Videoscopic supradiaphragmatic thoracic duct division using ultrasonic coagulator.

Three consecutive male patients underwent videoscopic supradiaphragmatic thoracic duct division using the Harmonic Scalpel with a hook blade (Ethicon Endo-Surgery, Cincinnati, OH, USA) for treatment of chyle leaks that developed after left upper lobectomy, graft replacement of a descending aortic aneurysm and thyroidectomy with concomitant partial sternal resection. The thoracic duct was exposed and divided using just the Harmonic Scalpel. The operations lasted 40, 20 and 18 min. No mortality, morbidity or recurrence occurred during follow-up periods of 27, 17 and 9 months. The Harmonic Scalpel with a hook blade can facilitate supradiaphragmatic exposure of the thoracic duct.     

A case of narcolepsy with increased cataplectic attacks after suffering from cerebrovascular disease

It is well known that narcoleptic patients have DR2 and DQw-1 on HLA typing. The development of narcolepsy is considered to depend on the two factors; genetic predispositions and exogenous factors such as head trauma, encephalitis, etc., mainly affecting the brainstem or diencephalon. We reported a 46-year-old man who had occasional sleep attacks after suffering from left thalamic hemorrhage and pontine vascular disorders. Rehabilitation was markedly disturbed due to frequent episodes of cataplectic attacks which was triggered by emotional lability such as laughing, anxiety, and excitement. HLA type examination showed both DR-2 and DQw-1 loci in the proband and his four other siblings. His elder brother also suffered from mild excessive daytime sleepiness during his younger age, but it subsided gradually. Analysis of overnight polysomnography in the patient revealed remarkable paradoxical alpha-blocking and frequent sleep onset REM stages as typically observed in narcoleptic patients. MRI examination showed multiple small hemorrhages and infarctions in the pontine tegmentum, in addition to the left thalamic hemorrhage and multiple subcortical ischemic lesions. Concerning the mechanism of frequent cataplexy in this patient, it is postulated that increased emotional incontinence might have stimulated the descending reticular system in the brainstem which in turn may inhibit anterior horn motor cell activities. Methylphenidate was initially given to the patient, resulting in some relief of attacks, and addition of imipramine dramatically suppressed cataplectic attacks. Imipramine is considered to inhibit the excitatory afferent pathway to the brainstem suppressing the hyperactivity of descending motor inhibitory system due to its anti-muscarinergic action.     

Effects of halothane on sensory evoked potentials

Intraoperative monitoring of central nervous system functions is useful for safe neurosurgical operations. For such a purpose, some kinds of sensory evoked potentials play significant roles, but their reliability during general anesthesia have not yet been established. The authors conducted experimental and clinical studies to reveal effects of halothane, a most popular anesthetic, on sensory evoked potentials. Eight adult cats, weighing 2.8-4.0 kg, were induced to anesthesia with thiopental and ether, and after tracheostomy and venous cannulation, they were immobilized with succinylcholine and artificially ventilated with mixture of oxygen, nitrous oxide halothane. The concentration of halothane was increased up to 4.0% by 0.5% steps. The body temperature, systemic blood pressure and carbon dioxide concentrations in expires gas were monitored continuously, and maintained within normal ranges as much as possible. The hypotension induced by halothane was easily corrected by dopamine infusion initially, but later became difficult to be controlled as the halothane concentration increased. In each concentration, short latency somatosensory evoked potentials by median nerve stimulations (SL-SEP), and brain stem auditory evoked potentials (BAEP) were recorded. Active electrode was placed on the bregma, and reference electrodes were placed on a hindlimb for SL-SEP, on the tongue for BAEP recordings. Peak amplitudes of SL-SEP were gradually decreased and finally disappeared without apparent dose dependency. Relatively the peaks with longer latencies were more affected than those with shorter latency such as P1 and N1. In BAEP, decrement of the amplitude was apparent in the peaks with longer latencies with an obvious dose dependency.(ABSTRACT TRUNCATED AT 250 WORDS)     

LIMITATIONS OF PERORAL CHOLANGIOSCOPY IN THE DIAGNOSIS OF BILIARY TUMORS

In patients with carcinoma of the bile duct, a primary tumor with tumor spread along the bile duct is frequently shown as a stricture of the bile duct with ductal irregularity and rigidity on ERCP. In patients in whom histological diagnosis is necessary, larger caliber peroral cholangioscopes with a larger working channel should be chosen because they have the advantage of simultaneous biopsy diagnosis. However, peroral cholangioscopy (POCS) has limitations to inspect mucosal tumor spread along the upstream ducts due to the tight stricture, to obtain sufficient biopsy material for confirming the diagnosis, and to identify submucosal tumor spread. With further improvement of techniques, the combined use of POCS with biopsy under direct vision and intraductal ultrasonography (IDUS) is expected to be the best way in the diagnosis of biliary tumors.     

A clinical evaluation of fluconazole in the treatment of deep mycosis

Fluconazole is a novel triazole antifungal agent developed by Pfizer Inc. and available in both oral and intravenous forms. It is characterized by a long serum half-life of 25 to 30 hours and good absorbability into tissues. In the present study, fluconazole was given to 12 patients with deep mycosis orally, intravenously or by local infusion. The patients included 4 cases of candidemia, 1 case each of candidemia and candiduria, candiduria, esophageal candidiasis, Candida hepatic abscess, pulmonary cryptococcosis and septicemia due to unspecified yeasts and 2 cases of pulmonary aspergillosis. Clinical efficacies of fluconazole against these infections were excellent in 2 cases, good in 8 and fair in 2. None of the patients reported any side effects. From the results of the study, fluconazole appears to be a useful and safe drug for the treatment of deep seated mycosis.     

Effects of a spider toxin (JSTX) on hippocampal CA1 neurons in vitro

The effect of a toxin (JSTX) obtained from Nephila clavata (Joro spider) on the CA1 pyramidal neurons of the hippocampus was studied using slice preparations. JSTX blocked the excitatory postsynaptic potentials (EPSPs) in the pyramidal neuron evoked by Schaffer collateral stimulation but was without effect on the antidromic action potentials or on the resting conductance. Depolarization induced by ionophoretic application of glutamate was readily suppressed by JSTX but aspartate-induced depolarization was much less sensitive to the toxin. Among preferential agonists activating 3 receptor subtypes for excitatory amino acids, quisqualate responses were most effectively suppressed by JSTX. Kainate responses were similarly suppressed but in some cells higher concentration of the toxin was needed to block the responses. N-methyl-D-aspartate (NMDA) responses were the least sensitive to JSTX but they were suppressed by +/- 2-amino-5-phosphonovaleric acid (APV). Long term potentiation (LTP) once it had taken place was not completely inhibited by APV. In the presence of JSTX, however, LTP was blocked and tetanic stimuli produced only a short-lived potentiation. In Mg2+ free solution, an orthodromic stimulation evoked repetitive spike responses which were superimposed on the depolarization following the initial spike. APV suppressed the depolarization and associated spikes leaving an orthodromic response which was sensitive to JSTX. The results suggest that JSTX blocks EPSPs in CA1 pyramidal neurons which are mediated by non-NMDA type receptors.     

Continuous ambulatory peritoneal dialysis in a diabetic patient with renal insufficiency and ventricular aneurysm

A diabetic patient with renal insufficiency and a giant ventricular aneurysm was treated by continuous ambulatory peritoneal dialysis (CAPD). No apparent exacerbation of the patient's cardiovascular function was observed after starting CAPD therapy, although his ejection fraction remained low and his angina attacks persisted. It is suggested that CAPD therapy has no deleterious effects on the cardiovascular system of patients with ventricular aneurysms, and that the benefits outweigh the risks.