Clinical evaluation of lower urinary tract symptoms following seed implant for prostate cancer

A total of 320 localized prostate cancer patients including 272 at low-risk and 48 at intermediate-risk were treated with permanent iodine-125 seed implants. Changes of lower urinary tract symptoms after the treatment were analyzed for one consecutive year using international prostate symptom score, quality of life (QOL) score and uroflowmetry. These patients did not have prostate hypertrophy or were not treated with any α1 blocker before the seed implant. Tamsulosin (0.2 mg/day) was prophylactically administered to all the patients for six months beginning the day after the seed implant. Both voiding and storage symptoms developed even in patients without any urinary symptoms before seed implant and worsened during the consecutive three months; and, QOL also worsened after seed implant. Lower urinary tract symptoms continued to be significantly severe for six months compared with that before the seed implant, then improved gradually to almost the initial level after one year. It seems to take longer for storage symptoms to diminish to the initial level compared with voiding symptoms. Neoadjuvant hormone therapy improved neither voiding nor storage symptoms in patients without prostate hypertrophy less than 40 ml in volume. In conclusion, a more effective α1 blocker or other potent prophylactic drug therapy should be used on the patients after seed implant because the disadvantage of seed implant is probably only urinary disturbance.     

Epidural fentanyl delayed emergence from anesthesia

An 83-year-old man (158 cm, 42 kg) was scheduled for cholecystectomy. He had a history of hypertension and atrial fibrillation. The patient received no premedication. An epidural catheter was inserted via the T9-10 interspace and 2% mepivacaine 7 ml was injected, producing a sensory block from T4 to T12. Anesthesia was induced with propofol and remifentanil, and was maintained with propofol, remifentanil, and nitrous oxide in oxygen. Rocuronium was given to provide neuromuscular block. Just before the completion of surgery, a bolus epidural injection of 2% mepivacaine 2 ml with fentanyl 50 microg was performed. Then epidural solution of ropivacaine 0.1% with fentanyl 6.25 microg x ml(-1), and droperidol 25 microg x ml(-1) was infused at 4 ml x hr(-1). Soon after the surgery, the patient developed atrial fibrillation that was treated with external electrocardioversion with 100 watt x sec. After the restoration of sinus rhythm, anesthetics were discontinued. The patient did not emerge from anesthesia though he breathed spontaneously Doxapram was slightly effective, but he did not respond to the verbal command. Epidural infusion was stopped and the patient was transferred to the ward. The patient fully recovered from anesthesia after 2 hours. Epidural infusion was restarted 17 hours later, and the patient fell asleep. He woke up after stopping epidural infusion. Epidurally administered fentanyl must have been the cause of delayed recovery from anesthesia. He could have been highly sensitive to fentanyl. Patient controlled epidural anesthesia may have been useful for this patient.     

Use of cryoprecipitate for dilution coagulopathy in a 7-month-old infant

We experienced a case of dilution coagulopathy successfully treated with cryoprecipitate. A seven-month-old male infant with tetralogy of Fallot and right femoral arteriovenous fistula had undergone a modified Blalock-Taussig shunt at 63 days of age. He was scheduled to undergo complete repair of TOF and closure of femoral arteriovenous fistula. The patient was transferred to the operating room with tracheal intubation. Anesthesia was induced with midazolam and fentanyl and maintained with sevoflurane and fentanyl. Before cardiopulmonary bypass (CPB), femoral arteriovenous fistula was corrected. Then complete repair of TOF was performed under CPB. Massive bleeding was observed and laboratory results showed low plasma fibrinogen level (45 mg x dl(-1)). Cryoprecipitate 2 units were given and fibrinogen level was restored (171 mg x dl(-1)). Bleeding quickly slowed down sufficiently for weaning from CPB. The patient was separated easily from CPB on dopamine and dobutamine infusion. Post-CPB bleeding was minimal and the patient was transferred to intensive care unit. The patient was discharged from the hospital on postoperative day 50. In the present case, dilution coagulopathy occurred as a result of the combination of excessive fluid infusion due to massive bleeding and blood dilution due to CPB. Fresh frozen plasma could have been contraindicated to supplement fibrinogen because the patient's body weight was low. Cryoprecipitate, a highly concentrated source of fibrinogen, was effective for correcting fibrinogen deficit.     

Prediction of AESD and neurological sequelae in febrile status epilepticus

ObjectiveThe clinical prediction rule (CPR) for acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) was developed with an area under the receiver operating characteristic curve (AUC) of 0.95 – 0.96. Our objective was to verify the AESD CPR in a new cohort and compare the utilities of three CPRs of acute encephalopathy: the Tada, Yokochi, and Nagase criteria.MethodsWe reviewed the clinical data and medical charts of 580 consecutive patients (aged < 18 years) with febrile convulsive status epilepticus lasting for ≥ 30 min in 2002 – 2017 and measured the performance of the CPRs in predicting AESD and sequelae.ResultsThe CPRs predicted AESD with an AUC of 0.84 – 0.88. The Tada criteria predicted AESD with a positive predictive value (PPV) of 0.25 and a negative predictive value (NPV) of 0.99. The Yokochi criteria predicted AESD with a PPV and NPV of 0.20 and 0.95, respectively, after 12 h. The Nagase criteria predicted AESD with a PPV and NPV of 0.14 and 1.00, respectively, after 6 h. The PPVs of the Tada, Yokochi, and Nagase criteria for sequelae were 0.28, 0.28, and 0.17, respectively; the corresponding NPVs were 0.97, 0.95, and 0.98, respectively.ConclusionsThe effectiveness of the AESD CPR in a new cohort was lower than that in the derivation study. CPRs are not sufficient as diagnostic tests, but they are useful as screening tests. The Nagase criteria are the most effective for screening among the three CPRs due to their high NPV and swiftness.     

A dosimetric and centeredness comparison of the conventional and novel endobronchial applicators: A preliminary study

PurposeThis study compared the applicator position relative to the tracheal wall and dosimetric parameters between conventional and novel applicators among patients receiving endobronchial brachytherapy (EBBT) for intratracheal tumors.Methods and MaterialsData from 7 patients who received EBBT for intratracheal tumors were retrospectively analyzed; 4 and 3 patients were treated with conventional (2-wing) or novel (5-wing) applicators, respectively. Applicator centrality was evaluated using the distance between the center of the trachea and main bronchus (TMB) lumen and path of source (L). Dosimetric parameters, including plans normalized to D_2cc of the TMB = 45 Gy (normalized plan), were compared between the applicators.ResultsThe mean and maximum values of L in cases of the 2-wing applicator group were approximately 5.0 mm and 10.0 mm, respectively. In the novel applicator group, the corresponding values were approximately 3.0 and 6.0 mm, respectively. In the normalized plan of the 2-wing applicator group, the ranges of median V_90% of clinical target volume (CTV) and D_0.1cc of the TMB in all cases were 23.0–91.9% and 66.3–153.1 Gy, respectively. In the 5-wing applicator group, the corresponding values were 69.2–83.8% and 60.4–84.5 Gy, respectively.ConclusionsIn the 5-wing applicator group, the range was narrow in all dose–volume parameters except for D_2cc of the TMB. Compared to the conventional applicator, the 5-wing applicator can give a stable dose to the CTV and can reduce the maximum dose of the TMB. This suggests that stable EBBT can be given to any patient using the 5-wing applicator.     

Change of body composition,physical strength,and nutritional status of patients with mandibular fractures

The aim was to determine changes in various parameters indicating physical conditions and nutritional status of patients during surgical and conservative treatment of mandibular fractures.A round by a nutrition support team was done once postoperatively for the surgical treatment group. For the conservative treatment group, three rounds were performed during the period of intermaxillary fixation. Data obtained from the rounds were compared between the groups.There were 29 patients surgically and 30 patients conservatively treated. A significant weight loss was observed in both groups postoperatively. The mean weight loss of the surgical treatment group measured at the postoperative round was 1.73 kg (SD ± 1.78) (P < 0.001) and that of the conservative treatment group at the third round was 2.74 kg (SD ± 2.35) (P < 0.001). During the entire treatment period, weight loss, body fat percentage, skeletal muscle percentage, grip strength and parameters indicating body composition and nutritional status of the conservative treatment group did not substantially differ from those of the surgical group.The influence of the conservative procedure on the nutritional condition of the patients seems to be limited and reversible at the end of the treatment. The weight loss observed here suggests that systematic nutrition support is necessary during both surgical and conservative treatment.     

Branchio‐oto‐renal syndrome: Comprehensive review based on nationwide surveillance in Japan

Branchio‐oto‐renal (BOR) syndrome is an autosomal dominant disorder characterized by branchiogenic malformation, hearing loss and renal anomalies. The prevalence of BOR syndrome is 1/40 000 in Western countries, and nationwide surveillance in 2009–2010 identified approximately 250 BOR patients in Japan. Three causative genes for BOR syndrome have been reported thus far: EYA1, SIX1, and SIX5, but the causative genes for approximately half of all BOR patients remain unknown. This review article discusses the epidemiology, clinical symptoms, genetic background and management of BOR syndrome.     

Microvascular decompression of the root emerging zone for hemifacial spasm: evaluation by fusion magnetic resonance imaging and technical considerations

Object

The root exit zone (RExZ) of the facial nerve has been considered to be the target in microvascular decompression (MVD) for hemifacial spasm. However, more proximal segments with oligodendrocyte-derived myelin, where the facial nerve root emerges at the pontomedullary sulcus and adheres to the brainstem surface (root emerging zone [REmZ]), may also be susceptible to neurovascular compression. This study evaluated the predictive value of magnetic resonance (MR) imaging in detecting and assessing the features of vascular compression, especially in the pontomedullary sulcus, and describes the technical considerations of MVD procedures for the more proximal segments of the facial nerve.

Methods

Twenty patients treated with MVD underwent three-dimensional constructive interference in steady-state MR imaging and three-dimensional time-of-flight MR angiography. Their fusion images were used to evaluate the anatomical neurovascular relationships and intraoperative findings were analyzed.

Results

Most offending arteries at the REmZ and the RExZ of the facial nerve were correctly identified by fusion MR imaging. During surgery, neurovascular contacts were identified at one or more segments of the facial nerve in all patients. The REmZ of the facial nerve was affected in 55 % of the patients. The most common offending vessel at the REmZ was the posterior inferior cerebellar artery rather than the anterior inferior cerebellar artery. The key procedure to explore the deep-seated REmZ in the pontomedullary sulcus was full dissection of the lower cranial nerves to the brainstem origin.

Conclusions

Our definition more correctly describes the specific anatomical relationship of the facial nerve origin from the brainstem and the clinically relevant target for MVD surgery. Fusion MR imaging is very useful to identify neurovascular contacts at both the RExZ and the REmZ of the facial nerve.     

Convergent Pre-motoneuronal Inputs to Single Trigeminal Motoneurons

Because pre-motor neurons targeting trigeminal motoneurons are located in various regions, including the supratrigeminal (SupV) and intertrigeminal (IntV) regions, the principal sensory trigeminal nucleus (PrV), and the region dorsal to the PrV (dRt), a single trigeminal motoneuron may receive differential convergent inputs from these regions. We thus examined the properties of synaptic inputs from these regions to masseter motoneurons (MMNs) and digastric motoneurons (DMNs) in brainstem slice preparations obtained from P1-5 neonatal rats, using whole-cell recordings and laser photolysis of caged glutamate. Photostimulation of multiple regions within the SupV, IntV, PrV, and dRt induced post-synaptic currents (PSCs) in 14 of 19 MMNs and 18 of 26 DMNs. Furthermore, the stimulation of the lateral SupV significantly induced burst PSCs in MMNs more often than low-frequency PSCs in MMNs or burst PSCs in DMNs. Similar results were obtained in the presence of the GABA(A) receptor antagonist SR95531 and the glycine receptor antagonist strychnine. These results suggest that both neonatal MMNs and DMNs receive convergent glutamatergic inputs from the SupV, IntV, PrV, and dRt, and that the lateral SupV sends burst inputs predominantly to the MMNs. Such convergent pre-motoneuronal inputs to trigeminal motoneurons may contribute to the proper execution of neonatal oro-motor functions.