

Methods

Patients with pancreatic cancer who had been initially planned for surgery received [¹⁸F]FMISO PET/CT. Peak standardized uptake value (SUV) of the pancreatic tumor was divided by SUVpeak of the aorta, and tumor blood ratio using SUVpeak (TBRpeak) was calculated. After preoperative examination, surgeons finally decided the operability of the patients. TBRpeak was compared with hypoxia-inducible factor (HIF)-1α immunohistochemistry when the tissues were available. Furthermore, correlation of TBRpeak with the recurrence-free survival and the overall survival were evaluated by Kaplan-Meyer methods.

Results

We analyzed 25 patients with pancreatic adenocarcinoma (11 women and 14 men, median age, 73 years; range, 58–81 years), and observed for 39–1101 days (median, 369 days). Nine cases (36.0%) were identified as visually positive of pancreatic cancer on [¹⁸F]FMISO PET/CT images. TBRpeak of the negative cases was significantly lower than that of the positive cases (median 1.08, interquartile range (IQR) 1.02–1.15 vs median 1.50, IQR 1.25–1.73, p < 0.001), and the cutoff TBRpeak was calculated as 1.24. Five patients were finally considered inoperable. There was no significant difference in TBRpeak of inoperable and operable patients (median 1.48, IQR 1.06–1.98 vs median 1.12, IQR 1.05–1.21, p = 0.10). There was no significant difference between TBRpeak and HIF-1α expression (p = 0.22). The patients were dichotomized by the TBRpeak cutoff, and the higher group showed significantly shorter recurrence-free survival than the other (median 218 vs 441 days, p = 0.002). As for overall survival of 20 cases of operated patients, the higher TBRpeak group showed significantly shorter overall survival than the other (median survival, 415 vs > 1000 days, p = 0.04).

Conclusions

[¹⁸F]FMISO PET/CT has the possibility to be a preoperative prognostic factor in patients with pancreatic cancer.

Electronic supplementary material

The online version of this article (10.1186/s13550-019-0507-8) contains supplementary material, which is available to authorized users.

Incidence and risk factors of interstitial lung disease of patients with head and neck cancer treated with cetuximab

BACKGROUND

Interstitial lung disease (ILD) is known as a potentially severe adverse event associated with epidermal growth factor receptor (EGFR)-targeted therapy. The incidence and risk factors of ILD in patients with head and neck squamous cancer (HNSCC) treated with cetuximab, an anti-EGFR monoclonal antibody, have not been established.

METHODS

We retrospectively reviewed patients with HNSCC who received cetuximab from December 2012 to December 2016 at our institute and evaluated the incidence and risk factors of ILD.

RESULTS

Of the 201 patients with HNSCC, ILD was observed in 9 patients (4.5%), 8 of whom had grade 3 or higher. High Krebs von den Lungen-6 (KL-6) and ≥50 pack-years of smoking were significantly predictive of associated with ILD (P = 0.00011 and 0.05, respectively).

CONCLUSION

The incidence of ILD in patients with HNSCC treated with cetuximab was <5%, but most of the ILD cases were severe. High KL-6 and smoking histories might be predictive for ILD among patients with HNSCC.

Quantification of osteoblastic activity in epiphyseal growth plates by quantitative bone SPECT/CT

OBJECTIVE

Quantifying the function of the epiphyseal plate is worthwhile for the management of children with growth disorders. The aim of this retrospective study was to quantify the osteoblastic activity at the epiphyseal plate using the quantitative bone SPECT/CT.

MATERIALS AND METHODS

We enrolled patients under the age of 20 years who received Tc-99m hydroxymethylene diphosphonate bone scintigraphy acquired by a quantitative SPECT/CT scanner. The images were reconstructed by ordered subset conjugate-gradient minimizer, and the uptake on the distal margin of the femur was quantified by peak standardized uptake value (SUVpeak). A public database of standard body height was used to calculate growth velocities (cm/year).

RESULTS

Fifteen patients (6.9-19.7 years, 9 female, 6 male) were enrolled and a total of 25 legs were analyzed. SUVpeak in the epiphyseal plate was 18.9 ± 2.4 (average ± standard deviation) in the subjects under 15 years and decreased gradually by aging. The SUVpeak correlated significantly with the age- and sex-matched growth velocity obtained from the database (R² = 0.83, p < 0.0001).

CONCLUSION

The SUV measured by quantitative bone SPECT/CT was increased at the epiphyseal plates of children under the age of 15 years in comparison with the older group, corresponding to higher osteoblastic activity. Moreover, this study suggested a correlation between growth velocity and the SUV. Although this is a small retrospective pilot study, the objective and quantitative values measured by the quantitative bone SPECT/CT has the potential to improve the management of children with growth disorder.

Skeletal standardized uptake values obtained by quantitative SPECT/CT as an osteoblastic biomarker for the discrimination of active bone metastasis in prostate cancer

Purpose

To investigate the improvement of prognostication of active bone metastatic burden by discriminating bone metastases from degenerative changes in hot foci, using skeletal standardized uptake values (SUVs) by quantitative bone single photon emission tomography/computed tomography (SPECT/CT) in patients with prostate cancer.

Methods

We investigated 170 patients with prostate cancer who underwent skeletal quantitative SPECT/CT using ^99mTc-methylene-diphosphonate (MDP), through conjugate gradient reconstruction with tissue zoning, attenuation, and scatter corrections applied, called as CGZAS reconstruction, in a retrospective cohort study. The maximum, peak, and average SUVs (SUVmax, SUVpeak, and SUVave, respectively) were obtained for visually normal thoracic (T; n = 100) and lumbar (L; n = 140) vertebral bodies as controls, as well as for bone metastases (n = 126) and degenerative changes (n = 114) as hot foci. They were also correlated with age, body-weight, height, biochemistry data, and extent of disease (EOD). Discrimination accuracy of the SUVs for bone metastases in hot foci was evaluated by a patient-based and lesion-based receiver-operator characteristic curve (ROC) analysis.

Results

The skeletal SUVmax was 7.58 ± 2.42 for T, 8.12 ± 12.24 for L, 16.73 ± 6.74 for degenerative changes, and 40.90 ± 33.46 for bone metastases. The SUVs of the bone metastasis group were significantly (p < 0.001) greater than of the other three groups. With disease extent, serum alkaline phosphatase and prostate specific antigen were increased, while SUVs for bone metastases were decreased in EOD grade 4. In ROC analyses for bone metastases by skeletal SUVs demonstrating the diagnostic accuracy of skeletal SUVs for discriminating bone metastasis from degenerative changes in hot foci, area under curves were 0.840, 0.817, and 0.845 in patient-based mode, and 0.932, 0.920, and 0.930 in lesion-based mode.

Conclusions

The skeletal SUVs by ^99mTc-MDP SPECT/CT for active bone metastases were greater than those for degenerative changes in patients with prostate cancer, with a feasible discrimination accuracy in the hot foci. Therefore, skeletal SUVs, especially SUVmax, in quantitative bone SPECT/CT may be helpful indices for the prognostication of bone metastatic burden, improving discrimination of active bone osteoblastic metastases in patients with prostate cancer from frequently coexisting degenerative changes.

Indwelling voice prosthesis insertion after total pharyngolaryngectomy with free jejunal reconstruction

Objectives

Total pharyngolaryngectomy with free jejunal reconstruction is often performed in patients with hypopharyngeal carcinoma. However, postoperative speechlessness significantly decreases patient quality of life. We investigated whether Provox® insertion could preserve speech after total pharyngolaryngectomy with free jejunal reconstruction.

Study Design

Retrospective chart review.

Methods

A total of 130 cases of secondary Provox® insertions after total pharyngolaryngectomy with free jejunal reconstruction were analyzed. Communication outcomes were compared using the Head and Neck Cancer Understandability of Speech Subscale. Outcomes and complications associated with insertion site (jejunal insertion vs. esophageal insertion) and adjuvant irradiation therapy were also evaluated.

Results

Provox® insertion had favorable communication outcomes in 102 cases (78.4%). Neither the insertion site nor irradiation affected the communication outcome. Complications were observed in 20 cases (15.4%). Local infection was the most common complication. Free jejunal insertion, in which the resection range was enlarged, had a lower complication rate than did esophageal insertion, and its complication rate was unaffected by previous irradiation. For all patients, the hospitalization duration and duration of speechlessness were 13.4 days and 14.6 months, respectively. Patients receiving jejunal insertions had a significantly shorter hospitalization duration than did those receiving esophageal insertions. Unlike Provox®2, Provox®Vega significantly reduced the complication rate to zero.

Conclusion

For jejunal inserson of a Provox® prosthetic, a sufficient margin can be maintained during total pharyngolaryngectomy and irradiation can be performed, and satisfactory communication outcomes were observed. Provox® insertion after total pharyngolaryngectomy with free jejunal reconstruction should be considered the standard therapy for voice restoration.

Level of Evidence

4.

Functional status of the articularis genus muscle in individuals with knee osteoarthritis

OBJECTIVES

To clarify the functional status of the articularis genus muscle (AGM) in individuals with knee osteoarthritis (OA) and to analyze the muscle's relationship with knee OA.

METHODS

Fifty-two individuals with knee OA (mean age, 73.4 years), 50 elderly individuals without knee OA changes (mean age, 71.2 years) and 75 young individuals (mean age, 20.2 years) were observed the AGM using ultrasonography. The thickness of the AGM, the anteroposterior distance of the suprapatellar bursa, and moving distance of the muscle insertion were measured both at rest and during isometric contraction, and values during contraction were expressed as percentages of the values at rest (%Muscle-Increase, %Bursa-Increase).

RESULTS

Muscle thickness at rest, %Muscle-Increase, %Bursa-Increase, and moving distance of the muscle insertion were significantly lower and anteroposterior distance of the suprapatellar bursa was significantly higher in the OA group than in the controls (p<0.001, all). In the OA group, these values for the AGM were significantly correlated with knee range of motion, knee pain, and Kellgren and Lawrence grade.

CONCLUSIONS

Individuals with knee OA exhibited atrophic changes and dysfunctions of the AGM, and these were associated with symptoms. Atrophic changes and dysfunctions of the AGM may be specific changes associated with knee OA.

[Total Glossolaryngectomy of an Advanced Oropharyngeal and Tongue Squamous-Cell Carcinoma: A 29-Case Series Study]

We report herein on 29 patients with advanced oropharyngeal and tongue squamous-cell carcinoma who underwent a total glossolaryngectomy at the Cancer Institute Hospital of the JFCR between July 2005 and June 2013. In this study, we tried to evaluate associations between several variables of the primary tumor and prognosis in these 29 patients. The cause-specific 5-year survival rate with the Kaplan-Meier method was 45% in all patients. Tumor recurrence occurred in 15 patients. Four patients had recurrence in the primary site, 11 patients in neck lymph nodes or in the lungs or bone. The multivariate analysis revealed that the number of neck lymph node metastases, age and alcohol drinking were poor prognostic markers for patients undergoing a total glossolaryngectomy. Cause-specific survival was compared between patients with salvage surgery and initial surgery using Kaplan-Meier survival curves with log-rank tests. There was no significant association with survival (log-rank test: p = 0.13). The overall local control rate was 69% in all patients. Regarding salvage surgery, 9 of 16 patients had no recurrence in the primary site or neck lymph nodes. The limitations of this study include the small number of patients especially regarding the prognosis study and may have included a selection bias regarding undergoing a total glossolaryngectomy.

A Clinical Study of Pharyngolaryngectomy with Total Esophagectomy: Postoperative Complications, Countermeasures, and Prognoses

OBJECTIVE

Patients with advanced hypopharyngeal or cervical esophageal cancer have a comparatively high risk of also developing thoracic esophageal cancer. Pharyngolaryngectomy with total esophagectomy is highly invasive, and few reports about it exist. We examined the postoperative complications and respective countermeasures and prognoses of patients who underwent pharyngolaryngectomy with total esophagectomy.

STUDY DESIGN

Case series with chart review.

SETTING

Department of Head and Neck Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Japan.

SUBJECTS AND METHODS

We examined the postoperative complications and respective countermeasures and prognoses of 40 patients who underwent pharyngolaryngectomy with total esophagectomy in our hospital.

RESULTS

Postoperative complications were observed in 23 patients (57.5%) and consisted of 8 groups: tracheal region necrosis in 5 patients; neck abscess formation/wound infection in 5; fistula in 4; tracheostomy suture leakage in 2; ileus in 2; lymphorrhea in 2; pulmonary complications in 2; and other complications, including hemothorax, tracheoinnominate artery fistula, temporary cardiac arrest due to intraoperative mediastinum operation, methicillin-resistant Staphylococcus aureus enteritis, and sepsis, in 1 patient each. A lethal complication-brachiocephalic vein hemorrhage due to tracheostomy suture leakage and hemorrhagic shock due to tracheoinnominate artery fistula-occurred in 2 (5%) patients. The crude 5-year survival rate was 48.6%.

CONCLUSIONS

Serious postoperative complications were related to tracheostomaplasty. Although pharyngolaryngectomy with total esophagectomy is highly invasive, we believe that our outlined treatment method is the most appropriate for cases of advanced hypopharyngeal or cervical esophageal cancer that also requires concurrent surgery for esophageal cancer.

Chemotherapy for anaplastic thyroid cancer using docetaxel and cisplatin: report of eight cases

Anaplastic thyroid carcinoma has a dismal prognosis and lacks an established therapeutic strategy. We have recently conducted chemotherapy with docetaxel and cisplatin as part of multimodal treatment for eight patients with anaplastic thyroid carcinoma. Docetaxel (75 mg/m²) and cisplatin (75 mg/m²) were administered on day 1 every 4 weeks for six courses. This chemotherapy was used as induction therapy in one patient, as therapy for distant metastases in five patients and as postoperative adjuvant therapy in two patients. Three patients showed partial responses and three patients showed stable disease. After excluding the two patients receiving the treatment as adjuvant therapy the response rate was 50 %. Grade 3 or 4 leukocytopenia occurred in seven patients (88 %), but these adverse events were tolerable. Chemotherapy with docetaxel and cisplatin may thus be feasible for anaplastic thyroid carcinoma.

Pilot data on telmisartan short-term effects on glucose metabolism in the olfactory tract in Alzheimer's disease

The possible effect of antihypertensive therapy on Alzheimer's disease (AD) has been studied, and angiotensin II receptor blockers (ARBs) have been suggested to exert an effect on cognitive decline. The purpose of this study is to clarify the functional effects of telmisartan, a long-acting ARB, on AD brain using prospective longitudinal (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) studies. For this purpose, brain glucose metabolism of four hypertensive patients with AD was examined with FDG-PET before and after administration of telmisartan. Studied subjects underwent three FDG-PET studies at intervals of 12 weeks. Antihypertensive treatment except for telmisartan was started after the first FDG-PET and continued for 24 weeks. Then 40-80 mg of telmisartan was added after the second FDG-PET and continued for 12 weeks.Glucose metabolism was significantly decreased during the first 12 weeks without telmisartan use at an area (-10, 21, -22, x, y, z; Z = 3.56) caudal to the left rectal gyrus and the olfactory sulcus corresponding to the left olfactory tract. In contrast, the introduction of telmisartan during the following 12 weeks preserved glucose metabolism at areas (5, 19, -20, x, y, z; Z = 3.09; 6, 19, -22, x, y, z; Z = 2.88) caudal to the bilateral rectal gyri and olfactory sulci corresponding to the bilateral olfactory tracts. No areas showed decreased glucose metabolism after the introduction of telmisartan. In AD, amyloid-β deposition is observed in the anterior olfactory nucleus (AON) of the olfactory tract. Glucose metabolism in AON may be progressively decreased and preserved by telmisartan.

Evaluation of both perfusion and atrophy in multiple system atrophy of the cerebellar type using brain SPECT alone

Background

Partial volume effects in atrophied areas should be taken into account when interpreting brain perfusion single photon emission computed tomography (SPECT) images of neurodegenerative diseases. To evaluate both perfusion and atrophy using brain SPECT alone, we developed a new technique applying tensor-based morphometry (TBM) to SPECT.

Methods

After linear spatial normalization of brain perfusion SPECT using ^99mTc-ethyl cysteinate dimer (^99mTc-ECD) to a Talairach space, high-dimension-warping was done using an original ^99mTc-ECD template. Contraction map images calculated from Jacobian determinants and spatially normalized SPECT images using this high-dimension-warping were compared using statistical parametric mapping (SPM2) between two groups of 16 multiple system atrophy of the cerebellar type (MSA-C) patients and 73 age-matched normal controls. This comparison was also performed in conventionally warped SPECT images.

Results

SPM2 demonstrated statistically significant contraction indicating local atrophy and decreased perfusion in the whole cerebellum and pons of MSA-C patients as compared to normal controls. Higher significance for decreased perfusion in these areas was obtained in high-dimension-warping than in conventional warping, possibly due to sufficient spatial normalization to a ^99mTc-ECD template in high-dimensional warping of severely atrophied cerebellum and pons. In the present high-dimension-warping, modification of tracer activity remained within 3% of the original tracer distribution.

Conclusions

The present new technique applying TBM to brain SPECT provides information on both perfusion and atrophy at the same time thereby enhancing the role of brain perfusion SPECT

Effective cellulose production by a coculture of Gluconacetobacter xylinus and Lactobacillus mali

A microbial colony that contained a marked amount of cellulose was isolated from vineyard soil. The colony was formed by the associated growth of two bacterial strains: a cellulose-producing acetic acid bacterium (st-60-12) and a lactic acid bacterium (st-20). The 16S rDNA-based taxonomy indicated that st-60-12 belonged to Gluconacetobacter xylinus and st-20 was closely related to Lactobacillus mali. Cocultivation of the two organisms in corn steep liquor/sucrose liquid medium resulted in a threefold higher cellulose yield when compared to the st-60-12 monoculture. A similar enhancement was observed in a coculture with various L. mali strains but not with other Lactobacillus spp. The enhancement of cellulose production was most remarkable when sucrose was supplied as the substrate. L. mali mutants for exocellular polysaccharide (EPS) production were defective in promoting cellulose production, but the addition of EPS to the monoculture of st-60-12 did not affect cellulose productivity. Scanning electron microscopic observation of the coculture revealed frequent association between the st-60-12 and L. mali cells. These results indicate that cell-cell interaction assisted by the EPS-producing L. mali promotes cellulose production in st-60-12.

Pathogenic potentials of glycoprotein C-negative syncytial mutants from rabbit T cells infected persistently with herpes simplex virus type 1

Human T cell lymphotropic virus type I (HTLV-I)-transformed T cells of rabbits were infected persistently with Herpes simplex virus type 1 (HSV-1) strain KOS. These infected cells yielded syncytial mutants, either glycoprotein C (gC)-negative or -positive, which predominated over and replaced the wild-type virus in a long-term culture for 2 years. An alignment of nucleotide sequences showed multiple mutations in glycoprotein B (gB) and gC genes of these mutants, which are or may be responsible for the mutant phenotypes. One of four mutants analyzed produced extensively large syncytia and possessed point mutations within the cytoplasmic domain of gB. All four mutants possessed multiple point mutations in gC and two possessed single insertions which resulted in a frame shift, leading to the premature termination of the gC polypeptide chain. The supernatant of the 2-year culture of cells infected persistently, containing only gC-negative syncytial mutants, induced encephalitic symptoms in B/Jas inbred rabbits, when injected intravenously. One gC-negative syncytial isolate from an encephalitic lesion, together with those from the culture supernatant, were examined for pathogenic potential in vitro and in vivo. All these mutants were more cytotoxic and more susceptible to complement inactivation than the parental virus, and could infect and replicate in adrenal glands when injected intravenously into rabbits. Invasion into the central nervous system appeared to be blocked at the portal of entry, the adrenal gland, i.e., none exhibited neuroinvasive potential by itself. Syncytial gC-negative mutants could thus be pathogenic in rabbits.

[3D-CT highly useful in diagnosing foreign bodies in the paraesophageal orifice]

Multislice computed tomography (CT) enables rapid, easy construction of 3-dimensional CT images (3D-CT), aiding diagnostic imaging. 3D-CT is reported to be highly useful in diagnosing temporal bone disorders, in otorhinolaryngology, especially abnormal shape and the ossicular chain of the auditory ossicles and facial bone fractures. Given the complexity of laryngeal anatomy, 3D-CT is useful in diagnosing the extent of infiltration of laryngeal cancer and in examining vocal cord movement, which is difficult to evaluate by conventional CT, magnestic resonance imaging (MRI), and fiberscopy. Among patients seen for a suspected foreign body between June 2002 and May 2003, we chose 3 in whom laryngoscopy at the first examination could not detect a foreign body but in whom symptoms and findings suggested such presence in the paraesophageal orifice. In all 3 cases, 3D-CT imaging showed the size, length, location, and direction of the foreign body, providing information useful for the surgical approach.

Specific gene silencing in the pre-implantation stage mouse embryo by an siRNA expression vector system

Recently, small interfering RNAs (siRNAs) have become a powerful and widely used tool for the analysis of gene function in mammalian cells. Here we report that the microinjection of an siRNA expression vector into the nucleus is an efficient and powerful method of specific gene silencing in pre-implantation mouse embryos. We used this method to examine the expression of two genes EGFP and Oct4. Vectors encoding siRNAs targeted against EGFP or Oct4 were injected into the pronucleus or nucleus of zygotes, which were then cultured until the blastocyst stage. When the effects of RNAi were examined in blastocyst stage eggs, there was robust inhibition of the gene product in a concentration-dependent manner at both the mRNA and the protein level. The expression of other endogenous genes was not affected, showing the specificity of the vector-mediated RNAi. In addition, this method was effective for inhibiting maternally expressed mRNA. To demonstrate that RNAi of Oct4 induced a similar phenotype to that of Oct4-null embryos, the blastocysts were further cultured in ES medium. After the fourth day of culture, the embryos either had outgrown only a layer of trophoblast cells or showed developmental arrest at the blastocyst stage (>90%). Moreover, concomitant with Oct4 suppression at the blastocyst stage, we observed inhibition of Fgf4, a gene that is known to be induced downstream of Oct4 expression. Taken together, these results demonstrate that the use of siRNA expression vector is a powerful way to achieve gene silencing in the pre-implantation stage embryo.

Failure of radioiodine treatment in Graves’ disease intentionally caused by a patient: Suspected Munchausen syndrome

We experienced a case with Graves' disease in which radioiodine treatment failed probably because of intentional spitting out of capsules of radioactive iodide. Chemical analysis of the substances collected from the trash in the treatment room demonstrated that its profile was the same as that of the capsules for radioiodine administration. Measurement of the iodine concentrations in a blood sample obtained at 24 h after the administration of radioiodine indicated that the patient showed iodine excess. These findings suggest that this may be a case of Munchausen syndrome.

Effective extracellular trehalose production by Cellulosimicrobium cellulans

A bacterium isolated from a petal of Casa Blanca Lily (ST26 strain) produced a marked amount of extracellular trehalose (alpha- d-glucopyranosyl-[1,1]-alpha- d-glucopyranose) in culture medium containing glucose. 16S rDNA-based phylogeny showed that ST26 belongs to, or is related to, Cellulosimicrobium cellulans, a close relative of Cellulomonas spp. Various Cellulomonas strains obtained from culture collections also showed extracellular trehalose productivity, suggesting that trehalose production is a common property of this bacterial genus. ST26 accumulated trehalose in medium supplied with glucose but not with sucrose, glycerol or maltose. Effective extracellular trehalose production by ST26 was achieved by supplying 0.5-1% ammonium sulfate and 0.5-1% CaCO(3). The addition of CaCO(3) adjusted the pH of the culture to around 5.0. The optimized culture conditions yielded trehalose from glucose at a conversion rate of 61%. The addition of ammonium sulfate greatly reduced the dry cell weight of ST26 and intracellular content of trehalose, which suggests that the addition of ammonium sulfate makes ST26 cells leak trehalose into the medium. ST26 effectively propagated in minimal medium containing trehalose as a sole carbon source, which suggests that trehalose serves as a carbohydrate reserve of this organism.

Corynebacterium efficiens sp. nov., a glutamic-acid-producing species from soil and vegetables

Three glutamic-acid-producing coryneform strains were isolated from soil and vegetable samples. Chemotaxonomic investigations indicated that these strains belonged to the genus Corynebacterium. Phylogenetic studies, based on 16S rDNA analysis, demonstrated that the three strains formed a distinct cluster within the genus Corynebacterium and that their nearest relatives were Corynebacterium glutamicum and Corynebacterium callunae, also known as glutamic-acid-producing species. The data from 16S rDNA sequence and DNA-DNA relatedness studies clearly indicated that the three isolates represented a new species within the genus Corynebacterium. All of the isolates could grow at 45 degrees C and produced acid from dextrin; these were the most significant characteristics differentiating the three isolates from their neighbours. On the basis of the data presented here, it is proposed that the three glutamic-acid-producing isolates together be classified as Corynebacterium efficiens sp. nov., the type strain of which is YS-314T (= AJ 12310T = JCM 11189T = DSM 44549T).

Involvement of MAPK activation in bacterial endotoxin-inducible tissue factor upregulation in human monocytic THP-1 cells

BACKGROUND

Monocytic tissue factor (mTF) hypercoagulation leading to thrombotic complications is commonly observed following sepsis.

OBJECTIVE

We herein study the intracellular mechanism of mTF upregulation in human model monocytic THP-1 cells in response to bacterial endotoxin (lipopolysaccharide, LPS; Escherichia coli O111:B04), determining if mitogen-activated protein kinase (MAPK) activation is involved in the signaling.

METHODS

We assessed mTF upregulation by its cell surface expression, protein synthesis, and functional activity based on flow cytometry, Western blotting analysis, and a single-stage clotting assay, respectively.

RESULTS

A 3-h challenge with LPS (100 ng/ml) drastically induced mTF functional activity, accompanied by elevated surface mTF expression and synthesis. The suppression by genistein (G) of LPS-inducible mTF upregulation implied the involvement of protein tyrosine kinase activation in mTF upregulation. LPS activated MAPK, which was significantly depressed by G, SB 203580 (SB), and PD 98058 (PD). Interestingly, inclusion of SB and PD also markedly diminished LPS-inducible mTF upregulation. The parallelism between MAPK and mTF activities revealed the involvement of MAPK activation in such mTF upregulation. Based on the ability of SB and PD to respectively block LPS-inducible tyrosine phosphorylation of p38 MAPK and Erk1/2, it was evident that tyrosine phosphorylation of MAPKs is required for mediating LPS-inducible mTF synthesis and upregulation. Contrasting with the established prevention of mTF upregulation by these inhibitors, failure to offset the already LPS-induced mTF activity seemed to be consistent with the view that LPS readily activated MAPK responsible for mTF synthesis.

CONCLUSION

Our data suggest that the tyrosine phosphorylation of MAPKs (p38 and Erk1/2) leading to their activation could be a prerequisite for LPS induction of mTF synthesis contributing to the upregulation of mTF-initiated extrinsic coagulation.

Effect of dietary seal and fish oils on lipid metabolism in hamsters

Eicosapentaenoic and docosahexaenoic acids were distributed mainly in the sn-1 and 3 positions of seal oil triacylglycerols and in the sn-2 position of fish oil triacylglycerols. Seal oil-rich or fish oil-rich fats having constant polyunsaturated (PUFAs)/monounsaturated/saturated fatty acids and n-6/n-3 PUFAs ratios were fed to hamsters for 3 weeks. The control fat contained linoleic acid as the sole PUFA. The concentration of triacylglycerols in the liver was significantly lower in the fish oil group than in the control group. Phospholipid concentration in serum was lower and that in the liver was higher in the seal oil group compared with the fish oil group. The activities of fatty acid synthase (FAS), glucose-6-phosphate dehydrogenase (G6PDH), and the malic enzyme were significantly lower in both the fish and seal oil groups than in the control group. Dietary seal oil more effectively reduced arachidonic acid content in liver phosphatidylcholine and phosphatidylethanolamine and serum phosphatidylcholine than fish oil. These results showed that different intramolecular distribution of n-3 PUFAs influenced glycerolipid metabolism and arachidonic acid content in serum and liver phospholipids of hamsters.

Crystallization and preliminary crystallographic studies of RhoGDI in complex with the radixin FERM domain

The Rho guanine nucleotide-dissociation inhibitor (RhoGDI) is a general regulator that forms a complex with the GDP-bound form of Rho-family GTPases and suppresses their activation. The FERM domains of ERM (ezrin/radixin/moesin) proteins bind to RhoGDI and dissociate Rho from RhoGDI. The formation of a complex between RhoGDI and the FERM domain is an important step in the regulatory cycle of Rho activation. In this study, crystals of RhoGDI complexed with the FERM domain of radixin were obtained. The crystals of the binary complex belong to the space group P2(1)2(1)2, with unit-cell parameters a = 130.9 (2), b = 151.2 (2), c = 71.2 (1) A, and contain two protein complexes in the crystallographic asymmetric unit. A 2.9 A resolution data set was collected using synchrotron radiation at SPring-8.

[Anesthetic management for an adult patient with secundum atrial septal defect associated with a large left-to-right shunt]

We describe the case of a 68-year-old woman with secundum atrial septal defect associated with a large left-to-right shunt and congestive heart failure. The patient with a pancreatic tumor was scheduled for hepatic cholangiojejunostomy and cholecystectomy. To determine the ratio of pulmonary to systemic flow (Qp/Qs) as an indicator for the magnitude of left-to-right shunt, oxymetric catheters were placed in the superior vena cava and pulmonary artery. In addition, oxygen delivery was assessed using superior vena cava oxygen saturation (SsvcO2). Although the patient was anesthetized with high-dose fentanyl to supplement nitrousoxide and sevoflurane, the Qp/Qs markedly increased after skin incision. Epidural local anesthetic was then administered. The Qp/Qs decreased to the preoperative value and the hemodynamic condition was improved thereafter. The operative course was uneventful. This case illustrates the potential usefulness of continuous measurement of the Qp/Qs and SsvcO2 for anesthetic management of adult patients with secundum atrial septal defect.

[Anesthetic management of a patient with deep venous thrombosis using temporary inferior vena cava filter]

A patient with deep venous thrombosis caused by a huge uterine leiomyoma underwent abdominal hysterectomy. To prevent pulmonary thromboembolism, the patient received anticoagulant therapy until 6 hr before surgery and temporary inferior vena cava filter was placed. A combination of preoperative anticoagulant therapy and the filter placement during perioperative period enabled this patient to be successfully-managed.

Establishment and characterization of a prostatic small-cell carcinoma cell line (PSK-1) derived from a patient with Klinefelter syndrome

BACKGROUND

Prostatic small-cell carcinoma (SMCC) is an extremely aggressive, rarely occurring tumor, and there has been no previous report of prostatic SMCC in association with Klinefelter syndrome. This study reports on the first such case and the establishment of the first cell line of SMCC from this tumor.

METHODS

Prostatic SMCC tissue was derived from a 29-year-old man with Klinefelter syndrome. Characteristics of the culture tumor cells were evaluated with cell growth in vitro, neuron-specific enolase (NSE) secretion ability, tumorigenicity in nude mice, chemosensitivity to anticancer drugs, and karyotypic analysis.

RESULTS

A culture cell line (PSK-1) was successfully established from prostatic SMCC with Klinefelter syndrome. PSK-1 cells had a polygonal epithelioid morphology and demonstrated loss of contact inhibition. These cells secreted NSE into the culture supernatant. Tumors produced in nude mice were histologically similar to the original SMCC. In a chemosensitivity test, PSK-1 cells were found to be sensitive in vitro to cisplatin, etoposide, and doxorubicin, but resistant to dacarbazine and 5-fluorouracil. Cytogenetic analysis showed that the PSK-1 cells at passage 35 revealed 76-84 chromosomes, with a mode of 82 chromosomes.

CONCLUSIONS

PSK-1 cells could represent some properties of the original tumor cells, and could be used in studies on the etiology and treatment of this disease.

[A case of free rupture of abdominal aortic aneurysm into the peritoneal cavity during posture change after induction of anesthesia]

We report a case in which posture change for radiography after induction of anesthesia caused free rupture of the abdominal aortic aneurysm (AAA) into the peritoneal cavity, resulting in shock, although in the patient an AAA had ruptured into only the retroperitoneal space and hemodynamics had been stable preoperatively. The massive bleeding was controlled with autotransfusion using a washing salvaging autotransfusion device and a roller pump for hemodialysis. In addition, international mild hypothermia was effective for protection of the brain from suspected ischemia during shock. Meticulous attention should be paid for anesthetic management of patients with ruptured AAA even if their hemodynamic status is stable.