A case of emergency surgery for acute mitral regurgitation due to complete papillary muscle rupture as complication of acute inferior myocardial infarction

We experienced a case with acute mitral regurgitation caused by complete posterior papillary muscle rupture as complication of acute inferior myocardial infarction, who underwent successfully emergency operation of mital valve replacement and coronary revascularization in acute stage. A 64-year-old woman developed sudden cardiogenic shock shortly after the onset of acute inferior myocardial infarction. The diagnosis of acute inferior myocardial infarction was based on the electrocardiographic findings. Under IABP support, preoperative coronary angiography visualized total occlusion of segment 3 of the right coronary artery, and preoperative left ventriculography showed akinesis of inferior wall and severe mitral regurgitation. At 6 hours after onset of papillary muscle rupture, emergency operation was performed. At operation, posterior papillary muscle was found to be totally ruptured. Coronary artery revascularization and mitral valve replacement were performed. Postoperative course was uneventful, with 4 days of IABP and 5 days of ventilatory support. She was discharged on the twentieth postoperative day in NYHA class I. Reports of successful emergency operation for total papillary muscle rupture following acute myocardial infarction are rare. Early diagnosis and surgical treatment are mandatory to save this group of patients.     

Role of positive selection of thymoma-associated T cells in the pathogenesis of myasthenia gravis

BACKGROUND: A human thymoma is a thymic epithelial neoplasm and is characterized by its frequent association with myasthenia gravis. The histological characteristic of thymoma is coexistence of a large number of lymphocytes, including CD4(+)CD8(+) double positive T cells, phenotypes of the cortical thymocytes. To elucidate the role of these T lymphocytes in the pathogenesis of thymoma-associated myasthenia gravis, we examined the usage of alphabeta or gammadelta T cell receptor of the T lymphocytes in thymoma in conjunction with the positive selection event. MATERIALS AND METHODS: Thymomas were obtained from 28 patients. Nine patients were associated with myasthenia gravis. Lymphocytes were freshly isolated from the tumor tissue and were subjected to four-color flow cytometric analysis. RESULTS: The average proportion of TCRalphabeta(+) cells in thymomas associated with myasthenia gravis was 47.0% and was significantly higher (P = 0.0008) than that without myasthenia gravis (23.4%). Positive selection event was then examined in terms of CD69, a positive selection marker. The mean proportion of TCRalphabeta(+)CD69(+)CD4(+)CD8(-) cells in the myasthenic thymomas (8.22%) was significantly greater (P = 0.015) than the nonmyasthenic thymomas (2.99%). On the other hand, there was not a significant difference in the mean proportion of TCRalphabeta(+)CD69(+)CD4(-)CD8(+) cells between the myasthenic and the nonmyasthenic thymomas. CONCLUSIONS: The possible role of development of TCRalphabeta(+) T cells, especially the role of positive selection of TCRalphabeta(+)CD4(+)CD8(-) T cells in thymoma, was suggested in the pathogenesis of thymoma-associated myasthenia gravis.     

Surgery for a pericardial diverticulum; report of a case

We report a case with pericardial diverticulum in the mediastinum. A 64-year-old woman visited our hospital because of cough and dyspnea. Chest X-ray showed a smooth-bordered mass in the right superior mediastinum and computed tomography (CT) showed a homogeneous cystic mass in the paratracheal area. During right mini-thoracotomy, a thin-walled cystic lesion was found involving the trachea, the superior vena cava, and the azygos vein. The cyst extended a duct toward the pericardium. We performed total excision and pathological examination confirmed the diagnosis of a pericardial diverticulum. Mini-thoracotomy provides an effective and minimally invasive means of excising the mediastinal mass, relieving symptoms, and allowing pathological examination.     

Case of autosomal dominant polycystic kidney disease associated with congenital hepatic fibrosis

A 31-year-old man was admitted to the hospital because of a low-grade fever, general malaise, nausea, vomiting, and a poor appetite. On admission his renal function was severely deteriorated (serum creatinine 16.12 mg/dl, BUN 163 mg/dl), and he had severe anemia (Hb 7.5 g/dl) and thrombocytopenia (67,000/microl). A radiological examination revealed the presence of multiple cysts in his kidneys bilaterally. The patient was diagnosed as having end-stage renal disease due to polycystic kidney disease, and hemodialysis was started on the day of admission. After the initiation of hemodialysis, his symptoms and laboratory tests improved, except for anemia and thrombocytopenia. He was noted to have marked splenomegaly and dilation of the portal vein, raising the suspicion of portal hypertension as the cause of the splenomegaly and pancytopenia. To treat his pancytopenia (anemia and thrombocytopenia) and to determine the reason for his portal hypertension, a splenectomy and open-wedge biopsy of the liver were performed. Histological findings in the liver included extensive fibrosis of the portal areas with an excess of moderately dilated bile ducts, compatible with a diagnosis of congenital hepatic fibrosis. After splenectomy, his red blood cell and platelet counts returned to normal, and he was discharged on maintenance dialysis. Congenital hepatic fibrosis is often associated with autosomal recessive polycystic kidney disease (ARPKD), but not with autosomal dominant polycystic kidney disease (ADPKD). However, both his mother and older brother had multiple renal cysts, indicating that this was an unusual case of ADPKD complicated by congenital hepatic fibrosis.     

Endovascular repair of a presumed aortoduodenal fistula.

This report describes the use of transluminal endovascular grafting for the treatment of a presumed aortoduodenal fistula. The patient was a 71-year-old man who had undergone resection and graft replacement for an abdominal aortic aneurysm. Three years after operation, melena was caused by perforation of the duodenal wall by a pseudoaneurysm at the proximal graft anastomosis. The pseudoaneurysm was treated by transluminal endovascular grafting. The pseudoaneurysm was subsequently thrombosed and absorbed. The ulcer-like lesions at the site of the duodenal wall perforated by the pseudoaneurysm also resolved. Endovascular stent-grafts may have a role to play in management of aortoduodenal fistula.     

A long-term follow-up of silicone-rubber interposition arthroplasty for osteoarthritis of the thumb carpometacarpal joint.

There are several surgical options for osteoarthritis (OA) of the thumb carpometacarpal (CMC) joint. This paper presents our long-term clinical and radiographic review of 12 thumbs in ten patients treated by partial trapezial excision and silicone-rubber interposition arthroplasty. The follow-up period averaged 15; three years with a ten-year minimum. Although the procedure provided early pain relief in most thumbs, all but two had mild to severe pain at follow-up. The average range of post-operative palmar abduction was 23 degrees. The average post-operative grip strength was 9.5 kg. Both tip and key pinch between thumb and index finger averaged about 50% that of normal subjects. Dislocation of the implant occurred in two joints and breakages in five. Bony erosions around the implant, which we attributed silicone synovitis, were found in four thumbs. The indications for silicone-rubber interposition arthroplasty for OA of the thumb CMC joint should be severely restricted as these produced unsatisfactory long-term results.     

A randomized study of prophylactic intravesical instillation of pirarubicin (THP) prior to transurethral resection of superficial bladder cancer

A prospective randomized study was conducted to evaluate the efficacy of prophylactic intravesical instillation of pirarubicin (THP) prior to transurethral resection (TUR) of superficial bladder cancer. A total of 63 patients were randomized into two groups, the THP group and the control group. In the THP group, 30 mg of THP dissolved in 50 ml saline was administered 4 times intravesically for 4 consecutive days before TUR. In the control group, no instillation was performed before TUR. The patients were followed by cystoscopy and urinary cytology every 3 months. The non-recurrence rates in the THP group and control group were 54.1% versus 37.6% at 1 year and 40.4% versus 26.8% at 2 years, respectively (P = 0.086). Time to recurrence for tumors larger than 1 cm was significantly longer in the THP group (P = 0.0137). Time to recurrence for single and grade 1+2 tumors tended to be longer in the THP group (P = 0.09, P = 0.079). No significant adverse effects were observed in any patient. Our findings suggest that intravesical THP instillation prior to TUR would be effective for patients with single, low grade lesions larger than 1 cm of superficial bladder cancer.     

The effects of neoadjuvant chemotherapy and chemo-radiation therapy on MRI staging in invasive bladder cancer: comparative study based on the pathological examination of whole layer bladder wall

Objective

We evaluated the correlation of radiological findings obtained by MRI study with pathological diagnosis in invasive bladder cancer treated with neoadjuvant chemotherapy, with or without radiation.

Design, Setting, and Participants

Twenty-seven patients, who underwent total or partial cystectomy for invasive bladder tumors, were enrolled into the present study. Eight cases had received neoadjuvant chemotherapy following the staging biopsy (group A), ten cases had received chemo-radiation therapy following the staging biopsy (group B), and nine cases had received preoperative staging biopsy alone (group C). As a final treatment, 12 of the 27 patients underwent total cystectomy and the other 15 patients underwent partial cystectomy. MRI was conducted prior to total or partial cystectomy in each case. The pathological stage was assessed by histological examination of the entire layer of the bladder wall.

Results and Limitations

Tumor stage assessed by MRI was consistent with pathological findings in 16 of the 27 cases (59.3%), while MRI produced over-staging in 7 cases and under-staging in 4 cases. The accuracy of staging was 75.0, 30.0, and 77.8% in groups A, B, and C, respectively. The accuracy of MRI staging in group B was lower than that in group C (P < 0.05). There was no difference in the accuracy of MRI staging between groups A and C.

Conclusion

MRI is useful for the staging of bladder cancer. However, care needs to be taken when staging invasive bladder tumors treated with neoadjuvant chemo-radiation therapy, because inflammatory infiltrations and/or fibrous changes caused by the chemotherapy or chemo-radiation therapy make precise staging with MRI difficult.     

Motion artifact reduction of diffusion‐weighted MRI of the liver: Use of velocity‐compensated diffusion gradients combined with tetrahedral gradients

Purpose:

To assess the effect of motion artifact reduction on the diffusion‐weighted magnetic resonance imaging (DWI‐MRI) of the liver, we compared velocity‐compensated DWI (VC‐DWI) and VC‐DWI combined with tetrahedral gradients (t‐VC‐DWI) to conventional DWI (c‐DWI) in the assessment of apparent diffusion coefficients (ADCs) of the liver.

Materials and Methods:

In 12 healthy volunteers, the liver was scanned with c‐DWI, VC‐DWI, and t‐VC‐DWI sequences. The signal‐to‐noise ratio (SNR) and ADC of the liver parenchyma were measured and compared among sequences.

Results:

The image quality was visually better for t‐VC‐DWI than for the others. The SNR for t‐VC‐DWI was significantly higher than that for VC‐DWI (P < 0.05) and comparable to that for c‐DWI. ADCs in both hepatic lobes were significantly lower for t‐VC‐DWI than for c‐DWI (P < 0.01). ADC in the left lobe was significantly lower for VC‐DWI than for c‐DWI (P < 0.01). Although ADC in the left lobe was significantly higher for c‐DWI (P < 0.01), no significant differences in ADCs were found between the right and left lobes for VC‐DWI and t‐VC‐DWI.

Conclusion:

The use of a t‐VC‐DWI sequence enables us to correct ADCs of the liver for artificial elevation due to cardiac motion, with preserved SNR. J. Magn. Reson. Imaging 2013;37:172–178. © 2012 Wiley Periodicals, Inc.     

Improved reproducibility of simple quantitative indices from 99mTc-GSA liver functional imaging

Objective

We evaluated intra- and interoperator reproducibilities in calculating the conventional indices HH15 and LHL15 from ^99mTc-diethylenetriamine pentaacetic acid galactosyl human serum albumin (^99mTc-GSA) scintigraphy, and proposed new, simple methods for the calculation of quantitative indices.

Methods

The results of ^99mTc-GSA scintigraphy in 33 patients were retrospectively analyzed. Heart and liver ROIs were drawn manually to cover cardiac blood pool and entire liver, respectively, and HH15 and LHL15 were calculated. In addition, square regions of interest (ROIs) of fixed sizes were placed at the highest activity in blood pool and the liver. Using the square heart ROI, sHH15, an equivalent of HH15, was computed. Fractional liver uptake at 15 min (FLU15) was calculated using the square heart and liver ROIs. Intra- and interoperator reproducibilities, as well as correlation with Indocyanine green retention rate at 15 min (ICG R15), were assessed for these four indices by linear regression analysis.

Results

Substantial intra- and interoperator variabilities were found for HH15 and LHL15. The correlation coefficients for intra- and interoperator comparisons were 0.884 and 0.869 for HH15, respectively, and 0.919 and 0.917 for LHL15, respectively. The use of square ROIs instead of hand-drawn ROIs improved reproducibility. The correlation coefficients for intra- and interoperator comparisons were 0.988 and 0.973 for sHH15, respectively, and 0.989 and 0.975 for FLU15, respectively. Correlation with ICG R15 was better for sHH15 (r = 0.619) and FLU15 (r = ?0.656) than for HH15 (r = 0.439) and LHL15 (r = ?0.490).

Conclusions

HH15 and LHL15 showed substantial intra- and interoperator variabilities, and the use of square ROIs are indicated to provide better reproducibility.