Aorto-pseudoaneurysm-ventricular regurgitation after aortic root replacement

We describe a 48-year-old man with aorto-pseudoaneurysm-ventricular regurgitation. It was due to disruption of both proximal and distal anastomoses after aortic root replacement for detachment of a prosthetic valve implanted for a sinus of Valsalva aneurysm with aortic valve regurgitation. The chest was opened during cardiopulmonary bypass using a deep hypothermic circulatory arrest to avoid rupture of the aneurysm because of a close relation between the pseudoaneurysm and the sternum. Aortic root re-replacement was performed successfully.     

Clinical diagnosis of soft tissue tumors

In the clinical diagnosis of a soft tissue tumor, it is important to determine whether the lesion is malignant as soon as possible. To establish such a diagnosis we perform aspiration cytology and needle biopsy simultaneously with computed radiography (CR) and echosonogram at the first visit. After the first day's investigations, it is usually possible to select the surgical procedures based on the working diagnosis in almost all patients. When the lesion is clearly benign by diagnosis, excision can be performed. For large lesions or lesions that are suspected to be malignant, CT, magnetic resonance imaging , isotope-investigation, and arteriography are also performed, effectively providing precision in an already established diagnosis. These imaging findings are useful for establishing a surgical plan by anticipating the surgical line of the safety margin. For these few patients in whom the diagnosis still remains uncertain or when preoperative treatment is planned, an incisional or excisional biopsy may be necessary to establish the final diagnosis. When preoperative treatment is performed, the effectiveness of this treatment can be evaluated by medical imaging. Received for publication on Nov. 16, 1997     

Carcinomatous Infiltration into the Submucosa as a Predictor of Lymph Node Involvement in Early Gastric Cancer

n = 25) and node-negative ( n = 81) groups. Among several pathologic factors, the diameter of the tumor and lymphatic involvement were significantly correlated with nodal involvement. Within the submucosal layer the depth of invasion and the horizontal cancerous expansion also correlated with lymph node disease ( p < 0.05). The size of the tumor did not correlate with the length of submucosal infiltration ( r = 0.12, p = 0.1). Patients with both slight invasion into the submucosa and less than 5 mm of horizontal expansion were often negative for lymph node involvement and thus may benefit from local surgery as an alternative to gastrectomy.     

Idiopathic mediastinal fibrosis: Report of a case

(Received for publication on Nov. 14, 1996; accepted on May 12, 1997)     

Evaluation of cardiac sympathetic nerve activity and aldosterone suppression in patients with acute decompensated heart failure on treatment containing intravenous atrial natriuretic peptide

Purpose

Aldosterone prevents the uptake of norepinephrine in the myocardium. Atrial natriuretic peptide (ANP), a circulating hormone of cardiac origin, inhibits aldosterone synthase gene expression in cultured cardiocytes. We evaluated the effects of intravenous ANP on cardiac sympathetic nerve activity (CSNA) and aldosterone suppression in patients with acute decompensated heart failure (ADHF).

Methods

We studied 182 patients with moderate nonischemic ADHF requiring hospitalization and treated with standard therapy containing intravenous ANP and 10 age-matched normal control subjects. ANP was continuously infused for >96 h. In all subjects, delayed total defect score (TDS), heart to mediastinum ratio, and washout rate were determined by ¹²³I-metaiodobenzylguanidine (MIBG) scintigraphy. Left ventricular (LV) end-diastolic volume, end-systolic volume, and ejection fraction were determined by echocardiography. All patients with acute heart failure (AHF) were examined once within 3 days and then 4 weeks after admission, while the control subjects were examined only once (when their hemodynamics were normal). Moreover, for 62 AHF patients, plasma aldosterone concentrations were measured at admission and 1 h before stopping ANP infusion.

Results

¹²³I-MIBG scintigraphic and echocardiographic parameters in normal subjects were more favorable than those in patients with AHF (all p?<?0.001). After treatment, all these parameters improved significantly in AHF patients (all p?<?0.001). We also found significant correlation between percent changes of TDS and aldosterone concentrations (r?=?0.539, p?<?0.001) in 62 AHF patients.

Conclusion

The CSNA and LV performance were all improved in AHF patients. Furthermore, norepinephrine uptake of myocardium may be ameliorated by suppressing aldosterone production after standard treatment containing intravenous ANP.     

Right ventricular 18F-FDG uptake is an important indicator for cardiac involvement in patients with suspected cardiac sarcoidosis

Purpose

Cardiac sarcoidosis is most commonly found in the left ventricular (LV) free wall. Presence in the right ventricle (RV) is less common but might be useful for detecting cardiac involvement of sarcoidosis. ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) PET has been used to detect LV regions with cardiac sarcoidosis. However, the same has not been done for RV involvement. The aims of the current study were to evaluate RV ¹⁸F-FDG uptake and its relationship to the distribution of LV wall ¹⁸F-FDG-positive segments in the LV, and to evaluate whether patients with positive RV ¹⁸F-FDG uptake met the 1993 diagnostic criteria of the Japanese Ministry of Health and Welfare (JMHW) guidelines regarding sarcoidosis with suspected cardiac involvement.

Method

Fifty-nine biopsy-proven extra-cardiac sarcoidosis patients (age 56.1 ± 14.7 years) with suspected cardiac involvement based on abnormal electrocardiography or echocardiography findings underwent fasting ¹⁸F-FDG PET or PET/CT. The LV wall was divided into 17 segments and RV uptake was also evaluated.

Result

Among 59 patients, 35 (59.3 %) showed some abnormal ¹⁸F-FDG uptake in the RV and/or LV wall. With respect to the RV wall, 13 (22.0 %) showed abnormal ¹⁸F-FDG uptake. The number of LV-involved segments was 4.8 ± 2.4 in the patients with RV ¹⁸F-FDG uptake, which was significantly higher than in the patients without RV uptake, 1.8 ± 2.2 (P < 0.0001). Patients with RV uptake more frequently met the diagnostic criteria of the 1993 JMHW guidelines (n = 27), than did those without RV uptake (84.6 vs. 34.8 %, P = 0.0033).

Conclusion

¹⁸F-FDG PET identified RV involvement less frequently than LV involvement in this study population. However, patients who had RV uptake showed a greater number of LV-involved segments and met the JMHW diagnostic criteria more frequently. Although RV uptake is less frequent, ¹⁸F-FDG RV uptake may be useful in diagnosing cardiac involvement in sarcoidosis.

Clinical trial registration

UMIN000006533.     

Primary neurogenous sarcoma of the lung; report of a case

We report a case of a 27-year-old woman with primary neurogenous sarcoma of the lung. She had no symptoms but an abnormal shadow of the right lower lung field on the chest X-ray. Chest computed tomography (CT) revealed a well defined round mass, 20 mm in maximum diameter, at the right S9. Pathological study of the specimen obtained by CT-guided percutaneous needle biopsy showed undefferentiated carcinoma. Positron emission tomography (PET) disclosed intensely increased uptake of fluoro-2-deoxy-D-glucose (FDG) at the lung lesion without other abnormal uptakes. The patient underwent right lower lobectomy of the lung and mediastinal lymph nodes dissection. Results from immunohistological study yielded a definitive diagnosis of neurogenous sarcoma. Postoperative course was uneventful, and there has been no evidence of recurrence and metastasis for more than a year after the surgery. Reported cases of primary neurogenous sarcoma of the lung are reviewed.     

Epinephrine Affects Pharmacokinetics of Ropivacaine Infiltrated Into Palate

Pulpal anesthesia success rates for ropivacaine following maxillary infiltration anesthesia seem to be low. We investigated the hypothesis that the addition of epinephrine would affect the pharmacokinetics of ropivacaine by retaining ropivacaine in the mucosa of the injected area through the time-dependent distribution of ropivacaine in the rat maxilla and serum following maxillary infiltration anesthesia using ³H-labeled ropivacaine. We then examined the vasoactivity of ropivacaine with or without epinephrine on local peripheral blood flow. The addition of epinephrine to ropivacaine increased ropivacaine concentrations in the palatal mucosa and adjacent maxilla by more than 3 times that of plain ropivacaine at 20 minutes. By observing the autoradiogram of ³H-ropivacaine, plain ropivacaine in the maxilla was remarkably reduced 20 minutes after injection. However, it was definitely retained in the palatal mucosa, hard palate, adjacent maxilla, and maxillary nerve after the administration with epinephrine. Ropivacaine with epinephrine significantly decreased labial blood flow. This study suggests that 10 μg/mL epinephrine added to 0.5% ropivacaine could improve anesthetic efficacy and duration for maxillary infiltration anesthesia over plain ropivacaine.Key Words: Ropivacaine, Infiltration anesthesia, EpinephrineRopivacaine, a levorotatory isomer (S-), has been widely used in clinical anesthesiology because of its decreased potential for systemic toxicity compared with the dextrorotatory isomer (R+)¹ as well as its high local anesthetic potency and long duration of action. The efficacy of dental conduction anesthesia with ropivacaine has been demonstrated.^2–4 Kimi et al⁵ observed that ropivacaine has a strong affinity for the palatal mucosa and maxillary nerve but not for the maxilla in vitro, and the concentration remained high in the palatal mucosa, including the injection site. It is reported that the addition of 5 μg/mL epinephrine to ropivacaine improves the anesthetic efficacy and duration of maxillary infiltration anesthesia.⁶ However, there is no report demonstrating how epinephrine influences the efficacy of oral infiltration anesthesia with ropivacaine. We hypothesized that epinephrine affects the pharmacokinetics of ropivacaine by retaining ropivacaine in the mucosa of the injected area. The authors investigated the hypothesis using the time-dependent distribution of ropivacaine in the rat maxilla and serum following maxillary infiltration anesthesia using ³H-labeled ropivacaine and then examined the vasoactivity of ropivacaine with or without epinephrine on the peripheral blood flow.     

Decreased body mass index as an independent risk factor for developing chronic kidney disease

BACKGROUND: Obesity and metabolic syndrome are risk factors for the development of chronic kidney disease (CKD). Few studies have examined the effect of change in body mass index (DeltaBMI) on CKD incidence in a general screening setting. METHODS: Subjects of this study were screenees that participated in the screening program of the Okinawa General Health Maintenance Association in 1993 and 2003 in Okinawa, Japan. Using identification number, birth date, sex, and other recorded identifiers, we identified 33,389 subjects among the 1993 screening participants (N = 143,948) who also participated in the 2003 screening. CKD was defined as estimated glomerular filtration rate <60 ml/min/1.73 m(2), according to the modification of diet in renal disease study equation. Obesity was defined as BMI > or = 25 kg/m(2). RESULTS: CKD prevalence was 13.8% in 1993 and 22.4% in 2003. The incidence of developing CKD in 10 years was 15.5%. The effect of DeltaBMI on CKD incidence was evaluated after considering other confounding factors such as age, sex, blood pressure, BMI, fasting plasma glucose, and proteinuria. Median DeltaBMI was 1.0%. The adjusted odds ratio (95% CI) for the effect of DeltaBMI on CKD incidence was 1.111 (1.026-1.204, P < 0.01; entire study population), 1.271 (1.116-1.448, P = 0.0030; men), and 1.030 (0.931-1.139, NS; women), when DeltaBMI > or = 1% was taken as a reference. DeltaBMI was an independent predictor of CKD incidence. CONCLUSIONS: The present results suggest that there was an inverse relationship between DeltaBMI and CKD incidence among screened subjects. The reasons for this observation are not clear, but careful follow-up for DeltaBMI is necessary, particularly in obese men with proteinuria.