Reoperation of the proximal aorta: impact of presternotomy extracorporeal circulation on clinical outcomes

Purpose  

Adverse events can occur during a sternotomy for reoperation of the proximal aorta. Presternotomy extracorporeal circulation is often employed to avoid catastrophic events. The purpose of this study was to investigate the impact of presternotomy extracorporeal circulation on clinical outcomes of redo proximal aortic surgery.     

In vivo three-dimensional skeletal alignment analysis of the hindfoot valgus deformity in patients with rheumatoid arthritis.

The purpose of this study was to analyze the skeletal alignment of the hindfoot valgus deformity in patients with rheumatoid arthritis using bone models reconstructed from three-dimensional computerized tomography data. Computed tomography was performed on 21 feet of patients with rheumatoid arthritis, and magnetic resonance imaging was taken of 10 normal feet of eight volunteers. An image processing system was used to create bone models and analyze the three-dimensional displacement of the calcaneus, talus, navicular, and cuboid bones. With a standard coordinate system in the distal tibia and a local coordinate system in each bone of the hindfoot, three rotational parameters and three translational parameters were used to evaluate the relative displacement. The talus showed plantar flexion. Both the calcaneus and navicular bones had valgus and lateral shift displacements. However, the cuboid had no displacement relative to the calcaneus, and the navicular showed no displacement relative to the cuboid. The calcaneus, navicular, and cuboid bones have the same pattern of deformity in patients with rheumatoid arthritis. This three-dimensional image-based technique successfully quantified the hindfoot valgus deformity resulting from rheumatoid arthritis and is beneficial for better understanding the deformity pathomechanism.     

Direct hemoperfusion using a polymyxin B immobilized column improves acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is characterized by a high mortality rate. We have studied whether direct hemoperfusion using a polymyxin B immobilized fiber column (PMX-DHP) is effective for acute lung injury (ALI) and ARDS. Two ALI and eighteen ARDS patients were evaluated, four congestive heart failure (CHF) patients were evaluated as cardiogenic pulmonary edema, and we retrospectively compared the outcome with ten patients with ARDS who had been hospitalized between 1990 and 1998 as the untreated group. PMX-DHP was carried out twice at a rate of 80-100 ml/minute for 2 hours, with a time interval of approximately 24 hours. We monitored systolic blood pressure (BP), diastolic BP, and the PaO(2)/FIO(2) (PF) ratio before and after PMX-DHP treatment. The mortality was classified if patients were alive at day 30 after initiating PMX-DHP. The mortality of ARDS patients was approximately 20%. Systolic BP increased significantly from 106 +/- 20 to 135 +/- 21 and to 125 +/- 20 mmHg on the following day. Diastolic BP increased from 61 +/- 16 to 78 +/- 15, and to 72 +/- 12 mmHg. The PF ratio increased significantly from 125 +/- 54 to 153 +/- 73, and 163 +/- 78 Torr. CHF patients did not reveal improvement of systolic, diastolic BP, and PF ratio after PMX-DHP. Eight of ten patients in the untreated group died through exacerbated ARDS. In ARDS patients, PMX-DHP improved circulatory disturbance and oxygenation despite the underlying diseases. The mortality improved compared with that before induction of PMX-DHP.     

Churg-Strauss syndrome (allergic granulomatous angitis) presenting with ileus caused by ischemic ileal ulcer

We report a rare case of Churg-Strauss syndrome (CSS) in a 41-year-old Japanese man with a history of middle-age onset of bronchial asthma who had severe abdominal pain. He presented with ileus caused by an annular ulcer of the ileum, attributable to mucosal ischemia resulting from necrotizing vasculitis of the mesenteric artery. He also had marked hypereosinophilia (51.5%), elevated serum IgE levels (34040 IU/ml), and generalized enlargement of the superficial cervical lymph nodes, containing eosinophilic granulomas. A stenotic lesion caused by an annular ulcer in the ileum was found and resected by laparotomy. Microscopic examination of the resected specimen revealed luminal narrowing or occlusion of small arteries in the ulcer base, subserosa, and mesenterium resulting from marked fibrotic intimal thickening with fragmentation or lack of the internal elastic lamina. These findings were diagnosed as vasculitis, scar stage. The postoperative course was uneventful, with the patient receiving a maintenance dose of prednisolone (10–15 mg/day) for 7 years subsequently. We must carefully diagnose and treat patients with middle-age onset asthma, because the symptom may be a lung manifestation of CSS, in which various organs including gastrointestinal tract are involved as a result of systemic necrotizing vasculitis. Received Jan. 30, 1997; accepted June 27, 1997     

Acute promyelocytic leukemia after living donor partial orthotopic liver transplantation

We encountered a 12-year-old girl with acute promyelocytic leukemia (APL) that occurred 21 months after a living donor partial orthotopic liver transplantation from her father for ornithine transcarbamylase deficiency. FK-506 had been administered for prophylaxis against graft-versus-host reaction. The bone marrow specimen revealed a massive infiltration of promyelocytic blasts (M3 by FAB classification) with chromosome 46, XX, t (15; 17) (q22; q12), being the recipient origin. A PML/RAR alpha chimeric gene was detected by RT-PCR. The patient was diagnosed as having APL and successfully induced to complete remission by chemotherapy including daunorubicin (DNR), cytarabine (araC), and all-trans retinoic acid (ATRA). She has been in continuous remission for 12 months after the treatment. Leukemia after liver transplantation is generally taken as a rare complication. However, recent advances in the survival rate of patients who have undergone liver transplantation will lead to an increase of such cases.     

Infected subdural hematoma in an infant

We report the case of a 1-year-old boy with an infected subdural hematoma due to Streptococcus pneumoniae identified by latex agglutination test and polymerase chain reaction amplification of a bacteria-specific gene. The present case demonstrated the need to include infected subdural hematoma in the differential diagnosis of suspected subdural empyema, and suggested the usefulness of combining these methods to identify a causative organism.     

A case of bronchial arterial aneurysm associated with recurrent massive hemoptysis]

A 69-year-old man was admitted to our hospital because of massive hemoptysis. Bronchial arteriography showed no abnormal findings. Bronchoscopic findings revealed a small, reddish elevated lesion on the posterior surface of the left upper lobe bronchus. Since the patient developed massive hemoptysis four times in a month, he underwent ligation and transection of the left bronchial artery, and bronchoplasty. Histopathologically, the resected tissue showed a bronchial arterial aneurysm without any inflammatory changes. We concluded that the aneurysm had developed in a malformed vessel.     

A rare case of a tracheal fibroepithelial polyp treated by an endobronchial resection

This report describes a very rare case of a tracheal fibroepithelial polyp. A 69-year-old male had been treated in this department because of chronic obstructive pulmonary disease since 2006. In July 2007, chest computed tomography revealed a bronchial tumor located at the distal end of the trachea. A bronchoscopic examination revealed a multilocular polyp. An endobronchial resection was performed to remove the lesion. A tracheobronchial fibroepithelial polyp is very rare. We herein describe and discuss the appropriate therapeutic policy and also review the pertinent literature.     

Evaluation of indications for the surgical treatment of cavernous hemangioma of the liver

The indications for liver resection performed in 18 patients with cavernous hemangioma of the liver at the Second Department of Surgery, Kyushu University Hospital, from 1985 to 1993, were reevaluated. The mean age of the patients was 49.7 years. Two patients had abdominal pain and 3 had gastric symptoms. Hepatocellular carcinoma could not be ruled out in 4 patients. None of the other patients had any clinical manifestations other than detection of the tumor. The average size of the tumors was 7.8cm (range 1–21 cm). In all, five partial resections, three subsegmentectomies, seven segmentectomies, and three bisegmentectomies of the liver were performed. No severe complications were encountered postoperatively, and no recurrences were found after the operation. A review of the literature revealed that spontaneous rupture of such tumors is infrequent. It therefore seems that there was no indications for surgery in our patients, except for the 4 in whom hepatocellular carcinoma could not be ruled out. Although elective liver resection for cavernous hemangioma is safe, the indications for surgery should be more narrowly defined in the future.     

From the Cover: Expanded palette of Nano-lanterns for real-time multicolor luminescence imaging

Fluorescence live imaging has become an essential methodology in modern cell biology. However, fluorescence requires excitation light, which can sometimes cause potential problems, such as autofluorescence, phototoxicity, and photobleaching. Furthermore, combined with recent optogenetic tools, the light illumination can trigger their unintended activation. Because luminescence imaging does not require excitation light, it is a good candidate as an alternative imaging modality to circumvent these problems. The application of luminescence imaging, however, has been limited by the two drawbacks of existing luminescent protein probes, such as luciferases: namely, low brightness and poor color variants. Here, we report the development of bright cyan and orange luminescent proteins by extending our previous development of the bright yellowish-green luminescent protein Nano-lantern. The color change and the enhancement of brightness were both achieved by bioluminescence resonance energy transfer (BRET) from enhanced Renilla luciferase to a fluorescent protein. The brightness of these cyan and orange Nano-lanterns was ∼20 times brighter than wild-type Renilla luciferase, which allowed us to perform multicolor live imaging of intracellular submicron structures. The rapid dynamics of endosomes and peroxisomes were visualized at around 1-s temporal resolution, and the slow dynamics of focal adhesions were continuously imaged for longer than a few hours without photobleaching or photodamage. In addition, we extended the application of these multicolor Nano-lanterns to simultaneous monitoring of multiple gene expression or Ca²⁺ dynamics in different cellular compartments in a single cell.Live imaging with fluorescent proteins (FPs) has revolutionized modern biology. Applications of FPs have been greatly expanded by improvements in brightness and development of color variants; however, a fundamental limitation is that fluorescence requires excitation light, the power density of which is usually above 0.1 W/cm² for live-cell imaging. This power is comparable with direct sunshine (0.13 W/cm²) and can sometimes cause problems, such as autofluorescence, phototoxicity, or photobleaching (1). Furthermore, to use FPs with recently developed optogenetic tools while avoiding unintended optogenetic stimulation, careful tuning of the spectrum for the stimulation and imaging has been necessary (2).Because luminescence imaging does not depend on excitation illumination at all, it is a good candidate as an alternative imaging modality to circumvent these potential problems caused by the excitation light. However, most existing luminescent proteins (LPs) are dim because of the low enzymatic activity and the low quantum yield (QY). For example, the QY of WT Renilla luciferase (RLuc) is so small (3) (QY = 0.02 in this report) (Fig. S1 A and B and Table S1) that 2% of the energy derived from the oxidation of the substrate, coelenterazine, is converted into photon emission, yielding only ∼0.2 photon s⁻¹ molecule⁻¹ photon emission. Long exposure (typically 1–10 min with conventional luciferase) has, thus, been required, and subcellular spatial resolution has been difficult to achieve. In addition, the color variants of LPs are limited compared with those of FPs. Thus, it has been difficult to apply LP for high-speed and multicolor imaging of living cells (4).Recently, we developed a bright yellowish-green LP called Nano-lantern (5), which is a chimera of RLuc8-S257G [an enhanced mutant (5) based on the stabilized variant called RLuc8 (3)], and Venus, a bright yellow FP with fast and efficient maturation properties (6). Three properties combined to make Nano-lantern 10 times brighter than RLuc (5), including (i) increased enzymatic activity of RLuc8-S257G (1.3 times higher than RLuc8), (ii) an optimized linker that facilitates efficient intramolecular bioluminescence resonance energy transfer (BRET) from RLuc8-S257G to Venus, and (iii) the high QY of Venus (QY = 0.57) (6). This enhanced brightness of Nano-lantern significantly improved the spatial and temporal resolution of luminescence imaging compared with that of conventional luciferase.In this paper, we extend this BRET-based approach to the development of color variants of Nano-lantern by using other FPs, such as cyan and orange FPs, as the BRET acceptor. We make use of this expanded color palette of bright LPs in three proof-of-principle applications of multicolor luminescence imaging. First, we apply the LPs as fusion tags to visualize the dynamics of subcellular microstructures, such as cytoskeletons and vesicular organelles. These submicron structures were continuously visualized at ∼1-s temporal resolution for longer than a few hours without photobleaching or photodamage. Second, an application as a multiple gene expression reporter is shown with photosensitive ES cells. Third, Ca²⁺ indicators were developed based on cyan Nano-lantern (CNL) and orange Nano-lantern (ONL), showing their usefulness as the basis for the development of luminescent indicators that are fully compatible with optogenetic tools and other optical manipulations.