Use of a laryngeal mask airway to stop a supraglottic air leak which prevented adequate ventilation via a tracheostomy in a patient with cerebral palsy and pneumonia

We report an adolescent developing ventilation failure due to supraglottic air leakage with the use of an uncuffed hand-made tracheal tube fit to her tracheobronchial deformity. To eliminate the supraglottic air leakage, a size 2.5 laryngeal mask airway (LMA) was inserted into the oral pharynx. Most of air leakage arose from the LMA. Supraglottic air leakage was not detected under mandatory mechanical ventilation following sealing of the 15-mm connector of the LMA with a piece of tape, and the respiratory condition of the patient gradually improved. The combination of a hand-made Y-shaped tube and the LMA was useful in restoring adequate ventilation. In conditions where air leaks through the glottis during mechanical ventilation interfere with adequate ventilation or the maintenance of airway pressure, the use of an LMA may be adequate to stop or significantly decrease the leak.     

Staged hybrid repair using telescoped stent graft fixation for aortic arch and descending aortic aneurysms

Staged repair of extensive thoracic aortic aneurysms is complicated, with a high incidence of interval rupture between stages. We describe the systematic staged hybrid procedure of a previous endovascular repair of a descending aortic aneurysm and open surgical repair of an aortic arch aneurysm. In the second-stage arch repair, the stent graft was easily retracted and fixed, without dissection, around the aortic arch aneurysm distal side. Extensive thoracic aortic aneurysms were managed without interim rupture or neurologic deficits. This approach avoided the potential for interim rupture because recovery from the first-stage endovascular repair was shorter than that from open repair.     

Right lung cancer with right aortic arch

An abnormal shadow was detected on chest X-ray mass screening in an asymptomatic 63-year-old man. The further examinations revealed the shadow to be primary lung cancer (Rt. S6. adenocarcinoma, cT2N0M0, c-stage IB) with right aortic arch. We used 3 dimentional-computed tomography (3D-CT) to assess an anatomical feature of vessels in detail. The right lower lobectomy and the dissection of medi astinal lymph nodes was performed. We confirmed no abnormal anatomy of pulmonary artery and vein at surgery, and it was possible to perform right lower lobectomy with the common procedure. Since lymph node was found by intraopetrative pathological examination, since no metastasis from interlobar to subcarinal lymph node was found, we did not perform dissection of upper mediastinal dissection, which was equivalent to ND2a lymph nodes dissection of the left lung cancer in General Rule for Clinical and Pathological Record of Lung Cancer. The patient with right aortic arch is known to have variant anatomy of other intrathoracic vessels occasionally. 3D-CT was quite useful in assessing anatomical feature, and enabled us to perform safe operation.     

Histological factors contributing to a high risk of recurrence of submucosal invasive cancer (pT1) of the colon and rectum after endoscopic therapy

We analyzed the histological high-risk factors for recurrence of submucosal invasive carcinomas (pT1) of the colon and rectum after endoscopic therapy, examining pT1 cancers treated primarily by endoscopic resection within a 23-year period. We compared recurrent and nonrecurrent cancers, evaluating the following "highrisk factors" of the primary lesion: massive invasion, a surgical margin <2 mm but negativity for cancer in the cut end, poorly differentiated adenocarcinoma (PD) (G3), undifferentiated carcinoma (G4), and/or positive angiolymphatic invasion. The following histological factors were defined as predictive of a low risk: minimum invasion, a surgical margin >2 mm, well or moderately differentiated adenocarcinoma (G1, G2), and no evidence of angiolymphatic invasion. We analyzed the records of 37 patients with pT1 cancers, including 15 with high-risk factors who underwent subsequent resection. Local recurrence with or without liver metastases developed in 4 of these 15 patients. The histological type was PD in three (75%) of the four recurrent lesions. All four (100%) lesions showed a desmoplastic response (DR). Only 1 (9%) of the 11 patients without recurrence after subsequent surgery had a lesion with a small component of PD, and only three (27%) lesions showed a mild DR. We concluded that endoscopic therapy is inadequate for pT1 cancers with a histological PD component, and/or a DR in the cancer stroma.     

Lung volume reduction surgery and nutritional status in patients with severe emphysema

Objective: We studied the short-term effect of lung volume reduction surgery on nutritional status including body composition and the relationship between preoperative nutritional status and postoperative morbidity.Methods: Subjects were 28 patients with emphysema who underwent bilateal thoracoscopic lung volume reduction surgery (23 simultaneously, 5 staged). Functional tests, body weight, and body composition were measured before and 6 months after surgery. Fat-free mass and fat mass were assessed by bioelectrical impedance analysis.Results: FEV₁₀ improved 35.2% following surgery and maximal oxygen uptake 23.8%. Body weight and fat-free mass increased significantly after surgery, while fat mass was unchanged. Of the 23 undergoing simultaneous bilateral lung volume reduction surgery, 8 had major complications-3 required additional surgery to close air leaks, 3 required mechanical ventilation (>72 hrs), and 2 developed postoperative infection. The preoperative percentage of ideal body weight and fat-free mass was significantly higher among patients without major complications.Conclusions: Bilateral lung volume reduction surgery increases fat-free mass and provides functional improvement for underweight patients with severe emphysema. We found fat-free mass and body weight to be good predictors of unacceptable postoperative complications following bilateral lung volume reduction surgery.     

Association between height loss and bone loss, cumulative incidence of vertebral fractures and future quality of life: the Miyama study

Introduction The study aimed to clarify associations between height loss, bone loss and the quality of life (QOL) score among general inhabitants of Miyama, a rural Japanese community. This population-based epidemiological study was conducted in Miyama, a village located in a mountain area in Wakayama Prefecture, Japan. Methods A list of all inhabitants comprising 1,543 inhabitants (716 men, 827 women) born in this village between 1910–1949 was compiled. From the above whole cohort, a subcohort to measure bone mineral density (BMD) was recruited, consisting of 400 participants, divided into four groups of 50 men and 50 women each, and stratified into age decades by decade of birth-year (1910–1919, 1920–1929, 1930–1939 or 1940–1949). BMD measurement, physical measurements of height (cm) and body weight (kg) were taken, and body mass index (BMI; kg/m²) were calculated. BMD and anthropometric measurements were repeated on the same participants at 3, 7 and 10 years after baseline measurement (1993, 1997 and 2000). Results and discussion Among 299 of 400 participants, changes in height over 10 years for men in their 40s, 50s, 60s and 70s were −0.7 cm, −0.5 cm, −1.2 cm and −1.5 cm, respectively, compared with −0.7 cm, −1.4 cm, −2.1 cm and −3.7 cm in women, respectively. No significant relationships between change in height and rate of change in BMD at the lumbar spine and femoral neck after adjustment for age in men (lumbar spine, β = 0.058, standard error of the mean (SE) = 0.031, P = 0.501, R² = 0.038; femoral neck, β = 0.100, SE = 0.038, P = 0.228, R² = 0.121) were identified. By contrast, among women, a significant positive association was identified between height change and change rate of BMD at the lumbar spine after adjusting for age (β = 0.221, SE = 0.039, P = 0.012, R² = 0.069), while no significant relationship was found between height change and change rate at the femoral neck (β = 0.107, SE = 0.039, P = 0.229, R² = 0.048). No significant relationship was noted between vertebral fractures (VFx) and height at baseline in men and women (men: odds ratio (OR) 0.93, 95% confidence interval (CI) 0.81–1.05, P = 0.24; women: OR 0.97, 95% CI 0.87–1.08, P = 0.58) or between VFx and height loss (men: OR 1.31, 95% CI 1.00–1.71, P = 0.051; women: OR 1.20, 95% CI 0.94–1.53, P = 0.14). In both men and women, no significant relationship was identified between utility of the EuroQol EQ5D questionnaire and height at baseline (men: β = −0.148, SE = 0.003, P = 0.202, R² = 0.076; women: β = 0.127, SE = 0.004, P = 0.235, R² = 0.048), and height change (men: β = −0.078, SE = 0.008, P = 0.452, R² = 0.065; women: β = 0.053, SE = 0.010, P = 0.608, R² = 0.038).     

Regulation of osteoclast differentiation by fibroblast growth factor 2: stimulation of receptor activator of nuclear factor kappaB ligand/osteoclast differentiation factor expression in osteoblasts and inhibition of macrophage colony-stimulating factor function in osteoclast precursors.

This study investigated the mechanism of direct and indirect actions of fibroblast growth factor 2 (FGF-2) on osteoclast differentiation using two mouse cell culture systems. In the coculture system of osteoblasts and bone marrow cells, FGF-2 stimulated osteoclast formation. This effect was decreased markedly by osteoprotegerin (OPG) or NS-398, a selective cyclo-oxygenase 2 (COX-2) inhibitor. FGF-2 (> or = 10(-9) M) stimulated receptor activator of nuclear factor kappaB ligand/osteoclast differentiation factor (RANKL/ODF) messenger RNA (mRNA) expression from 2 h to 7 days in cultured osteoblasts. NS-398 did not affect the early induction but decreased the later one, indicating that the later effect is mediated by COX-2 induction in osteoblasts. To study the direct action of FGF-2 on osteoclast precursors, we used mouse macrophage-like cell line C7 cells that can differentiate into osteoclasts in the presence of soluble RANKL/ODF (sRANKL/ODF) and macrophage colony-stimulating factor (M-CSF). Although osteoblasts expressed all FGF receptors (FGFR-1 to -4), only FGFR-1 was detected in C7 cells at various differentiation stages. FGF-2 alone or in combination with sRANKL/ODF did not induce osteoclastogenesis from C7 cells; however, FGF-2 from lower concentrations (> or = 10(-11) M) significantly decreased osteoclast formation induced by M-CSF in the presence of sRANKL/ODF. FGF-2 did not alter mRNA levels of M-CSF receptor (Fms) or RANK in C7 cells. Immunoprecipitation/ immunoblotting analyses revealed that tyrosine phosphorylation of several cellular proteins including Fms in C7 cells induced by M-CSF was inhibited by FGF-2 in the presence of sRANKL/ODF. We conclude that FGF-2 regulates osteoclast differentiation through two different mechanisms: (1) an indirect stimulatory action via osteoblasts to induce RANKL/ODF partly through COX-2 induction and prostaglandin production and (2) a direct inhibitory action on osteoclast precursors by counteracting M-CSF signaling.     

Mitral Regurgitation After Partial Left Ventriculectomy As the Cause of Ventricular Redilatation

BACKGROUND: It remains unclear whether ventricular redilatation after partial left ventriculectomy (PLV) is due to underlying pathology or to continued volume overload amenable to surgery. METHODS: Among patients undergoing PLV, 32 had Doppler echocardiography preoperatively, immediately after surgery (< 1 week), early after surgery (1-3 months), and late after surgery (8-14 months). Patients were divided into groups with mitral regurgitation (MR; MR+, n = 16) and without postoperative MR (MR-, n = 16) and were compared for ventricular size, performance, and survival. RESULTS: After initial surgical reduction, left ventricular dimension on average gradually increased back to the preoperative level in subgroups of patients with valvular disease and cardiomyopathy and in all patients combined. Most patients showed drastically reduced left ventricular dimension early after PLV. In MR+ patients, dimension increased back to the preoperative level within 3 months after surgery, whereas the MR- group maintained reduced dimension throughout the first year in all patients combined and in a subgroup of patients with cardiomyopathy. Occurrence of significant MR after PLV appeared to be related to severity of fibrosis in excised myocardium but not to severity of preexisting MR, etiology, or performance of mitral valvuloplasty. CONCLUSIONS: Early postoperative MR, residual or new, appeared to play an important role in dictating early hemodynamics and late outcome in patients undergoing PLV. Results suggest an aggressive simultaneous approach to abolish MR. Causative role of myocardial fibrosis remains unclear and needs further study.     

Traumatic paraplegia in snowboarders

STUDY DESIGN: Patients with traumatic paraplegia resulting from snowboarding accidents were reviewed. OBJECTIVE: To understand the clinical features and mechanisms of paraplegic snowboarding injuries. SUMMARY OF BACKGROUND DATA: The recent explosion in the popularity of snowboarding has resulted in dramatically increased numbers of snowboarding injuries. However, little information is available as to the types and mechanisms of snowboard-related spinal injuries and their neurologic involvement. METHODS: The subjects of this study were six male patients, with an average age of 23.7 years, referred to the authors' institution for neurologic deficits associated with spinal injuries between January 1996 and March 1999. The clinical features of these patients were reviewed with respect to the mechanism of the injury, fracture pattern, neurologic status, treatment, and clinical outcome. The mean follow-up period was 23.7 months. RESULTS: The six snowboarders with traumatic paraplegia constituted a very homogenous group with the following features: They were all young men between the ages of 23 and 25 years. All the injuries had occurred at the vertebral junctions. The primary mechanism of the fractures was a backward fall from an intentional jump. The fracture patterns were of the flexion-distraction type. These homologous features suggest that this snowboarding group is at high risk for severe spinal injury. CONCLUSION: The high risk of traumatic paraplegia for a group within the snowboarding population requires the development and provision of injury prevention strategies specific to this group.