Recovery of postural stability following conscious sedation with midazolam in the elderly

Purpose. To investigate the differences in recovery of postural stability, after obtaining similar intravenous sedation levels with midazolam, in elderly and younger patients undergoing dental surgery. Methods. We studied 15 elderly patients (>65 years) and 15 younger patients (<55 years) after intravenous sedation. Midazolam was carefully titrated over 4–5 min until slow response to verbal commands, ptosis of the eyelid, or slight slurring of speech was obtained. Parameters were postural balance tests and an addition test, as a psychomotor function test. Results. The dose of midazolam in the elderly group (0.045 ± 0.012 mg·kg⁻¹) was 62% of that in the younger group (0.074 ± 0.026 mg·kg⁻¹). In evaluation of the percentile rank of a balance test with a visual feedback system, which contained a dynamic balance element, recovery at 60 min in the elderly group was significantly slower than that in the younger group. However, the recovery times for the balance test and the addition test, at which the significantly changed values were restored to the baseline values, were 120 min and 90 min, respectively, in both groups. Conclusion. In the recovery from sedation, elderly patients had more difficulty in acquiring postural adjustment during movement than in maintaining a standing posture. If the dose is carefully administered, however, even elderly patients might be able to return home 2 h after midazolam administration, as could the younger patients. Received: November 6, 2001 / Accepted: April 22, 2002     

Measurement of health-related quality of life in patients with chronic kidney disease in Japan with EuroQol (EQ-5D)

Background  

Chronic kidney disease (CKD) is a health-related quality-of-life (HRQOL) deteriorating disease which is not only a public health but also a socioeconomic problem. Interest in developing cost-effective interventions to control CKD has increased. The aim of this study was to measure HRQOL in terms of quality-adjustment weights for cost-effectiveness analysis using EQ-5D in patients with CKD. The relationships between the measured HRQOL and clinical indices/complications were also analyzed.     

Isaacs' syndrome associated with myasthenia gravis, showing remission after cytoreductive surgery of pleural recurrence of thymoma

We report a patient with Isaacs' syndrome associated with myasthenia gravis and pleural recurrence of thymoma, who showed severe limb pain attributed to hyperexcitability of sensory nerves. Myokymia and severe pain were successfully treated with cytoreductive surgery and intraoperative hyperthermic intrathoracic perfusion chemotherapy, but neither pharmacotherapy nor plasma exchange showed obvious clinical effects. Pleural thymoma in our patient may have caused Isaacs' syndrome, probably by unconfirmed humoral immune mechanisms. Cytoreductive treatment for recurrent thymoma should be actively considered as a potent therapeutic option in refractory patients with disabling neuromyotonia symptoms.     

Methicillin-resistant Staphylococcus-aureus-associated glomerulonephritis on the decline: decreased incidence since the 1990s

We believe that bacterial-infection-associated glomerulonephritis (GN), so-called methicillin-resistant Staphylococcus aureus (MRSA)-GN, was exterminated in Japan. The control of bacterial infection is the most important part of infection-associated GN. In 1990s Japan, hospital-associated MRSA (HA-MRSA) caused MRSA-GN outbreaks. On the other hand, MRSA-GN incidence has been quite limited since 2000. This epidemiological transition suggests that antibacterial therapies and health programs for HA-MRSA infection in Japan were effective against MRSA-GN. Moreover, it appears that staphylococcal superantigens act in the pathogenesis of GN. The change of superantigen production might have influenced to the disappearance of MRSA-GN. If HA-MRSA-producing superantigen outbreaks occur in developing countries, our experience in Japan can provide guiding principles for preventing and eradicating GN.     

Complication caused by use of fibrin glue in vessel transposition for trigeminal neuralgia

A 64-year-old man underwent microvascular decompression of the left superior cerebellar artery (SCA) for left trigeminal neuralgia (TN) using a sling of Teflon tape fixed to the tentorium with fibrin glue. The TN disappeared immediately after surgery, but recurred unusually rapidly at 2 weeks later at the same intensity as before. Second surgery revealed the SCA was suspended from the tentorium, but the trigeminal nerve was stretched and displaced superolaterally because of adhesion to the superior petrosal vein. The adhesion was thought to involve the fibrin glue used during the sling retraction procedure. The nerve was meticulously dissected from the adhesion, and the trigeminal nerve was placed in the correct position. The postoperative course was uneventful, and the TN disappeared completely. We recommend that the smallest amount of the fibrin glue possible be used to avoid adhesion to the surrounding neurovascular elements.     

Involvement of the cerebellar dorsal vermis in vergence eye movements in monkeys

Frontal-eyed primates use both smooth pursuit in frontoparallel planes (frontal pursuit) and pursuit-in-depth (vergence pursuit) to track objects moving slowly in 3-dimensional (3D) space. To understand how 3D-pursuit signals represented in frontal eye fields are processed further by downstream pathways, monkeys were trained to pursue a spot moving in 3D virtual space. We characterized pursuit signals in Purkinje (P) cells in the cerebellar dorsal vermis and their discharge during vergence pursuit. In 41% of pursuit P-cells, 3D-pursuit signals were observed. However, the majority of vermal-pursuit P-cells (59%) discharged either for vergence pursuit (43%) or for frontal pursuit (16%). Moreover, the majority (74%) of vergence-related P-cells carried convergence signals, displaying both vergence eye position and velocity sensitivity during sinusoidal and step vergence eye movements. Preferred frontal-pursuit directions of vergence + frontal-pursuit P-cells were distributed in all directions. Most pursuit P-cells (73%) discharged before the onset of vergence eye movements; the median lead time was 16 ms. Muscimol infusion into the sites where convergence P-cells were recorded resulted in a reduction of peak convergence eye velocity, of initial convergence eye acceleration, and of frontal-pursuit eye velocity. These results suggest involvement of the dorsal vermis in conversion of 3D-pursuit signals and in convergence eye movements.     

Merits and Demerits of Operative Procedure to the Trachea in Patients with Differentiated Thyroid Cancer

Local radical thyroidectomy, including cervical lymph node dissection and combined circumferential resection of the trachea, has been performed over the past 20 years in 31 patients with differentiated cancer invading the trachea. The 5- and 10-year survival rates for these patients were 77.4% and 66.7%, respectively. In 19 of the 31 (61%) cases the recurrent nerve was resected because of direct cancer invasion. Bilateral recurrent nerve palsy occurred in 12 patients, 3 of whom were managed postoperatively using a T-shaped tube for preservation of the larynx. Hoarseness remained in 21 patients. In two patients with recurrent cancer invasion of the larynx, partial laryngectomy and hemilaryngectomy were performed, and reconstruction was done using ear cartilage without postoperative dyspnea or dysphagia. Parathyroid function is an important factor in regard to the quality of life of patients. In 22 patients at least one of the parathyroids was preserved. Postoperative calcium administration was necessary in 14 patients. Our long-term observations indicate that local radical thyroidectomy with combined resection of the trachea can serve as a useful treatment for advanced differentiated cancer invading the airway.     

Successful Resection of Ampullary Carcinoma in a Father and Adenoma in a Daughter with Familial Adenomatous Polyposis Following Detection by Surveillance: Report of Two Cases

This report describes the successful resection of ampullary carcinoma in a 58-year-old man and an adenoma in his 28-year-old daughter after they had undergone proctocolectomy for familial adenomatous polyposis (FAP). Both patients had been monitored by surveillance endoscopy once a year since their proctocolectomy. The father was found to have an ampullary adenoma 26 years after proctocolectomy, and ampullary carcinoma was detected 2 years later, for which pancreatoduodenectomy was performed. Histological examination of the specimen revealed an ampullary carcinoma, 2.5 × 1.7 cm, that had invaded the submucosal layer, but no lymph node metastasis was found. The patient's daughter underwent endoscopy, which showed an ampullary polyp 6 years after total colectomy. Endoscopic mucosal resection of the peri-ampullary lesion was performed, and histological examination revealed a dysplastic tubular adenoma 0.6 × 0.4 cm in diameter. This report reinforces the importance of long-term periodic surveillance of patients with FAP by gastroduodenal endoscopy. Received: January 9, 2001 / Accepted: July 17, 2001     

Surgical treatment for an idiopathic renal arteriovenous fistula with a large aneurysm

Interventional embolization is currently the first line treatment for arteriovenous fistulas; however, the efficacy of repeated embolization remains controversial. A case is reported of an idiopathic renal arteriovenous fistula with large aneurysmal dilatation treated by surgery following the failure of interventional embolization. A 42-year-old woman was admitted to Ichikawa General Hospital, Japan, with gross hematuria containing many clots. Right renal arteriogram showed an aberrant vessel arising from the main trunk of the renal artery, which was followed by the formation of an aneurysm and rapidly ended in arteriovenous shunting. The aneurysm was approximately 35 mm in size. As interventional embolization had failed, surgical treatment including extracorporeal renal surgery was performed. Postoperative renal angiography revealed excellent renal function and beautiful vascular architecture. Although the indication for surgical treatment of renal vascular disease has decreased owing to the advancement of interventional techniques, there are still some risky cases for which surgical repair should be recommended.