Combined coronary artery bypass grafting and abdominal aortic aneurysm repair

The purpose of this paper was to assess the results and feasibility of simultaneous coronary artery bypass grafting and abdominal aortic aneurysm repair. Twenty nine patients with a mean age of 65 years underwent simultaneous coronary artery bypass grafting and abdominal aortic aneurysm repair between June 1990 and March 2002. All patients had significant coronary artery disease and were considered as indicated for coronary artery bypass grafting. This was performed first in 28 patients and simultaneously with abdominal aortic aneurysm repair in one, with a mean number of grafts of 2.5, a mean aortic cross-clamp time of 40 minutes, and a mean bypass time of 115 minutes. Eight straight and 21 bifurcated grafts were employed. The total operating time averaged 400 minutes. The median postoperative hospital stay was 18 days. One patient died of stroke and mediastinitis, for a mortality rate of 3.5%. This experience suggests that combined coronary artery bypass grafting and abdominal aortic aneurysm repair is both safe and effective.     

Detection of BCL2-IGH rearrangement on paraffin-embedded tissue sections obtained from a small submucosal tumor of the rectum in a patient with recurrent follicular lymphoma

A 59-year-old woman was admitted to our hospital because of recurrent follicular lymphorna (FL). Colonoscopic examination revealed a rectal submucosal tumor (SMT) without any erosions and ulcers. In this patient, it was difficult to distinguish non-Hodgkin‘s lymphoma (NHL) invasion from other disorders of the colon including carcinoid tumor merely based on endoscopic findings. Histopathologic and immunohistochemical studies on biopsy specimens showed an infiltration of atypical lymphocytes that were positive for CD20 and BCL2 but negative for UCHL-1. Fluorescence in situ hybridization on paraffin-embedded tissue sections (T-FISH) identified a translocation of BCL2 with IGHgene.Based on these findings, the tumor was defined as an invasion of FL. T-FISH method is useful for the detection of a monoclonality of atypical lymphocytes in an SMT of the gastrointestinal tract, and particularly for the detection of chromosomal translocations specific to lymphoma subtypes.     

Retrograde blood flow in the inactive limb is enhanced during constant-load leg cycling in hypoxia

Purpose

This study aimed to elucidate the effects of hypoxia on the pattern of oscillatory blood flow in the inactive limb during constant-load dynamic exercise. We hypothesised that retrograde blood flow in the brachial artery of the inactive limb would increase during constant-load leg cycling under hypoxic conditions.

Methods

Three maximal exercise tests were conducted in eight healthy males on a semi-recumbent cycle ergometer while the subjects breathed a normoxic [inspired oxygen fraction (FIO₂) = 0.209] or two hypoxic gas mixtures (FIO₂ = 0.155 and 0.120). Subjects then performed submaximal exercise at the same relative exercise intensity of 60 % peak oxygen uptake under normoxic or the two hypoxic conditions for 30 min. Brachial artery blood velocity and diameter were recorded simultaneously during submaximal exercise using Doppler ultrasonography.

Results

Antegrade blood flow gradually increased during exercise, with no significant differences among the three trials. Retrograde blood flow showed a biphasic response, with an initial increase followed by a gradual decrease during normoxic exercise. In contrast, retrograde blood flow significantly increased during moderate and severe hypoxic exercise, and remained elevated above normoxic conditions during exercise. At 30 min of exercise, the magnitude of the change in retrograde blood flow during exercise was greater as the level of hypoxia increased (normoxia: ?18.7 ± 23.5 ml min^?1; moderate hypoxia: ?39.3 ± 21.4 ml min^?1; severe hypoxia: ?64.0 ± 36.3 ml min^?1).

Conclusion

These results indicate that moderate and severe hypoxia augment retrograde blood flow in the inactive limb during constant-load dynamic leg exercise.     

The Need for a Coagulation Assay after Initiation of New Oral Anticoagulants in Patients with Renal Dysfunction: A Case Report

Background

Dabigatran etexilate, a new oral anticoagulant, was recently approved as an efficacious alternative to warfarin for the prevention of first and recurrent stroke in patients with nonvalvular atrial fibrillation. Limited data are available for dabigatran use in patients with a creatinine clearance rate (CrCL) of 15-30 mL/min. Furthermore, current guidelines do not recommend frequent blood monitoring after dabigatran use. We report herein a patient with severe renal dysfunction who exhibited profound coagulopathy after 2 days of dabigatran use.

Case Report

An 87-year-old woman was admitted for altered mental status and left-side weakness. She was diagnosed with right middle cerebral artery infarction. The baseline assessment revealed a serum creatinine concentration of 1.29 mg/dL and a CrCL of 27.2 mL/min. Dabigatran therapy was started 5 weeks after admission at a dosage of 110 mg twice daily. After 2 days of dabigatran use, the patient developed multiple bruises and evidence of upper-gastrointestinal bleeding. Laboratory tests demonstrated a severe coagulopathy, with a prothrombin time of 85.9 sec, an international normalized ratio of 11.36, an activated partial thromboplastin time of 119.2 sec, and a thrombin time of 230.8 sec. Serial assessment of the patient''s renal function revealed substantial fluctuation of the CrCL (range, 17.9-26.5 mL/min).

Conclusions

The present case emphasizes the need for frequent checking of renal function and assessment using coagulation assays after commencing dabigatran therapy in patients with moderate-to-severe renal impairment.     

Cytological findings of appendiceal mixed adenoneuroendocrine carcinoma in pleural effusion: Morphological changes evident after metastasis

Goblet cell carcinoid (GCC) of the appendix is now regarded as a malignant tumor, and mixed adenoneuroendocrine carcinoma (MANEC) is a carcinoma progressing from GCC. We describe a man initially diagnosed with GCC of the appendix who died 4 years after diagnosis. Pleural fluid due to metastasis was noted in the terminal phase. Histological findings of the initial tumor indicated that cells with signet‐ring morphology were predominant, but the cytological morphology of the fluid was more atypical, making it difficult to diagnose as metastatic GCC by cellular morphology alone. The cells in the pleural fluid were immunopositive for synaptophysin, which was compatible with GCC, but p53 and ki67 staining indicated that the metastatic tumor was more aggressive. These findings suggested a final diagnosis of poorly differentiated adenocarcinoma‐type MANEC, which we define as a tumor with typical GCC characteristics and foci that cannot be distinguished from a poorly differentiated adenocarcinoma. This case, which we believe is reported here for the first time, indicates the cytological features of GCC cells may change at metastatic sites to be more atypical and aggressive as the tumor progresses, and these changes should be considered in diagnosis. Diagn. Cytopathol. 2015;43:577–580. © 2014 Wiley Periodicals, Inc.     

Tenofovir disoproxil fumarate monotherapy for nucleos(t)ide analogue-na?ve and nucleos(t)ide analogue-experienced chronic hepatitis B patients

Background/Aims

This study investigated the antiviral effects of tenofovir disoproxil fumarate (TDF) monotherapy in nucleos(t)ide analogue (NA)-naive and NA-experienced chronic hepatitis B (CHB) patients.

Methods

CHB patients treated with TDF monotherapy (300 mg/day) for ≥12 weeks between December 2012 and July 2014 at a single center were retrospectively enrolled. Clinical, biochemical, and virological parameters were assessed every 12 weeks.

Results

In total, 136 patients (median age 49 years, 96 males, 94 HBeAg positive, and 51 with liver cirrhosis) were included. Sixty-two patients were nucleos(t)ide (NA)-naïve, and 74 patients had prior NA therapy (NA-exp group), and 31 patients in the NA-exp group had lamivudine (LAM)-resistance (LAM-R group). The baseline serum hepatitis B virus (HBV) DNA level was 4.9±2.3 log IU/mL (mean±SD), and was higher in the NA-naïve group than in the NA-exp and LAM-R groups (5.9±2.0 log IU/mL vs 3.9±2.0 log IU/mL vs 4.2±1.7 log IU/mL, P<0.01). The complete virological response (CVR) rate at week 48 in the NA-naïve group (71.4%) did not differ significantly from those in the NA-exp (71.3%) and LAM-R (66.1%) groups. In multivariate analysis, baseline serum HBV DNA was the only predictive factor for a CVR at week 48 (hazard ratio, 0.809; 95% confidence interval, 0.729-0.898), while the CVR rate did not differ with the NA experience.

Conclusions

TDF monotherapy was effective for CHB treatment irrespective of prior NA treatment or LAM resistance. Baseline serum HBV DNA was the independent predictive factor for a CVR.