A surgical case of subdural hematoma with hemophilia A

A 54-year-old man presented with unconsciousness. Computed tomography revealed acute subdural hematoma. Emergency evacuation of hematoma was performed showing any excessive tendency to bleed or difficulty to stop bleeding during the operation. However transfusion of fresh frozen plasma was needed to stop continuous bleeding from the surgical wound after the operation. The patient underwent craniotomy again 18 days after the operation because he suffered hemorrhagic infarction and recurrence of acute subdural hematoma. After the second operation, a coagulability examination revealed that his activated partial thromboplastin test was prolonged (74.5 seconds) and his plasma factor VIII level was 20% of normal, so he was diagnosed as having mild hemophilia A. Cranioplasty was accomplished with replacement therapy, and he was discharged with mild recent memory disturbance and homonymous hemianopsia.     

Usefulness of Radio-guided Surgery Using Technetium-99m Methoxyisobutylisonitrile for Primary and Secondary Hyperparathyroidism

The efficacy of technetium-99m methoxyisobutylisonitrile (^99mTc-MIBI)-guided surgery for detecting abnormal parathyroid glands in patients with secondary hyperparathyroidism (2-HPT) was evaluated and compared with the results from the same examination in patients with primary hyperparathyroidism (1-HPT). The results were also compared with those found by ultrasonography (US) and preoperative ^99mTc-MIBI scintigraphy was also made. At operation ^99mTc-MIBI accumulated in 64 nodules of 15 cases of 2-HPT, and all of 60 parathyroid swellings were detected (true-positives 60, sensitivity 100%, accuracy 94%). In the cases of 1-HPT, ^99mTc-MIBI revealed 11 hot nodules in 10 cases, and the evaluation was true-positive 10, sensitivity 100%, and accuracy 91%. US and preoperative ^99mTc-MIBI scintigraphy in patients with 2-HPT had a sensitivity of 75% and 67% and an accuracy of 70% and 66%, respectively. The usefulness of ^99mTc-MIBI-guided surgery for detecting abnormal parathyroid tissue in 2-HPT patients was similar to that in 1-HPT patients but was superior to US and preoperative ^99mTc-MIBI scintigraphy. Intraoperative ^9mTc-MIBI for patients with 2-HPT is effective and makes the surgery easier, especially when the parathyroid glands are ectopic or when a few glands are markedly enlarged but the other glands are atrophied.     

Correlation between angiogenesis and reduction ratio measured using<Superscript>201</Superscript>Tl chloride single photon emission computed tomography in patients with oral cavity squamous cell carcinoma

OBJECTIVE: The aim of this study is to examine the correlation between tumor angiogenesis and response to preoperative radiotherapy evaluated using 201Tl single photon emission computed tomography (Tl SPECT) in oral cavity squamous cell carcinoma (SCC). METHODS: Tl SPECTs before and after preoperative radiotherapy were obtained from 11 patients diagnosed with SCC in oral cavity. Regions of interest were set around the tumor and scalp respectively, and the ratio of mean counts in the tumor to those in the scalp was calculated (T/N). Immunohistochemical staining for investigating microvessel density of pre-treatment biopsy specimen was performed using CD31 monoclonal antibody. We compared microvessel density with semi-quantitative parameters obtained using Tl SPECT (T/N at pre- an post-treatment, reduction ratio) and prognosis. RESULTS: The subgroup with higher microvessel density showed a significantly higher reduction ratio than the one with lower microvessel density. Regarding prognosis, the subgroup with locoregional recurrent disease exhibited a significantly higher microvessel density than the one without recurrence. CONCLUSIONS: In SCC of the oral cavity, there was a significant correlation between microvessel density and response to preoperative radiotherapy. Namely, it was revealed that change of 201Tl uptake after preoperative radiotherapy correlated with tumor angiogenesis of oral cavity SCC.     

Maternal-fetal interactions and birth order influence insulin variable number of tandem repeats allele class associations with head size at birth and childhood weight gain

Polymorphism of the insulin gene (INS) variable number of tandem repeats (VNTR; class I or class III alleles) locus has been associated with adult diseases and with birth size. Therefore, this variant is a potential contributory factor to the reported fetal origins of adult disease. In the population-based Avon Longitudinal Study of Pregnancy and Childhood birth cohort, we have confirmed in the present study the association between the INS VNTR III/III genotype and larger head circumference at birth (odds ratio [OR] 1.92, 95% CI 1.23-3.07; P = 0.004) and identified an association with higher cord blood IGF-II levels (P = 0.05 to 0.0001). The genotype association with head circumference was influenced by maternal parity (birth order): the III/III OR for larger head circumference was stronger in second and subsequent pregnancies (OR 5.0, 95% CI 2.2-11.5; P = 0.00003) than in first pregnancies (1.2, 0.6-2.2; P = 0.8; interaction with birth order, P = 0.02). During childhood, the III/III genotype remained associated with larger head circumference (P = 0.004) and was also associated with greater BMI (P = 0.03), waist circumference (P = 0.03), and higher fasting insulin levels in girls (P = 0.02). In addition, there were interactions between INS VNTR genotype and early postnatal weight gain in determining childhood BMI (P = 0.001 for interaction), weight (P = 0.005), and waist circumference (P = 0.0005), such that in the approximately 25% of children (n = 286) with rapid early postnatal weight gain, class III genotype-negative children among this group gained weight more rapidly. Our results indicate that complex prenatal and postnatal gene-maternal/fetal interactions influence size at birth and childhood risk factors for adult disease.     

Pulmonary metastases from uterine malignancies: results of surgical resection in 133 patients

OBJECTIVE: The long-term results of the surgical treatment for patients with pulmonary metastases from uterine malignancies were clarified. METHODS: A total of 133 patients who underwent pulmonary metastasectomy for uterine malignancies were enrolled in the Metastatic Lung Tumor Study Group of Japan between March 1984 and February 2002. These patients constituted the study population, and their clinical, pathologic, and prognostic data were retrospectively analyzed. RESULTS: The morbidity and mortality rates related to the operation were minimal (1% and 1%, respectively). The 5- and 10-year survivals after the surgical resection in all cases were 54.6% and 44.9%, respectively. The 5-year survivals for each histologic type were estimated to be 46.8% for squamous cell carcinoma (n = 58), 40.3% for cervical adenocarcinoma (n = 13), 75.7% for endometrial adenocarcinoma (n = 23), 86.5% for choriocarcinoma (n = 16), and 37.9% for leiomyosarcoma (n = 11). In the univariate analysis, the following were shown to be associated with poor survival: primary tumor in the cervix, short disease-free interval (<12 months), large number of resected metastases (> or =4), and large tumor size (> or =3 cm). After mutual adjustment, short disease-free interval (<12 months) alone was related to risk of death (hazard ratio = 2.26, 95% confidence interval = 1.06-4.78) for 105 patients, excluding patients with choriocarcinoma and miscellaneous histologic types. CONCLUSION: Pulmonary metastasectomy for uterine malignancies is a safe and acceptable treatment to improve survival. Patients with a disease-free interval of 12 months or more are good candidates for this treatment if there is adequate control of the primary tumor without extrapulmonary metastasis.     

Activation of nuclear factor-kappa B and macrophage invasion in cyclosporin A-and tacrolimus-treated renal transplants

This retrospective study was designed to compare the efficacy of cyclosporin A (CyA) and tacrolimus (FK506) on chronic rejection (CR) associated with nuclear factor-kappa B (NF-kappaB) activation and macrophage invasion. Non-episodic day 50 protocol renal biopsy was performed in 63 consecutive patients with renal transplants from living donors, treated with either CyA or FK506. Southwestern histochemistry for NF-kappaB, immunostaining for CD68, and Banff classification were performed, and these findings were compared with outcome over 34 +/- 13 months. Compared with specimens from FK506-treated patients (n = 20), specimens from CyA-treated patients (n = 43) showed a significant increase in tubulointerstitial CD68-positive cells (1.5 +/- 0.9 vs. 0.9 +/- 0.8, p < 0.01), although no significant differences were observed in NF-kappaB activation. Specimens with Banff acute rejection (AR) grade > or = 1A (n = 20) showed increased macrophages (p < 0.01) compared with specimens with AR < 1A (n = 43). Specimens from patients with clinical AR prior to day 50 biopsy (n = 23) also showed increased macrophage invasion (p < 0.01) compared with specimens from patients without prior clinical AR (n = 40). The cumulative well-functioning (serum creatinine < 1.5 mg/dL) graft survival rate was significantly lower in patients with increased tubulointerstitial CD68-positive cells (n = 63, p < 0.05). Our findings suggest that tacrolimus is more effective than CyA against CR with respect to macrophage invasion and AR.     

Changes in body temperature during profound hypothermic cardiopulmonary bypass in adult patients undergoing aortic arch reconstruction

Purpose Our aim was to characterize changes in body temperatures during profound hypothermic cardiopulmonary bypass (CPB) conducted with the sternum opened.Methods In ten adult patients who underwent profound hypothermic (20°C) CPB for aortic arch reconstruction, pulmonary arterial temperature (PAT), nasopharyngeal temperature (NPT), forehead deep-tissue temperature (FHT), and urinary bladder temperature (UBT) were recorded every 1min throughout the surgery. In addition, the CPB venous line temperature (CPBT), a reasonable indicator of mixed venous blood temperature during CPB and believed to best reflect core temperature during stabilized hypothermia on CPB, was recorded during the period of total CPB.Results PAT began to change immediately after the start of cooling or rewarming, closely matching the CPBT (r = 0.98). During either situation, the other four temperatures lagged behind PAT (P 0.05); however, NPT followed PAT more closely than the other three temperatures (P 0.05). During stabilized hypothermia, PAT, NPT, and FHT, but not UBT, closely matched the CPBT, with gradients of less than 0.5°C.Conclusion During induction of profound hypothermia and its reversal on total CPB with the heart in situ, a PA catheter thermistor, presumably because of its placement immediately behind the superior vena cava, would provide a reliable measure of the mixed venous blood temperature. During stabilized profound hypothermia, PAT, NPT, and FHT, but not UBT, serve as a reliable index of core temperature.This work was presented, in part, at the 50th annual meeting of the Japanese Society of Anesthesiologists, Yokohama, May 29–31, 2003, and at the annual meeting of the American Society of Anesthesiologists, San Francisco, USA, October 11–15, 2003.     

Long-term pain relief effects in four patients undergoing percutaneous vertebroplasty for metastatic vertebral tumor

We reviewed long-term pain relief in four patients undergoing percutaneous vertebroplasty (PVP) for lumbar or back pain due to metastatic vertebral tumors. The patients received anesthesiological palliative care with analgesics until their death after PVP. Pain intensity, the presence or absence of recurrence of pain, changes in dosage of analgesics given before and after PVP, and complications associated with PVP were evaluated. A numerical rating scale (NRS) from 0 (no pain) to 10 (worst pain imaginable) was used to measure pain. The patients were three men and one woman (mean age, 58 years). PVP was performed in five vertebrae (one thoracic and four lumbar). The NRS scores on moving before PVP were 10, 8, 10, and 10. After PVP, NRS decreased to 0, 3, 5, and 0, respectively, within 72 h. No recurrence of pain in the treated area occurred until death in any of these patients. The dosages of analgesics given were decreased in two cases, but no changes were made in the other two cases. There were no complications associated with PVP. Percutaneous vertebro-plasty is a safe and effective treatment for long-time pain relief in patients with metastatic vertebral tumors.     

Surgical Treatment of Bone Metastasis Followed by a Primary Lung Cancer Lesion: Report of a Case

In August 1997, a 68-year-old man presented with right pelvic pain. Pelvic computed tomography (CT) and bone scintigraphy showed a huge tumor of the right iliac bone. No other lesion was detected, in spite of a high serum carcinoembryonic antigen level (CEA, 963ng/ml). In October 1997, the iliac bone tumor was widely resected, and thereafter was diagnosed to be a metastatic adenocarcinoma of unknown origin. After a resection, the serum CEA level dropped as low as 6.4ng/ml, but gradually went up to 80ng/ml in October 1999. Next, a lung tumor in the left upper lobe was detected by routine chest CT. In January 2000, a left upper lobectomy was performed, and based on not only the pathological findings but also on an immunohistochemical analysis for napsin A expression, the tumor was diagnosed to be lung adenocarcinoma. The histological and immunohistochemical findings in the previously resected bone lesion were completely compatible with those in the pulmonary tumor, which was finally regarded as M1 lung cancer. In October 2002, the patient was alive without any symptoms, although the serum CEA level was elevated again. We consider this case worthy of presentation because of its unique clinical course as well as the successful long-term survival after surgical treatment alone, for both the primary and metastatic lesions.