Surgical approach to the spinal accessory nerve for brachial plexus reconstruction

An easy, safe, and less invasive surgical approach to the spinal accessory nerve for brachial plexus reconstruction is described. The technique avoids a longitudinal unsightly scar over the neck and preserves the branches innervating the upper part of the trapezius.     

Iatrogenic distal femur fracture following medial femoral supracondylar bone graft harvest: a case report and finite element analysis

Objective: This report presents a case of supracondylar femur fracture with finite element analysis and discusses its causes and prevention.Patient and Methods: A 53-year-old man presented with right talar osteonecrosis after osteosynthesis for a talus fracture. A medial femoral condyle-free vascularized bone graft (size, 20 × 12 × 17 mm) from the contralateral femur was performed, including the posteromedial cortical corner. The patient suffered a donor-site supracondylar femoral fracture while standing up from a cross-legged sitting position on the bed on postoperative day 6. The fracture was treated with intramedullary nailing. We analyzed the effects of the location of the bone graft harvest in an intact model using the three-dimensional finite element method (FEM).Results: The talar necrosis and the femur fracture healed. The FEM result revealed that the longitudinal axial pressure had minimal effect on the femur; however, the stress around the bone defect increased with rotation, especially in the posteromedial bone defect model.Conclusion: Harvesting the bone graft should not include the posteromedial corner of the supracondylar femur. The patient should strictly limit the motion of torsional stress, such as standing from a cross-legged sitting position or pivoting turn.     

Second allogeneic peripheral blood stem cell transplantation with fludarabine-based low-intensity conditioning regimen for relapsed myelodysplastic syndrome after allogeneic bone marrow transplantation

We describe the case of a 51-year-old patient with relapsed myelodysplastic syndrome after allogeneic bone marrow transplantation (BMT), who underwent allogeneic peripheral blood stem cell transplantation (PBSCT) after conditioning with a novel regimen consisting of fludarabine, busulfan, and antithymocyte globulin. The second PBSCT was performed early, at 3 months after the initial allogeneic BMT, but it was well tolerated and complete hematologic remission was documented. The patient did not experience any early transplantation-related organ toxicity but died from opportunistic infection 6 months after the second transplantation. Our experience suggests that this novel regimen may induce remission and could be offered to patients relapsing after the first transplantation; however, the fludarabine-containing regimen might be accompanied by profound immunosuppression.     

Treatment with cytapheresis for antineutrophil cytoplasmic antibody-associated renal vasculitis and its effect on anti-inflammatory factors

To evaluate the efficacy of cytapheresis for the treatment of rapidly progressive glomerulonephritis (RPGN) caused by myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA)-associated vasculitis, the renal prognosis and the mortality rate at 1 year after treatment were compared between a Cytapheresis Group and a Steroid Pulse Group. The Cytapheresis Group included 10 patients who were treated with cytapheresis and oral corticosteroids. Five had granulocytapheresis with the Adacolumn (Japan Immuno Research Laboratories Co. Ltd, Takasaki, Japan) and the remaining five had leukocytapheresis with the leukocyte removal filter, Cellsorba (Asahi Medical Co. Ltd, Tokyo, Japan). The Steroid Pulse Group was comprised of 12 patients who were treated with methylprednisolone pulse therapy and oral corticosteroids. In the Cytapheresis Group, renal function recovered in 70% of the patients and the mortality rate was 10%. In the Steroid Pulse Group, renal function recovered in 66.7% and the mortality rate was 33.3%, with infection as the cause of death. Total doses of corticosteroids converted to prednisolone dose during a 1 month period, ranged from 280 mg to 1226 mg in the Cytapheresis Group. On the other hand, these dosages ranged from 2375 mg to 8380 mg in the Steroid Pulse Group. These results indicated that the mortality rate by infection could be reduced by adding cytapheresis therapy. Concerning the mechanism of cytapheresis, anti-inflammatory factors such as soluble tumor necrosis factor receptor, and interleukin-10 reduced after cytapheresis. These changes might be responsible for the efficacy of cytapheresis. In conclusion, cytapheresis is thought to be one of the effective treatments for RPGN caused by MPO-ANCA-associated vasculitis, reducing the levels of anti-inflammatory factors.     

Effects of Statin Plus Ezetimibe on Coronary Plaques in Acute Coronary Syndrome Patients with Diabetes Mellitus: Sub-Analysis of PRECISE-IVUS Trial

Aim: Coronary plaque regression is weak in acute coronary syndrome (ACS) patients with diabetes mellitus (DM). We evaluated whether dual lipid-lowering therapy (DLLT) with ezetimibe and atorvastatin attenuates coronary plaques in ACS patients with DM.Methods: The prospective, randomized controlled, multicenter PRECISE-IVUS (Plaque Regression with Cholesterol Absorption Inhibitor or Synthesis Inhibitor Evaluated by Intravascular Ultrasound) trial assigned 246 patients undergoing percutaneous coronary intervention to DLLT or atorvastatin monotherapy and evaluated IVUS-derived changes in percent atheroma volume (ΔPAV), at baseline and 9–12-month follow-up, in 126 ACS cases, including 25 DM patients. The atorvastatin dose was up-titrated to achieve low-density lipoprotein cholesterol (LDL-C) < 70 mg/dL.Results: In DM patients, the monotherapy group (n = 13) and the DLLT group (n = 12) showed a similar prevalence of coronary risks and baseline lipid profiles. During the study, the change in LDL-C level was similar between DM and non-DM patients. Compared with non-DM patients, DM patients showed weaker regression of ΔPAV by DLLT than those who underwent monotherapy (DM: −2.77 ± 3.47% vs. −0.77 ± 2.51%, P = 0.11; non-DM: −2.01 ± 3.36% vs. −0.08 ± 2.66%, P = 0.008). The change in LDL-C level was not correlated with ΔPAV in non-DM patients, but there was significant correlation between the change in LDL-C level and ΔPAV in DM patients (r = 0.52, P = 0.008).Conclusions: ACS patients with DM showed weaker coronary plaque regression than their counterparts. A significant correlation between the change in LDL-C level and ΔPAV in DM patients suggested that more intensive lipid-lowering therapy is required in ACS patients with DM.     

Portal encasement: Significant CT findings to diagnose local recurrence after pancreaticoduodenectomy for pancreatic cancer

Background/objectives

To demonstrate the utility of portal encasement as a criterion for early diagnosis of local recurrence (LR) after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC).

Impact of a single human leucocyte antigen (HLA) allele mismatch on the outcome of unrelated bone marrow transplantation over two time periods. A retrospective analysis of 3003 patients from the HLA Working Group of the Japan Society for Blood and Marrow Transplantation

A previous Japanese study revealed that a human leucocyte antigen (HLA)‐A or ‐B allele mismatch was associated with higher overall mortality, whereas an HLA‐C or ‐DRB1 allele mismatch did not affect mortality after serologically matched unrelated bone marrow transplantation (BMT). This study reanalysed 3003 adult patients who underwent unrelated BMT from a serologically HLA‐A, ‐B, or ‐DR matched unrelated donor between 1993 and 2009 using the latest database, that included 1966 HLA‐matched unrelated BMT and 187, 31, 524, and 295 unrelated BMT with a single HLA‐A, ‐B, ‐C, or ‐DRB1 allele mismatch, respectively. As opposed to our previous findings, HLA‐C and ‐DRB1 mismatches had a significant negative impact [hazard ratio (HR) 1·35, P < 0·001, and HR 1·45, P < 0·001] on survival in the period 2000–2009. The negative impact of each single HLA allele mismatch was not significantly different among the HLA‐A, ‐B, ‐C, and ‐DRB1 mismatches (P = 0·79). An interaction test revealed that the effects of single HLA‐C and ‐DRB1 allele mismatches significantly differed over the two time periods (P = 0·032 and P = 0·0072, respectively). In conclusion, the impact of a single HLA allele mismatch changed over time. In the recent cohort, the negative impact of HLA‐DRB1 and ‐C mismatches became apparent.