Adverse effects of long-term drain placement and the importance of direct aspiration: a retrospective cohort study

BACKGROUND

Long-term placement of prophylactic drains may result in retrograde infections.

AIM

To investigate the association between the timing of drain removal and clinical outcomes.

METHODS

This retrospective, single-centre cohort study evaluated 110 patients who underwent elective gastrointestinal or hepatopancreatobiliary surgery and developed subsequent organ/space surgical site infection (SSI) between 2016 and 2020. The difference between the culture-positive species of prophylactic drains and direct aspiration was evaluated; whether the prophylactic drains functioned effectively at the time of SSI diagnosis; and whether the empirical antibiotics administered before drainage were effective against all the detected bacteria. Finally, clinical outcomes were compared between early (i.e. cases wherein the prophylactic drain had already been removed or replaced at the time of SSI diagnosis) and late (removal after diagnosis) drain removal.

FINDINGS

The prophylactic drains functioned effectively in only 27 (25%) patients at the time of SSI diagnosis. Due to the results of direct aspiration cultures, 43% of patients required antibiotic escalation. The median time to drain removal or first replacement was seven postoperative days. The early removal group included 43 patients (39%). Compared with early removal, late removal resulted in a higher frequency of vancomycin use (7.0% vs 22.4%; P = 0.037).

CONCLUSION

Prolonged prophylactic drain placement is associated with complicated infections requiring vancomycin; therefore, the drains should be removed as soon as possible. Additionally, obtaining the cultures of direct aspiration should be actively considered, as escalation of antimicrobial therapy is often performed based on culture results.

Cross-Sectional and Longitudinal Associations of Creatinine-to-Cystatin C Ratio with Sarcopenia Parameters in Older Adults

OBJECTIVES

Accumulating evidence from cross-sectional studies suggests that the serum creatinine-to-cystatin C ratio (CCR) may be a useful biomarker for sarcopenia. This study aimed to assess the cross-sectional and longitudinal associations of CCR with sarcopenia and its parameters in community-dwelling older adults.

DESIGN

Cross-sectional and longitudinal study.

SETTING AND PARTICIPANTS

This 6-year prospective cohort study included the repeated measurement data from 1,253 Japanese residents (662 males and 591 females) aged ≥65 years who underwent medical checkups in Kusatsu and Hatoyama, Japan. A total of 4,421 observations were collected.

MEASUREMENTS

The CCR was grouped into quartiles by sex (Q1-Q4) using Q4 as the reference category. Sarcopenia was defined according to the Asian Working Group for Sarcopenia 2019 algorithm. Skeletal muscle mass index (SMI) measured using segmental multifrequency bioelectrical impedance analysis, handgrip strength (HGS), usual gait speed (UGS), and maximal gait speed (MGS) were measured repeatedly as sarcopenia parameters. The association of the CCR with changes in sarcopenia, SMI, HGS, UGS, and MGS during the 6-year period were analyzed using a generalized linear mixed-effects model.

RESULTS

The prevalence of sarcopenia at baseline was 13.1% (11.9% in males and 14.5% in females). In a cross-sectional analysis, the CCR quartile was inversely associated with sarcopenia and was positively associated with SMI, HGS, and MGS (P for trend < 0.001). In a longitudinal analysis during the 6 years, a significant increase in sarcopenia in Q2 (B = 1.1% point/year; P = 0.026 for group-by-time interaction) and significant declines in SMI (B = -0.01 kg/m2/year; P = 0.044 for group-by-time interaction) and MGS (B = -0.008 m/sec/year; P = 0.041 for group-by-time interaction) in Q1 were observed compared with Q4. However, the dose-response relationship was significant only for MGS (P = 0.033 for trend). No significant group-by-time interaction was observed for HGS. CCR was not significantly associated with UGS either cross-sectionally or longitudinally.

CONCLUSIONS

CCR is a useful biomarker regarding the status of sarcopenia. It may be used for sarcopenia screening even in older adults whose physical function is difficult to assess. However, further longitudinal studies are needed to determine whether CCR can be a predictor of future sarcopenia.

Epstein-Barr virus-associated inflammatory pseudotumor variant of follicular dendritic cell sarcoma of the liver: a case report and review of the literature

BACKGROUND

Follicular dendritic cell sarcoma is a rare stromal tumor with no standard treatment. However, some reports have revealed that follicular dendritic cell sarcoma has an inflammatory pseudotumor variant associated with Epstein-Barr virus infection that has a relatively good prognosis. In this report, we present a case of a resected inflammatory pseudotumor variant of follicular dendritic cell sarcoma of the liver, and have reviewed the literature on the clinicopathological, molecular, and genomic features of this tumor.

CASE PRESENTATION

The inflammatory pseudotumor variant of follicular dendritic cell sarcoma originates only in the liver or spleen, causes no symptoms, and is more common in middle-aged Asian women. It has no characteristic imaging features, which partially explains why the inflammatory pseudotumor variant of follicular dendritic cell sarcoma is difficult to diagnose. Pathologically, the inflammatory pseudotumor variant of follicular dendritic cell sarcoma has spindle cells mixed with inflammatory cells and is variably positive for follicular dendritic cell markers (CD21, CD23, and CD35) and Epstein-Barr virus-encoded RNA. On genetic analysis, patients with this tumor high levels of latent membrane protein 1 gene expression and extremely low levels of host C-X-C Chemokine Receptor type 7 gene expression, indicating that the inflammatory pseudotumor variant of follicular dendritic cell sarcoma has a latent Epstein-Barr virus type 2 infection.

CONCLUSIONS

The inflammatory pseudotumor variant of follicular dendritic cell sarcoma is an Epstein-Barr virus-associated tumor and a favorable prognosis by surgical resection, similar to Epstein-Barr virus-associated gastric cancer.

Hemoadsorption of high-mobility group box chromosomal protein 1 using a column for large animals

BACKGROUND

High-mobility group box chromosomal protein 1 (HMGB1) has recently been identified as an important mediator of various kinds of acute and chronic inflammation. A method for efficiently removing HMGB1 from the systemic circulation could be a promising therapy for HMGB1-mediated inflammatory diseases.

MATERIALS AND METHODS

In this study, we produced a new adsorbent material by chemically treating polystyrene fiber. We first determined whether the adsorbent material efficiently adsorbed HMGB1 in vitro using a bovine HMGB1 solution and a plasma sample from a swine model of acute liver failure. We then constructed a column by embedding fabric sheets of the newly developed fibers into a cartridge and tested the ability of the column to reduce plasma HMGB1 levels during a 4-hour extracorporeal hemoperfusion in a swine model of acute liver failure.

RESULTS

The in vitro adsorption test of the new fiber showed high performance for HMGB1 adsorption (96% adsorption in the bovine HMGB1 solution and 94% in the acute liver failure swine plasma, 2 h incubation at 37°C; p < 0.05 vs. incubation with no adsorbent). In the in vivo study, the ratio of the HMGB1 concentration at the outlet versus the inlet of the column was significantly lower in swine hemoperfused with the newly developed column (53 and 61% at the beginning and end of perfusion, respectively) than in those animals hemoperfused with the control column (94 and 93% at the beginning and end of perfusion, respectively; p < 0.05). Moreover, the normalized plasma level of HMGB1 was significantly lower during perfusion with the new column than with the control column (p < 0.05 at 1, 2, and 3 h after initiation of perfusion).

CONCLUSION

These data suggest that the newly developed column has the potential to effectively adsorb HMGB1 during hemoperfusion in swine.

Modulation of gonadotrophin-releasing hormone pulse generator activity by the pheromone in small ruminants

In small ruminants, such as goats and sheep, a primer pheromone produced by males induces an out-of-seasonal ovulation in anoestrous females, a phenomenon known as the male effect. The male effect is unique in that an external chemical stimulus can immediately modulate the activity of the hypothalamic gonadotrophin-releasing hormone (GnRH) pulse generator. We have established a monitoring method of the GnRH pulse generator activity in Shiba goat. Using this method as a sensitive bioassay to assess the male effect pheromone activity, we have shown that the male effect pheromone is synthesised in an androgen-dependent manner in the sebaceous glands or their vicinity in specific body regions in goats. Although chemical identity of the pheromone is yet to be determined, analyses of male goat hair extracts by gas chromatography fractionation suggest that the male effect pheromone is a volatile substance with relatively small molecular weight. From morphological and molecular biological studies in goats, it is suggested that the pheromone molecule is detected by a member of the V1R family located on both the olfactory neurones and the vomeronasal sensory neurones, and the pheromone signal is conveyed to the medial nucleus of amygdala via the main olfactory and vomeronasal pathways and, subsequently, to the hypothalamic GnRH pulse generator to enhance its activity.

Unfavourable prognosis associated with K-ras gene mutation in pancreatic cancer surgical margins

BACKGROUND

Despite intent to cure surgery with negative resection margins, locoregional recurrence is common in pancreatic cancer.

AIMS

To determine whether detection of K-ras gene mutation in the histologically negative surgical margins of pancreatic cancer reflects unrecognised disease.

PATIENTS

Seventy patients who underwent curative resection for pancreatic ductal adenocarcinoma were evaluated.

METHODS

All patients had surgical resection margins (pancreatic transection and retroperitoneal) that were histologically free of invasive cancer. DNA was extracted from these paraffin embedded surgical margins and assessed by quantitative real time polymerase chain reaction to detect the K-ras gene mutation at codon 12. Detection of K-ras mutation was correlated with standard clinicopathological factors.

RESULTS

K-ras mutation was detected in histologically negative surgical margins of 37 of 70 (53%) patients. A significant difference in overall survival was demonstrated between patients with margins that were K-ras mutation positive compared with negative (median 15 v 55 months, respectively; p = 0.0008). By univariate and multivariate analyses, detection of K-ras mutation in the margins was a significant prognostic factor for poor survival (hazard ratio (HR) 2.8 (95% confidence interval (CI) 1.5-5.3), p = 0.0009; and HR 2.8 (95% CI 1.4-5.5), p = 0.004, respectively).

CONCLUSIONS

Detection of cells harbouring K-ras mutation in histologically negative surgical margins of pancreatic cancer may represent unrecognised disease and correlates with poor disease outcome. The study demonstrates that molecular-genetic evaluation of surgical resection margins can improve pathological staging and prognostic evaluation of patients with pancreatic ductal adenocarcinoma.

Methylated estrogen receptor alpha in tumors and sera of melanoma patients

8026

Background: The mechanisms regulating the variable expression of estrogen receptor alpha (ER-α) in melanoma are unknown. Silencing of ER-α expression in melanoma may be regulated by the hypermethylation of promoter region CpG islands. To determine the significance of ER-α hypermethylation-induced transcription silencing in melanoma progression, we assessed hypermethylation of ER-α DNA in primary tumors, metastatic tumors, and sera of AJCC stage I-IV melanoma patients. Methods: The methylation status of theER-α DNA promoter region in tumor (n = 107) and sera (n = 119) from AJCC stage I-IV melanoma patients was examined by methylation-specific PCR (MSP) and capillary array electrophoresis (CAE). To determine the significance of free circulating hypermethylated ER-α DNA, we assessed the therapeutic response, progression-free and overall survival among AJCC stage IV melanoma patients receiving biochemotherapy. Results: The frequency of ER-α DNA methylation in AJCC stage I, II, and III primary melanomas was 36% (4 of 11), 26% (5 of 19), and 35% (8 of 23), respectively. The frequency of methylated ER-α DNA detected in stage III and IV metastatic melanomas was 42% (8 of 19) and 86% (30 of 35), respectively. ER-α DNA was methylated in 38 of 54 (70%) metastatic tumors, a more than two-fold increase compared to primaries (p = 0.0003). In the analysis of 109 melanoma patients’ sera, the frequency of methylated ER-α DNA in AJCC stage I, II, III, and IV was 10% (2 of 20), 15% (3 of 20), and 26% (5 of 19), and 32% (16 of 50), respectively. The frequency of methylated ER-α DNA detected in stage III/IV was significantly higher than in stage I/II (p=0.034). In a multivariate analysis, circulating hypermethylated ER-α DNA was the only independent factor predicting progression-free (risk ratio 2.64, 95% CI 1.36–5.13, p = 0.004) and overall survival (risk ratio 2.31, 95% confidence interval 1.41–5.58, p = 0.003) among stage IV patients receiving biochemotherapy. Conclusion: Hypermethylation of ER-α DNA in primary and metastatic melanoma tumors and serum is a significant factor in melanoma progression. The detection of methylated serum ER-α DNA predicts poor response to systemic therapy and is an unfavorable prognostic factor in advanced melanoma.

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Multiple gastric carcinoid tumors with type A gastritis concomitant with gastric cancer: a case report

We describe a case with multiple gastric carcinoid tumors combined with early gastric carcinoma originated from the type A gastritis-affected tissue. Microcarcinoid foci were observed from the deeper layers of the propria mucosa to the submucosa and were surrounded by endocrine cell micronests (ECMs), while carcinoma was limited within the mucosa. Serum gastrin level was high (1,100 pg/ml) pre-operatively but returned to normal (44 pg/ml) post-operatively. It suggested that the longstanding hypergastrinemia may have played a causative role in the development of multiple carcinoids and cancer. Surgical treatment was considered essential for treatment in this case of coincident multiple carcinoid tumors and cancer.

Use of glass slides coated with apatite-collagen complexes for measurement of osteoclastic resorption activity

This study was designed to evaluate the use of apatite-collagen complexes (ACC) coated onto glass slides for measurement of osteoclastic resorption activity. ACC-coated glass slides were prepared by immersion in beta-glycerophosphate solution for 7-14 days after glass slides coated with type I collagen had been treated with alkaline phosphatase and phosvitin. Osteoclast-containing cell suspensions were prepared from the long bones of 1-day-old rabbits and were seeded in medium 199 (containing 10% FBS) onto ACC-coated glass slides. After allowing the cells to attach for 1.5 h, the glass slides were incubated for periods of up to 96 h. The cells were observed by scanning electron microscopy and cytochemically for tartarate resistant acid phosphatase (TRAP) activity. Some slides were treated with FITC-phalloidin and anti-type I collagen antibody. TRAP-positive multinucleated cells were located in transparent spaces on the glass slides. These spaces did not stain immunohistochemically with anti-type I collagen antibody. Podosome formation was observed in the multinucleated cells facing the edge of the transparent spaces. The scanning electron microscopy demonstrated well-spread large cells located on the flattened surface on apatite particles covering the glass surface. Our results suggest that osteoclasts could resorb the apatite particles and coated collagen on the glass slide. The resorption lacunae appeared as transparent spaces, and the cytoskeleton of resorbing osteoclasts was observed in these spaces. ACC-coated glass slides could be useful for investigating the function and metabolic activities of osteoclasts.