Chordoma: Radiological–pathological correlation

This review correlates the imaging findings and histological appearances seen in chordomas in a series of patients presenting at our institution, together with a published literature review. A parallel presentation of photographs of imaging findings and microscopic histological findings is made, with the aim being to enhance recognition of this uncommon but clinically significant entity.     

Intraoperative hemodilutional autotransfusion using a closed circuit for patients of Jehovah's Witness

We conducted hemodilutional autotransfusion using a closed circuit combined with a cell washing reinfusing system (Cell Saver) for two surgical patients of Jehovah's Witness. One was a 12 yr-old boy for extirpation of the teratoma in the anterior mediastinum and another was a 44 yr-old woman for left total hip replacement. The patients and their relatives had consented to the use of blood substitutes, hemodilutional autotransfusion using a closed circuit and Cell Saver. We devised a closed circuit system for hemodilutional autotransfusion combined with Cell Saver, in which two pumps for blood transfusion were used; one was for drawing blood from the femoral or the internal jugular vein and the other for returning blood to the peripheral vein. Blood volume in a bag interposed in the closed circuit was easily controlled by adjusting the speed of each pump. Blood collected from the surgical field by Cell Saver was also led to the bag. Acid citrate dextrose solution was infused into the closed circuit from the site close to the blood drawing. Both of our surgical patients were safely managed without homologus blood transfusion, although there remained some problems concerning the use of anticoagulants.     

Evaluation with blink reflex of bilateral facial palsy

We examined the accuracy of electroneuronography (ENoG) and blink reflex as prognostic indicators in four patients with bilateral facial palsy. Electrophysiological investigation consisted of the recording of ENoG amplitude and R1 amplitude of blink reflex elicited by the peripheral nerve stimulation. Examinations were performed at the first visit, after 10 days, 2, 4 and 6 weeks. ENoG amplitude was less reliable for the neurological evaluation of bilateral facial palsy, because in three cases amplitude ratio of affected side to the other side was more than 100%. R1 amplitude of blink reflex recovered satisfactorily in two cases of good outcome. In other two cases of poor outcome, R1 amplitude was absent during the examination period. These findings suggest that analysis of blink reflex provides valuable information for evaluation of the prognosis of patients with bilateral facial palsy.     

Validation of the Proximal Isovelocity Surface Area Method for Assessing Mitral Regurgitation in Children

The proximal isovelocity surface area (PISA) method for calculating volume flow through the regurgitant orifice has attracted significant attention. A number of in vitro studies and clinical studies in adults suggest that the method is accurate. However, when applying the method to children it must be noted that the absolute regurgitation volume is small, and the range of body sizes is wide. This study investigated the accuracy of the PISA method for quantitative assessment of the severity of mitral regurgitation in children. Twenty children aged 7 months to 12 years (average 4.7 years) with mitral regurgitation but without interventricular shunt or aortic stenosis were selected for this study. Underlying cardiac diseases included atrioventricular septal defects in nine, isolated mitral regurgitation in five, and association with other heart defects in six. The PISA radius (r) and the duration of regurgitation (T) were measured on color M-mode recordings, with the M line passing through the center of the PISA. Assuming that the PISA is a hemisphere, maximal regurgitant flow rate (MFR: ml/s) was calculated as MFR = 2π×~ r ²×~ V (r= maximal radius, V= aliasing velocity), and regurgitant stroke volume (RSVpisa) as RSVpisa = 2π×~ MSR ×~ V×~ T (MSR = mean square of the PISA radius during regurgitation). As a validating standard, total stroke volume (TSV) using two-dimensional echocardiography determined by the area–length volumetry method and forward stroke volume (FSV) by the pulsed Doppler method were measured, and regurgitant stroke volume (RSV_D: RSV_D= TSV − FSV) and regurgitant fraction (RF: RF = RSV_D/TSV) were calculated. A linear correlation was found between MFR, RSVpisa, and RSV_D (X) (MFR = 4.2X + 54.0, r= 0.84. RSVpisa = 1.0X + 9.8, r= 0.90), and both RSVpisa and MFR divided by body surface area (BSA: m²) revealed a significant correlation with regurgitant fraction (X) by nonlinear regression analysis (RSVpisa/BSA = 26.2 ×~ X/(1 − X) + 16.8, r= 0.85. MFR/BSA = 121.8 ×~ X/(1 − X) + 92.2, r= 0.79). It is concluded that maximal regurgitant flow rate, regurgitant stroke volume, and regurgitant fraction can be accurately predicted in children using the PISA method by Doppler echocardiography.     

Pembrolizumab-related Immune Thrombocytopenia in a Patient with Lung Adenocarcinoma Treated by Radiotherapy: Potential Immune-related Adverse Event Elicited by Radiation Therapy

The effect of radiotherapy during immunotherapy on immune-related adverse events (irAEs) is not fully understood. We herein report a 74-year-old woman diagnosed with lung adenocarcinoma with programmed death ligand 1 expression ≥50% and treated with pembrolizumab. She developed fatal immune thrombocytopenia associated with pembrolizumab immediately following radiotherapy. A flow cytometry analysis of peripheral blood detected an increased expression of programmed death-1 (PD-1) and Ki-67 in CD4^＋ and CD8^＋ T cells after radiotherapy, compared with pre-irradiation measurements. This case suggests that radiotherapy may evoke irAEs during treatment with anti-PD-1 antibodies, which physicians should consider when using radiotherapy in patients treated with these drugs.     

Upcycling of Pharmaceutical Glass into Highly Porous Ceramics: From Foams to Membranes

The present COVID-19 emergency has dramatically increased the demand for pharmaceutical containers, especially vials. End-of-life containers, however, cannot be easily recycled in the manufacturing of new articles. This paper presents some strategies for upcycling of pharmaceutical glass into various porous ceramics. Suspensions of a fine glass powder (70 vol%) are used as a starting material. Highly uniform cellular structures may be easily prepared by vigorous mechanical stirring of partially gelified suspensions with added surfactant, followed by drying and firing at 550–650 °C. Stabilization of the cellular structures at temperatures as low as the glass transition temperature (T_g) of the used glass is facilitated by thermal decomposition of the gel phase, instead of viscous flow sintering of glass. This finding enabled the preparation of glass membranes (∼78 vol% open porosity), by direct firing of hardened suspensions, avoiding any surfactant addition and mechanical stirring. The powders obtained by crushing of hardened suspensions, even in unfired state, may be used as a low-cost sorbent for dye removal.     

Duloxetine-induced Syndrome of Inappropriate Secretion of Antidiuretic Hormone in a Super-elderly Patient

Duloxetine is widely used for pain control and depressive syndromes. One of its potential side effects is syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Duloxetine-induced SIADH causes hyponatremia, which leads to a variety of symptoms and has previously been reported in the elderly. In the present case, we experienced a case of the rapid onset of SIADH in a super-elderly woman receiving low-dose duloxetine. Elderly patients tend to have lower duloxetine doses and an earlier onset than non-elderly patients. When hyponatremia occurs after duloxetine administration, duloxetine-induced SIADH should be considered, especially in high-risk elderly patients, regardless of the duloxetine dose or duration of treatment.     

Early detection of the no-reflow phenomenon in reperfused acute myocardial infarction using technetium-99m tetrofosmin imaging

Evaluation of myocardial perfusion in the early stage of acute myocardial infarction (MI) is clinically important for adjunctive therapies to minimize infarct size. To determine the role of early scintigraphic detection of impaired myocardial reperfusion after primary coronary angioplasty (PTCA) in patients with acute MI, semiquantitative technetium-99m tetrofosmin single-photon emission tomographic (SPET) imaging was performed before primary PTCA (before; area at risk), 60 min after PTCA (after) and at 1 month (1 M; final infarct) in 35 patients with acute MI. The left ventricle was divided into 13 segments and the defect score was calculated as the sum of the perfusion defect of each segment, from 3 (complete defect) to 0 (normal perfusion). A significant myocardial perfusion change after PTCA was defined as a change in the defect score (before minus after PTCA) of >/=4. The echocardiographic asynergic score was defined as the number of asynergic (severe hypokinetic or akinetic) segments corresponding to the analogous segments on SPET images, and recovery of wall motion was calculated as absolute change in the asynergic score (before PTCA minus 1 M). Among the 35 patients, 15 (43%) had a change in the defect score of <4 (no reflow: group 1) while 20 had a change in the defect score of >/=4 (reflow: group 2). There were no significant differences between the two groups with respect to the time between admission to PTCA, revascularization time, collateral grade or Thrombolysis in Myocardial Infarction (TIMI) flow grade before PTCA. Despite the lack of a difference in area at risk between the two groups (group 1 = 12.8+/-4.3 and group 2 = 15.1+/-4.7), final infarct size in group 1 was significantly larger compared with that in group 2 (8.1+/-4.3 vs 4.9+/-3.0, P<0.001). Recovery of wall motion was significantly smaller in group 1 than in group 2 (4.3+/-1.7 to 3.5+/-1.5 vs 4. 1+/-2.1 to 1.6+/-1.6, P<0.001). In conclusion, a small change (<4) in defect score (scintigraphic no-reflow phenomenon) after primary PTCA indicates persisting impaired myocardial perfusion or irreversible cellular damage just after PTCA which is associated with poor recovery of wall motion, as compared with that observed in cases of reflow (>/=4 in defect score).     

Prospective analysis of clinical evaluation and self-assessment by patients after decompression surgery for degenerative lumbar canal stenosis.

BACKGROUND CONTEXT: Objective measures including neurological findings, radiographic evaluation, and the Japanese Orthopaedic Association (JOA) score are commonly used for the evaluation of surgical outcomes. Because many surgeries are performed primarily to improve quality of life, a patient's subjective evaluations are also important for accurately assessing surgical outcomes. Currently available instruments for assessing quality of life include the Short-Form 36 (F-36), the Oswestry disability index (ODI), and the visual analog scale (VAS) clinical pain scale. PURPOSE: The aims of this study were to measure surgical outcomes by using both objective measures and subjective measures including patient self-assessments and psychological changes; to assess the adequacy of the JOA alone for measuring outcome; and to determine which measures, the SF-36v2, ODI, VAS, or JOA correlate with the VAS pain scale score in lumbar canal stenosis. STUDY DESIGN: We performed a prospective study to measure surgical outcomes for lumbar canal stenosis using traditional objective measures such as neurological findings and subjective measures such as performance of ADLs, patient self-assessments, and psychological changes. PATIENT SAMPLE: Forty-two surgical patients with a mean age of 66.8+/-10.9 years at the time of surgery were included in the study. All cases were followed for more than 2 years. Surgical indications included no response to conservative treatment and neurological deterioration. Neurological symptoms were classified as nerve root type, cauda equine type, or combined type. We performed surgical decompression at the location of the dural or root indentation by myelography. The concomitant diagnosis causing the spinal stenosis was degenerative spondylolisthesis in 20 cases undergoing posterolateral fusion with pedicle screws. OUTCOME MEASURES: Surgical outcomes were assessed by comparing preoperative and 24-month postoperative JOA scores for low back pain, SF-36v2, ODI-v2, and VAS scores. Statistical analysis was performed by using the analysis of variance. A p value<0.05 was considered statistically significant. METHODS: Objective clinical measures, patient self-assessments, and psychological changes were measured before and at 24 months postoperatively. We also examined which measurements correlated with the VAS scale for pain evaluation, thereby relating patient satisfaction to surgery outcome. RESULTS: All JOA, SF-36v2, ODI-v2, and VAS scores significantly improved postoperatively. The physical component summary (PCS) of the SF-36 v2 showed significant improvement, although all scores remained less than the Japanese norm-based scores (NBSs). The mental component summary (MCS) exhibited such a significant improvement that all postoperative subscales were higher than the Japanese NBS. JOA scores significantly correlated only with postoperative lower-extremity VAS score. All PCS and two MCS scores significantly correlated with the VAS score for low back pain. Parts of the PCS and MCS significantly correlated with the lower-extremity VAS. The ODI significantly correlated with both the preoperative and postoperative VAS scores for low back pain as well as with the postoperative lower-extremity VAS score. CONCLUSIONS: The JOA, SF-36, ODI, and VAS questionnaires are all useful instruments for measuring surgical outcomes. The VAS score is a better assessment of physical rather than mental health. The ODI is more reflective of patients' subjective symptoms. Finally, the SF-36 is particularly informative because it includes questions addressing both psychological and physical status. Therefore, when combined, the SF-36v2, VAS, and ODI scores are a valuable complement to the JOA scores in evaluating outcomes of surgery for lumbar canal stenosis.     

Antiinflammatory effect of heparin-coated circuits with leukocyte-depleting filters in coronary bypass surgery

Cardiac surgery with cardiopulmonary bypass is associated with a systemic inflammatory response. We examined combined use of heparin coating of the cardiopulmonary bypass circuit and a leukocyte-depleting arterial line filter to reduce this response. Thirty patients were allocated randomly to equal groups with a conventional circuit and arterial line filter (C group), a heparin-coated circuit with a conventional filter (H group), or a heparin-coated circuit with a leukocyte-depleting arterial line filter (HF group). Cytokines and respiratory function were repeatedly measured perioperatively. Plasma interleukin (IL)-6 concentrations in the HF group were lower than in the C group immediately following bypass and operation, at 4 h, and 12 h (p < 0.05). Plasma IL-8 was lower in the HF group than in the C group at 4 h (p < 0.05). The respiratory index was lower immediately after bypass in the HF group than the C group (0.61 +/- 0.2 versus 1.05 +/- 0.4, p < 0.05). Heparin-coated circuits with leukocyte-depleting filters decrease inflammatory responses and improve pulmonary function during operation.