Double valve replacement without blood transfusion in a case complicated with liver cirrhosis and pancytopenia

A 63-year-old woman complicated with liver cirrhosis and pancytopenia was admitted for aortic and mitral valve replacement. As laboratory findings at time of admission showed pancytopenia with Hb of 7.3 g/dl, WBC of 2,200/mm3, and platelet of 6.2 x 10(4)/mm3, splenectomy was first conducted and the blood cells and platelet increased in number. At 27 days after splenectomy, double vale replacement was performed without blood transfusion and her postoperative course was unevenfull. It is considered that preoperative splenectomy is useful in management of patients complicated with hypersplenism and pancytopenia.     

The PRB-dependent FOXO1/IGFBP-1 axis is essential for progestin to inhibit endometrial epithelial growth

Progestin inhibits the growth of normal and cancerous endometria via the progesterone receptor (PR), but the distinct functions and signalings of PR subtypes have not been fully understood. The aim of the present study was to dissect the key pathways of progestin to inhibit endometrial epithelial growth. Immortalized endometrial epithelial cells (EM-E6/E7/TERT) with stable PRA or PRB expression were established and used for the experiments. In vitro growth inhibition by progestin was mainly observed in EM-E6/E7/TERT cells with PRB rather than those with PRA. RT-PCR assay confirmed that FOXO1, a key gene for progestin action, was up-regulated by progestin in a PRB-dependent manner. cDNA microarray analysis identified IGFBP-1, which contains FOXO1 binding sites on its promoter, to be induced by medroxyprogesterone acetate (MPA) in EM-E6/E7/TERT cells with PRB but not with PRA. siRNA knockdown of FOXO1 disturbed the induction of IGFBP-1 by MPA, while IGFBP-1 knockdown showed no effect on MPA-induced FOXO1 expression, indicating that FOXO1 is an upstream regulator of IGFBP-1. Luciferase reporter assays showed that MPA activated the IGFBP-1 promoter, which was cancelled by FOXO1 knockdown. Chromatin immunoprecipitation assay confirmed the in vivo binding of FOXO1 to the core promoter of IGFBP-1. IGFBP-1 knockdown significantly attenuated the growth inhibitory effects of MPA. The FOXO1/IGFBP-1 axis is essential for PRB-dependent growth inhibition of endometrial epithelial cells, offering a potential therapeutic clue to enhance the progestin effect.     

Intracardiac Eustachian Valve Cyst in an Adult Detected with Other Cardiac Anomalies: Usefulness of Multidetector CT in Diagnosis

We present an unusual case of an intracardiac Eustachian valve cyst observed concurrently with atresia of the coronary sinus ostium, a persistent left superior vena cava (LSVC) and a bicuspid aortic valve. There have been several echocardiographic reports of Eustachian valve cysts; however, there is no report of multidetector computed tomography (MDCT) findings related to a Eustachian valve cyst. Recently, we observed a Eustachian valve cyst diagnosed on MDCT showing a hypodense cyst at the characteristic location of the Eustachian valve (the junction of the right atrium and inferior vena cava). MDCT also demonstrated additional cardiovascular anomalies including atresia of the coronary sinus ostium and a persistent LSVC and bicuspid aortic valve.     

The effect of milrinone for the shock patients after cardiac surgery

The effect of milrinone in the 16 postoperative shock patients of cardiovascular surgery was studied. The preoperative hemodynamic status were 12 of cardiogenic shock, 2 cases of chronic heart failure and 2 cases of unstable angina pectoris. The operative procedure were 8 cases of coronary artery bypass grafting, 4 cases of valvular surgery, 2 cases of closure of ventricular septal perforation, 2 cases of Bentall operation and 1 case of ascending aortic replacement. The postoperative hemodynamic status were 15 cases of cardiogenic shock, 10 cases of hemorrhagic shock and 1 case of septic shock. Continuous intravenous infusion of 0.5 microgram/kg/min without initial bolus loading was administered immediately after the entrance of the intensive care unit. Significant increase in the maximum blood pressure 3 hours after the infusion were observed (84 +/- 17 mmHg vs 94 +/- 12, p = 0.033). The maximum blood pressure was increased gradually until 24 hours after the infusion. Significant increase in the peripheral body temperature 3 hours after the infusion were observed (32.5 +/- 2.0 degrees C vs 35.9 +/- 1.1 degrees C, p = 0.001). The difference between the peripheral temperature and the central body temperature diminished until 24 hours after the infusion. No significant change in the central venous pressure, pulmonary arterial pressure, pulmonary and cardiac index wedge pressure were observed. No significant change in the platelet number was observed until 3 days after the infusion. Twenty patients (75%) were discharged. Four hospital deaths included 1 cardiac and 3 septic cause were seen. These data suggest that the administration of milrinone for the shock patients after cardiac surgery showed safe and that the continuous intravenous infusion of 0.5 microgram/kg/min without bolus loading showed effective for the recovery of the peripheral circulation.     

The retention indices of 201Tl-SPECT in brain tumors

OBJECTIVE: The aim of this study was to assess the utility of 201Tl SPECT in the differential diagnosis of intracranial tumors and to determine the relationship between 201Tl uptake and histological types. METHODS: Thirty-eight patients (19 males and 19 females) with thirty-eight brain tumors were evaluated with 201Tl-SPECT. The early and delayed 201Tl uptake ratio was calculated, and the retention index (RI) was applied as follows; RI = delayed uptake ratio/early uptake ratio. RESULTS: The RI of malignant tumors was higher (0.72 +/- 0.18) than that of benign tumors (0.50 +/- 0.16) and the difference was statistically significant (p = 0.00045). The difference between high-grade glioma (0.80 +/- 0.15) and metastatic tumors (0.64 +/- 0.19) was statistically significant (p = 0.039). CONCLUSION: 201Tl-SPECT may add useful biochemical information and could differentiate malignant brain tumors from benign lesions, but the RI of metastatic tumors varied depending on the organs with the primary lesion and histological types.     

Long-term outcomes after laparoscopy-assisted gastrectomy for advanced gastric cancer: a large-scale multicenter retrospective study

Background

Recently, the number of laparoscopic procedures for gastric cancer has increased rapidly. Laparoscopic surgery is reported to have many advantages over open gastrectomy with oncologic safety in early gastric cancer. However, there were few reports on long-term outcomes of laparoscopy-assisted gastrectomy (LAG) for advanced gastric cancer (AGC). The aim of this study was to investigate long-term survival outcomes after LAG for AGC.

Methods

The data of 1,485 patients who underwent LAG between April 1998 and December 2005 by ten surgeons at ten hospitals were collected retrospectively. Among them, 239 patients who were diagnosed with AGC on final pathologic examination were enrolled in the present study to investigate long-term clinical outcomes.

Results

The ratio of male to female patients was 151:88 and the mean age was 57.1?years. One hundred ninety-three subtotal gastrectomies, 41 total gastrectomies, and 5 proximal gastrectomies were performed. D1?+?α, D1?+?β, and D2 lymph node dissections were performed for 14, 62, and 163 cases, respectively. The median follow-up period was 55.4?months. The overall 5-year survival rate of the 239 AGC patients was 78.8% and the disease-specific 5-year survival rate was 85.6%. The 5-year survival rates of the TNM staging system’s (7th ed.) stages were 90.5% (stage Ib, n?=?86), 86.4% (stage IIa, n?=?53), 78.3% (stage IIb, n?=?44), 52.8% (stage IIIa, n?=?24), 52.9% (stage IIIb, n?=?24), and 37.5% (stage IIIc, n?=?8) (p?Conclusion The long-term survival outcome rates of LAG for AGC in the present study were comparable to those previously reported for open gastrectomy. Based on the present results, a well-designed phase III trial comparing LAG and open gastrectomy for AGC will be needed to affirm the validity of LAG for AGC.     

Endoscopic submucosal dissection versus surgical resection for early gastric cancer: a retrospective multicenter study on immediate and long-term outcome over 5 years

Background

Endoscopic submucosal dissection (ESD) is an alternative to surgical resection for treating early gastric cancer (EGC). However, there have been limited reports on the long-term outcome of ESD compared to that of surgical resection. The aim of this study was to evaluate the immediate and long-term clinical and oncologic outcomes of ESD compared to surgical resection.

Method

We retrospectively reviewed data of patients in five centers who were treated with ESD or surgical resection for EGC within expanded criteria for ESD from 2006 to 2008.

Result

ESD group had significantly shorter procedure times, shorter fasting period, and shorter hospital stay than the surgical resection group. Immediate complications in the surgical resection group were more common compared to those in the ESD group. Five-year cancer recurrence rate of the ESD group was 12.3 % and significantly higher than 2.1 % of the surgical resection group (P = 0.001). Five-year disease-free survival rate of the surgical resection group was 97 %, which was significantly higher than 85 % of the ESD group (P = 0.001). Metachronous lesions were equally found every year during the follow-up period in the ESD group. Five-year overall survival rates were 100 % for both groups.

Conclusion

ESD might be an acceptable and effective treatment for EGC considering overall survival rates with fewer early complication rates and shorter duration of hospital stay compared to surgical resection. However, intensive and persistent endoscopic surveillance should be performed after ESD for early detection of metachronous lesions.

     

64Cu-Labeled tetraiodothyroacetic acid-conjugated liposomes for PET imaging of tumor angiogenesis

IntroductionWe synthesized and evaluated ⁶⁴Cu-labeled tetraiodothyroacetic acid (tetrac)-conjugated liposomes for PET imaging of tumor angiogenesis, because tetrac inhibits angiogenesis via integrin α_Vβ₃.MethodsTetrac-PEG-DSPE and DOTA-PEG-DSPE were synthesized and formulated with other lipids into liposomes. The resulting tetrac/DOTA-liposomes were labeled with ⁶⁴Cu at 40 °C for 1 h and purified using a PD-10 column. ⁶⁴Cu-DOTA-liposomes were also prepared for comparison. Human aortic endothelial cell (HAEC) binding studies were performed by incubating the liposomes with the cells at 37 °C. MicroPET imaging followed by tissue distribution study was carried out using U87MG tumor-bearing mice injected with tetrac/⁶⁴Cu-DOTA-liposomes or ⁶⁴Cu-DOTA-liposomes.ResultsHAEC binding studies exhibited that tetrac/⁶⁴Cu-DOTA-liposomes were avidly taken up by the cells from 1.02 %ID at 1 h to 11.89 %ID at 24 h, while ⁶⁴Cu-DOTA-liposomes had low uptake from 0.47 %ID at 1 h to 1.57 %ID at 24 h. MicroPET imaging of mice injected with tetrac/⁶⁴Cu-DOTA-liposomes showed high radioactivity accumulation in the liver and spleen. ROI analysis of the tumor images revealed 1.93 ± 0.12 %ID/g at 1 h and 2.70 ± 0.36 %ID/g at 22 h. In contrast, tumor ROI analysis of ⁶⁴Cu-DOTA-liposomes revealed 0.54 ± 0.08 %ID/g at 1 h and 0.52 ± 0.09 %ID/g at 22 h. Tissue distribution studies confirmed that the tumor uptakes of tetrac/⁶⁴Cu-DOTA-liposomes and ⁶⁴Cu-DOTA-liposomes were 1.75 ± 0.03 %ID/g and 0.36 ± 0.01 %ID/g at 22 h, respectively.ConclusionThese results demonstrate that tetrac/⁶⁴Cu-DOTA-liposomes have significantly enhanced tumor uptake compared to ⁶⁴Cu-DOTA-liposomes due to tetrac conjugation. Further studies are warranted to reduce the liver and spleen uptake of tetrac/⁶⁴Cu-DOTA-liposomes.     

Coronary malperfusion due to acute type A aortic dissection; surgical strategy and results

Coronary malperfusion due to acute type A aortic dissection (DAA) is a lethal complication. It is especially difficult to rescue the patients with left coronary malperfusion because of acute global myocardial infarction (AMI), even with successful surgical treatments, including the replacement of the ascending aorta and coronary artery bypass grafting (CABG). We review our experience and illustrate our approach to these critically ill patients. In addition, we classify the mechanism of malperfusion into 4 types based upon perioperative findings and discuss surgical management indivisually. From January 1990 to April 2005, a total of 260 patients were operated for DAA in our institution. Twenty (7.7%) patients, 11 men and 9 women were suffering from coronary malperfusion due to DAA. The mean age was 55 (range 28-72) years. The right coronary artery was involved in 9 patients, and the left in 11. All procedures such as graft replacement and CABG were done on an emergent or urgent basis. Hospital mortality rate of right coronary malperfusion was 22% (2/9 patients), and that related to left coronary malperfusion was 5/11 (45%). Assisting device was required in 9 cases, veno-arterial bypass (VAB) in 6 cases, left ventricular assist system (LVAS) in 1, left heart bypass (LHB) in 1, LHB+right heart bypass (RHB) in 1. We lost all patients using VAB. Only 3 patients supported with strong assist device survived. Aggressive myocardial resuscitation and early operation are the key factors in the management of these critically ill patients. But once severe myocardial infarction occurs, V-A bypass (percutaneous cardiopulmonary support) is useless in treating patients with DAA who develop severe heart failure. We recommend to implant stronger assist device including LVAS immediately before exacerbation of multiple organ failure. In conclusion, surgical management is not easy for emergency patients with DAA in association with myocardial ischemia. However, reasonable surgical results can be obtained with supplemental CABG and strong mechanical support of the left ventricle.