Functional giant parathyroid cyst with high concentration of CA19-9 in cystic fluid

A 63-year-old man was admitted to our hospital for the evaluation of hypercalcemia and anterior neck mass. Laboratory findings revealed hypercalcemia, hypophosphatemia, and hypercalciuria, as well as elevated serum levels of parathyroid hormone (PTH) and alkaline phosphatase. Computerized tomography and magnetic resonance images showed that the mass contained a cystic area. Parathyroid scintigraphy using either 99mTc-sestamibi alone or 201Tl-chloride in conjunction with 99mTc-pertechnetate for thyroid image subtraction showed uptake of the radioactivity into the cyst wall, suggesting that the mass originated from the parathyroid. Fine needle aspiration biopsy revealed that the cyst fluid was serous and bloody with extremely high concentrations of both PTH and CA19-9. The patient was diagnosed as primary hyperparathyroidism caused by parathyroid cyst and cervical exploration was performed. The cyst was dissected away along with the right lobe of the thyroid gland. After tumor removal, serum calcium and PTH levels were normalized. Histological study showed that the tumor possessed malignant potential with capsular invasion as well as moderate cellular atypia with trabecular pattern in arrangement. Parathyroid cells in the wall of the cystic tumor were immunostained positively for CA19-9, suggesting that CA19-9 in the cyst fluid was produced from the cells.     

Membranoproliferative glomerulonephritis and circulating cryoglobulins

Background

Previous studies on membranoproliferative glomerulonephritis (MPGN) and cryoglobulinemic glomerulopathy (CG) were based upon case series that were performed before hepatitis C virus (HCV) infection was routinely investigated. Therefore, it remains unknown how far HCV contributes to MPGN or CG, and there have only been a few reports about HCV-negative idiopathic MPGN.

Patients and methods

Thirty-five patients with MPGN diagnosed by renal biopsy who underwent examination for HCV infection at our institute between 1990 and 2008 were recruited for this study. Patients with HCV infection at presentation were included, but patients with complications such as underlying lymphoproliferative disorders, autoimmune diseases like lupus nephritis, infection, and liver disease due to hepatitis B virus or alcohol abuse were excluded. A total of 35 patients were enrolled and they were divided into two groups according to the presence/absence of circulating cryoglobulins (cryo). The 23 patients who had cryo-negative and HCV-negative idiopathic MPGN were divided into subgroups with type 1 and type 3 disease.

Results

In the cryo-positive group (n = 9), 7 patients were positive for HCV infection, while 2 patients were negative. In the cryo-negative group (n = 26), 3 patients were positive for HCV infection, while 23 patients were negative (idiopathic MPGN). Compared with the cryo-negative group, the cryo-positive group had several characteristics such as more severe thrombocytopenia, higher serum immunoglobulin (Ig)G and IgM levels, lower levels of hemolytic complement (CH50) and complement component (C)4, predominant IgM staining, and type 1 histology. Patients with cryo-negative and HCV-negative ‘idiopathic’ MPGN showed predominant staining for IgG in both type 1 and type 3 cases, unlike the predominant staining for IgM in the cryo-positive group. Compared with type 3 cases, type 1 cases had a younger age, lower levels of CH50, C3 and C4, and less proteinuria. In the cryo-positive group, 4 patients (44.4 %) died, with death from B cell lymphoma and liver failure in 2 patients each, while 1 patient (8 %) developed end-stage renal failure requiring dialysis. In contrast, all patients in the cryo-negative group remained alive during follow-up, although 4 patients (2 type 1 cases and 2 type 3 cases) required dialysis.

Conclusion

Cryo-positive MPGN shows a close relationship with HCV infection and IgM, resulting in a poor prognosis. Cryo-negative and HCV-negative idiopathic MPGN has a close relationship with IgG staining, and type 1 cases feature characteristics such as a younger age, more severe hypocomplementemia, and less proteinuria than in type 3 cases.     

Comparison of Insertion of the Modified i-gel Airway for Oral Surgery With the LMA Flexible: A Manikin Study

We previously modified the i-gel airway to enable its use in the field of oral and maxillofacial surgery and reported its fabrication methods. In general, the standard i-gel airway is quick to insert and has a high success rate, but the modified i-gel airway has yet to be assessed for these attributes. We, therefore, set out to compare the ease of insertion of the modified i-gel airway with the LMA Flexible to investigate the usefulness of the modified i-gel airway. The study participants, who included 20 new interns with no experience using either the LMA Flexible or the modified i-gel airway, inserted each device 3 times into an intubation practice manikin. The variables measured in this study were insertion time and rate of successful insertions. Mean insertion time over 3 attempts was significantly shorter for the modified i-gel™ airway (18.9 ± 4.7 seconds) than the LMA Flexible (24.9 ± 5.1 seconds, P < .001). The rate of successful insertions as a total of all 3 attempts was significantly higher for the modified i-gel airway (56/60 times, 93.3%) than the LMA Flexible (45/60 times, 75%; P = .012). When used by an inexperienced operator, the modified i-gel™ airway is faster and has a higher success rate than the LMA Flexible, suggesting that it can be easily manipulated during insertion.Key Words: Oral and maxillofacial surgery, Supraglottic airway device, Modified i-gel™ airwayThe first laryngeal mask (LMA) was the LMA Classic, developed by Dr Brain. It was later followed by a number of groundbreaking new products, such as the LMA ProSeal, which features a high-pressure seal and a gastric tube orifice, and the LMA Fastrack that can be used to pass an endotracheal tube into the trachea. Today, these and other products comprise the LMA family. One of them, the LMA Flexible (Laryngeal Mask Company, Jersey, UK; Figure 1: top) was developed for oral and maxillofacial surgery and other types of head and neck surgery. The flexible wire-reinforced airway tube of this device has the advantages of avoidance of interference with the operative field, even in oral surgery, and being able to withstand pressure from surgical manipulation.^1,2 Thus, the LMA Flexible is currently the gold standard supraglottic device in the field of oral and maxillofacial surgery. The flexibility of the shaft of the reinforced airway tube, however, makes it difficult to exert any force on the shaft,^1,2 making insertion more difficult than with the LMA Classic.³Open in a separate windowFigure 1.LMA Flexible (top) and modified i-gel airway (bottom).The i-gel airway (Intersurgical Ltd, Wokingham, UK) is a disposable supraglottic device that was developed by Dr Nasir. It consists of an airway tube with a noninflatable gel-like cuff designed to fit perfectly over the larynx and also has a gastric tube orifice. The i-gel airway features a high-pressure seal (pharyngeal leak pressure),⁴ potentially preventing leakage of blood and water into the airway, which is a frequent problem during dental treatment and in oral and maxillofacial surgery. Hence, although this device may be very useful in oral and maxillofacial surgery, its use is limited by the thickness of the shaft of the airway.We previously modified the i-gel airway (modified i-gel airway; Figure 1: bottom) to enable its use in the field of oral and maxillofacial surgery and reported its fabrication methods.⁵ In general, the standard i-gel airway is quick to insert and has a high success rate, but the modified i-gel airway has yet to be assessed for these attributes. We, therefore, set out to compare the ease of insertion of the modified i-gel airway and the LMA Flexible to investigate the usefulness of the modified i-gel airway.     

Nucleation of Surfactant–Alkane Mixed Solid Monolayer and Bilayer Domains at the Air–Water Interface

We investigated the wetting transitions of tetradecane and hexadecane droplets in dodecyltrimethylammonium bromide (C12TAB), tetradecyltrimethylammonium bromide (C14TAB), and hexadecyltrimethylammonium bromide (C16TAB) aqueous solutions. By varying the surfactant concentration, the formation of mixed monolayers of a surfactant and an alkane was observed at the air–water interface. Depending on the combination of surfactant and alkane, these wetting monolayers underwent another thermal phase transition upon cooling either to a frozen mixed monolayer (S1) or a bilayer structure composed of a solid monolayer of a pure alkane rested on a liquid-like mixed monolayer (S2). Based on the phase diagrams determined by phase modulation ellipsometry, the difference in the morphology of the nucleated S1 and S2 phase domains was also investigated using Brewster angle microscopy. Domains of the S1 phase were relatively small and highly branched, whereas those of the S2 phase were large and circular. The difference in domain morphology was explained by the competition of the domain line tension and electrostatic dipole interactions between surfactant molecules in the domains.     

Assessment of preoperative anxiety in patients entering the operating room on foot using state-trait anxiety inventory

The purpose of this prospective study was to assess the effect of walking into the operating room on preoperative anxiety level. Sixty non-premedicated patients scheduled for elective surgery were randomly divided into two groups based on how they were transported into the operating room. One group was carried on a stretcher (n = 30) and the other entered on foot under their own power (n = 30). A subjective assessment of anxiety was performed using a state-trait anxiety inventory (STAI) the day before surgery and on arrival at the operating room. STAI values were not increased in the operating room as compared to the day before surgery for either group and did not differ between groups, though they showed a high level of anxiety throughout the preoperative period. We conclude that walking into the operating room has no significant influence on preoperative anxiety level.     

Inter- and/or Intra-organ distribution of mitochondrial C3303T or A3243G mutation in mitochondrial cytopathy

Fatal infantile mitochondrial cytopathy associated with a C3303T mutation in the mitochondrial tRNA(Leu(UuR)) gene has been reported clinically, biochemically and genetically. Here we have analyzed the percentage of this mutation in various autopsied tissues, and also in single muscle fibers using a micromanupulator, to evaluate the correlation between the pathology and heteroplasmic condition using polymerase chain reaction/restriction fragment length polymorphism. A 5-month-old Japanese girl was admitted to our hospital showing generalized muscle weakness, hepatomegaly, and cardiomegaly with lactic acidosis, and died at 6 months of age. Skeletal muscle showed severe degenerating myopathy found to be full of ragged-red fibers (RRFs), an increased number of lipid droplets, and severe cytochrome c oxidase (COX) deficiency. Microscopically hepatocytes showed massive accumulation in lipid droplets, and the heart muscle showed a network pattern suggesting metabolic cardiomyopathy. The activities of respiratory chain enzyme complex I and complex IV in the skeletal muscle were significantly decreased to 23.4% and 5.0%, respectively, of the control value. The percentage of C3303T mutation in the patient tissues were variable, and ranged from 25% in the pancreas to 99% in the spinal cord. By single fiber analysis, the percentages of C3303T mutation in RRFs with COX negative (group 1; 42.4+/-7.0) and with COX positive (group 2; 58.2+/-5.8) were significantly higher than in non RRFs with normal COX staining (group 3; 10.7+/-6.3) (both P>0.001). Our patient showed a fatal infantile form of encephalopathy, myopathy and cardiomyopathy associated with widely distributed C3303T mutation in all of somatic cells.     

Evaluation of adhesive tape containing lidocaine using current perception threshold measurement

Lidocaine adhesive tape (Penles; Wyeth Lederle Japan, Ltd, Tokyo, Japan) is placed for pain relief prior to puncturing a vein with a needle. We investigated the optimal time interval from application of Penles to vein puncture by measuring current perception threshold (CPT) levels with a Neurometer, by which it was possible to measure the extent of nerve block in a non-invasive and quantitative manner with 3 electrical stimulus rates (2000 Hz, 250 Hz, and 5 Hz). Penles was applied to the dorsum of volunteers' hands for 1, 2, 4, 6 and 12 hours before measuring CPT levels. With a stimulation rate of 2000 Hz and 250 Hz, CPT, levels were found to increase 4 hours after the Penles application, while peak CPT levels for 5 Hz stimulation were observed from 6 to 12 hours after application. However, CPT levels tended to decrease 12 hours after application, regardless of the stimulus rate. From the result, we conclude that Penles provides maximum benefit when applied 6 hours prior to vein puncture.