Cancer‐associated ischemic stroke is associated with elevated d‐dimer and fibrin degradation product levels in acute ischemic stroke with advanced cancer

Aim: Although several studies have reported various causes of ischemic stroke in patients with cancer, only a few have evaluated the clinical relevance of ischemic stroke pathogenesis to cancer. The aim of the present study was to elucidate the clinical characteristics of cancer‐associated ischemic stroke. Methods: We evaluated 154 ischemic stroke patients without cancer and 57 ischemic stroke patients with cancer who had either received continuous treatment for cancer within 5 years before to the onset of ischemic stroke, or who had been diagnosed with cancer within 1 year after the onset of ischemic stroke. Cancer patients were grouped into “cancer‐associated ischemic stroke,” the “conventional ischemic stroke,” or “other.” Results: A total of 15 patients (26%) were classified into the cancer‐associated ischemic stroke in cancer patients. In univariate analysis of the cancer‐associated ischemic stroke and the others, there were significant differences in the prevalence of hypertension, hyperlipidemia and advanced cancer (clinical stage IV), and the levels of d ‐dimer, fibrin degradation product and hemoglobin. With multivariate regression analysis of those factors, the prevalence of hypertension, hyperlipidemia and advanced cancer (clinical stage IV), and the levels of d ‐dimer and fibrin degradation product remained as statistically independent factors, which were associated with cancer‐associated ischemic stroke (n = 111, χ² = 67.21, P < 0.0001). Conclusion: In acute ischemic stroke, the cancer‐associated ischemic stroke is associated with elevated d ‐dimer and fibrin degradation products, even after controlling hypertension, hyperlipidemia and advanced cancer (clinical stage IV). Geriatr Gerontol Int 2012; 12: 468–474.     

A newly designed bioabsorbable substitute for the treatment of diaphragmatic defects

Purpose

Earlier studies have investigated the suitability of various materials and autologous grafts for the repair of diaphragmatic defects. Our group investigated the feasibility of using an artificial diaphragm (AD) to repair wide diaphragmatic defects.

Methods

Twelve pigs were laparotomized and, in each pig, a defect was fashioned by resecting a round 8-cm diameter hole in the left diaphragm. Next, the defect was repaired by implanting an AD. The animals were relaparotomized 8 or 24 weeks after implantation for gross, histological and radiological observation of the implanted sites.

Results

All recipient animals survived until killing for evaluation. Chest X-ray examinations showed no differences between the preoperative diaphragms and the grafted diaphragms at 8 and 24 weeks after implantation. At 8 weeks after implantation, the implanted sites exhibited fibrous adhesions to the liver and lungs without deformities or penetrations. Parts of the surface tissue at the graft sites had a varnished appearance similar to those of the native diaphragm. Histology performed at 8 weeks detected no trace of the ADs in the graft sites; however, numerous inflammatory cells and profuse fibrous connective tissue were observed. At 24 weeks after implantation, no differences were found in the thorax between the areas with the grafts and the unaffected areas. Histology of the graft sites in the thorax confirmed growth of mesothelial cells similar to that observed in the native diaphragm.

Conclusions

Artificial diaphragms can be a novel substitute for diaphragmatic repair.     

The multiphasic learning curve for robot-assisted rectal surgery

Background

Robotic rectal surgery is gaining in popularity. We aimed to define the learning curve of an experienced laparoscopic colorectal surgeon in performing robot-assisted rectal surgery. We hypothesized that there are multiple phases in this learning process.

Methods

We performed a retrospective analysis. Consecutive patients who underwent robot-assisted rectal surgery between July 2007 and August 2011 were identified. Operating times were analyzed using the CUSUM (cumulative sum) technique. CUSUMs were model fitted as a fourth-order polynomial. χ², Fisher’s exact, two independent samples t test, one-way ANOVA, Kruskal–Wallis, and Mann–Whitney tests were used. A p value of <0.05 was considered statistically significant.

Results

We identified 197 patients. The median (range) total operative, robot, console, and docking times (min) were 265 (145–515), 140 (59–367), 135 (50–360), and 5 (3–40), respectively. CUSUM analysis of docking time showed a learning curve of 35 cases. CUSUM analysis of total operative, robot, and console times demonstrated three phases. The first phase (35 patients) represented the initial learning curve. The second phase (93 patients) involved more challenging cases with increased operative time. The third phase (69 patients) represented the concluding phase in the learning curve. There was increased complexity of cases in the latter two phases. Of phase 1 patients, 45.7 % had tumors ≤7 cm from the anal verge compared to 64.2 % in phases 2 and 3 (p = 0.042). Of phase 1 patients, 2.9 % had neoadjuvant chemoradiotherapy compared to 32.7 % of patients in phases 2 and 3 (p < 0.001). Splenic flexure was mobilized in 8.6 % of phase 1 patients compared to 56.8 % of patients in phases 2 and 3 (p < 0.001). Median blood loss was <50 ml in all three phases. The patients in phases 2 and 3 had a longer hospital stay compared to those in phase 1 (9 vs. 8 days, p = 0.002). There were no conversions.

Conclusion

At least three phases in the learning curve for robot-assisted rectal surgery are defined in our study.     

Salivary β-galactosidase activity affects physiological oral malodour

ObjectivesPrevious reports have associated salivary β-galactosidase activity with non-periodontopathic oral malodour. In this study, we investigated the localization of β-galactosidase and elucidated the relationship between its enzymatic activity and physiological oral malodour.Study designFifty-six patients complaining of halitosis were separated into two groups: periodontally healthy and periodontitis. Saliva samples from the subjects were separated by centrifugation, and the level of β-galactosidase activity was measured in the supernatant, pellet lysate, and whole saliva using the chromogenic substrate o-nitrophenyl-β-d-galactopyranoside. The correlation of salivary β-galactosidase activity with breath odour and associated parameters was examined.ResultsSimilar levels of β-galactosidase activity were detected in the pellet lysate and whole saliva, but not in the saliva supernatant. Positive correlations were observed between the β-galactosidase activity in whole saliva and oral malodour levels in the periodontally healthy group, but not in the periodontitis group. In addition, the plaque index and tongue coating score were positively correlated with β-galactosidase activity in the periodontally healthy group. Overall, stimulated salivary flow and salivary pH were negatively correlated with enzyme activity. The amounts of total bacteria, Fusobacterium nucleatum, and Streptococcus salivarius were positively associated with β-galactosidase activity in the periodontally healthy group. Furthermore, the amounts of total bacteria and S. salivarius were positively associated with the amount of volatile sulphur compounds.ConclusionsOur results indicate that β-galactosidase is located on the cell surface of oral bacteria derived from dental plaque and tongue coating, and it plays an important role in producing the malodour underlying physiological oral malodour.     

Ultrasonographic nerve enlargement of the median and ulnar nerves and the cervical nerve roots in patients with demyelinating Charcot–Marie–Tooth disease: distinction from patients with chronic inflammatory demyelinating polyneuropathy

Demyelinating Charcot–Marie–Tooth disease (CMT) and chronic inflammatory demyelinating polyneuropathy (CIDP) are both demyelinating polyneuropathies. The differences in nerve enlargement degree and pattern at multiple evaluation sites/levels are not well known. We investigated the differences in nerve enlargement degree and the distribution pattern of nerve enlargement in patients with demyelinating CMT and CIDP, and verified the appropriate combination of sites/levels to differentiate between these diseases. Ten patients (aged 23–84 years, three females) with demyelinating CMT and 16 patients (aged 30–85 years, five females) with CIDP were evaluated in this study. The nerve sizes were measured at 24 predetermined sites/levels from the median and ulnar nerves and the cervical nerve roots (CNR) using ultrasonography. The evaluation sites/levels were classified into three regions: distal, intermediate and cervical. The number of sites/levels that exhibited nerve enlargement (enlargement site number, ESN) in each region was determined from the 24 sites/levels and from the selected eight screening sites/levels, respectively. The cross-sectional areas of the peripheral nerves were markedly larger at all evaluation sites in patients with demyelinating CMT than in patients with CIDP (p < 0.01). However, the nerve sizes of CNR were not significantly different between patients with either disease. When we evaluated ESN of four selected sites for screening from the intermediate region, the sensitivity and specificity to distinguish between demyelinating CMT and CIDP were 0.90 and 0.94, respectively, with the cut-off value set at four. Nerve ultrasonography is useful to detect nerve enlargement and can clarify morphological differences in nerves between patients with demyelinating CMT and CIDP.     

Alpha2-macroglobulin as a promising biomarker for cerebral small vessel disease in acute ischemic stroke patients

Alpha2-macroglobulin is a protease inhibitor that enhances procoagulant properties via the neutralization of plasmin, plasminogen activators and metalloproteinases. Additionally, alpha2-macroglobulin is thought to be involved in inflammatory reactions as a carrier protein for interleukin-6 (IL-6). The objective of this study was to evaluate the usefulness of alpha2-macroglobulin as a biomarker for cerebrovascular diseases. Patients with acute ischemic stroke (n = 159; 93 male and 66 female, 71.6 ± 10.3 years) and patients with no previous history of stroke (n = 77; 38 male and 39 female, 70.7 ± 9.5 years) were consecutively enrolled in this study. White matter lesions were assessed via the fluid-attenuated inversion recovery image of magnetic resonance images using the Fazekas classification. The serum alpha2-macroglobulin levels were measured by nephelometry. The serum alpha2-macroglobulin levels at admission in patients with acute ischemic stroke were higher than those in the control patients (230.2 ± 73.7 vs. 205.0 ± 55.8 mg/dl, p = 0.009). The serum alpha2-macroglobulin levels were positively correlated with age and the severity of the white matter lesions (R ² = 0.048, p < 0.001 and R ² = 0.058, p < 0.001, respectively), although there was no significant association between serum alpha2-macroglobulin levels and IL-6 levels. In addition, multivariate analysis showed that increased serum alpha2-macroglobulin levels were independently associated with the severity of white matter lesions [standardized partial regression coefficient (β) 0.102, p = 0.026]. Increased serum alpha2-macroglobulin levels might be involved in the pathophysiology of acute ischemic stroke. Furthermore, serum alpha2-macroglobulin levels, which were associated with high-grade white matter lesions, may reflect the chronic pathophysiological condition of cerebral small vessel disease.     

Elevated urinary β2 microglobulin in the first identified Japanese family afflicted by X-linked myopathy with excessive autophagy

Here we report what is to our knowledge the first identified Japanese family afflicted by X-linked myopathy with excessive autophagy. The index case is a 52-year-old man with almost 40 years of progressive proximal muscle weakness. High urinary β2 microglobulin, normal serum β2 microglobulin, autophagic vacuoles with sarcolemmal features, and a hemizygous c.164–7T>G mutation in the VMA21 gene were found. His two maternal uncles had similar clinicopathological findings. High urinary β2 microglobulin without obvious renal dysfunction might result from decreased urine acidification in the distal convoluted tubules caused by the VMA21 gene mutation. These findings might prove to be useful as a preliminary marker suggestive of X-linked myopathy with excessive autophagy.     

Interindividual anatomical variations affect the plate‐to‐bone fit during osteosynthesis of distal radius fractures

We hypothesized that interindividual variations in the teardrop, which represents the volar projection of the lunate facet of the distal radius, cause unsatisfactory fitting of the volar locking plate to the bone. This can cause flexor tendon ruptures. Herein, we conducted a cross‐sectional study and measured the ratio of teardrop height and the teardrop inclination angle as parameters of teardrop configuration for 200 standardized lateral radiographs (average age of the patients, 51 years). We also quantified the influence of the teardrop morphology by analyzing the fit of three locking plates to three radii with differing teardrop inclination angles using a three‐dimensional computer‐aided design system. The average ratios of the teardrop height and teardrop inclination angle were 0.42° (0.30–0.56°) and 28.8° (9.9–44.9°), respectively. The teardrop inclination angle was moderately correlated with age in men but not in women. In the plate‐to‐bone fit analyses, the fit of all the plates was significantly different between bones, with the configuration of the radius with the lowest teardrop inclination angle being the closest approximation to that of each plate. We demonstrated the interindividual variation in the shape of the teardrop and its influence on the fit of the volar plate, highlighting the importance of careful plate selection for achieving osteosynthesis of bones with a high teardrop inclination angle. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:953–960, 2016.