Cardiac arrest during bilateral inguinal herniorrhaphy under epidural anesthesia

A 73-year-old man with hyper gamma-globulinemia was scheduled for bilateral herniorrhaphy and hemorroidectomy. In preoperative examination, the serum concentrations of gamma-globulin and total protein were 7.31 g x dl(-1) and 11.9 g x dl(-1). Although platelet count was 6.5 x 10(4) x microl(-1), epidural anesthesia was selected to minimize hemodynamic changes which could increase a risk of thrombosis. Epidural catheters were inserted at T 12-L 1 and L 4-5. Analgesia level checked by a pin prick was T 4 after administering 10 ml of 2% lidocaine, 7 ml into T 12-L 1 and 3 ml into L 4-5. Bilateral herniorrhaphy started simultaneously. When bilateral peritoneum was stretched, heart rate suddenly decreased to 40 beats x min(-1). Although 0.5 mg of atropine was immediately administered intravenously, cardiac arrest was observed for several seconds and the patient was unconscious for about 10 seconds. After stopping surgery, heart beat and consciousness recovered immediately. By administration of 10 mg of ephedrine, blood pressure increased to 130/80 mmHg with heart rate of 55 beats x min(-1). Vagal reflex induced by bilateral inguinal herniorrhaphy might cause cardiac arrest. We should be careful for vagal reflex during bilateral herniorrhaphy.     

Favorable outcome in a case of perinatal enterovirus 71 infection

A 5-day-old newborn baby presented with skin eruption, oral vesicles, and fever. His mother developed skin eruption at the same time, and his four-year-old sister was diagnosed with hand-foot-mouth disease 1 week before his delivery. Enterovirus 71 was isolated from cerebrospinal fluid that showed mild pleocytosis. This rare case of virology documented perinatal enterovirus 71 infection recovered without sequelae.     

Diagnosis of visceral pleural invasion by lung cancer using intraoperative touch cytology

BACKGROUND: Invasion to the visceral pleura is an important component of lung cancer staging and an independent prognostic factor. However, the accuracy of pathologic examination depends on how the sections are made, and the pathologist may miss the most invaded part of the pleura. Therefore, we have designed "touch" cytology in an effort to more accurately diagnose the pleural invasion by lung cancer. METHODS: Immediately after thoracotomy, the surface of the visceral pleura just above the tumor was gently touched by a glass slide without scrubbing in 100 patients who simultaneously underwent pleural lavage cytology or cytology of the subclinical pleural effusion. RESULTS: Seventeen percent of the tumors were diagnosed as invading the visceral pleura by touch cytology. Lavage cytology was found to be positive in 7%. In reference to the pathologic examination of the tumor specimen, touch cytology was found to be positive in all of p3, 5 out of 6 of p2, 5 out of 30 of p1, and 5 out of 62 of p0 cases. Touch cytology correctly diagnosed all the positive cases detected by lavage or effusion cytology. CONCLUSIONS: This study suggests that our method is useful in detecting the visceral pleural invasion and raises a possibility that pathologic p0 and p1 lung cancers include a subset of patients with tumor cells exposed on the pleural surface.     

A Case of Traumatic Brain Injury Developing Frontal Lobe Syndrome after a Long Incubation Period

Abstract : A 55‐year‐old man, who was a heavy drinker for about 30 years, had experienced a heavy blow on the right posterior temporal region on account of a traffic accident at the age of 16. He recovered without any sequelae. However, he began to make mistakes and had trouble with his job about 40 years after the accident. His symptoms and neuropsychological examination suggested frontal lobe syndrome. Cranial magnetic resonance imaging (MRI) showed that the frontal and temporal lobes seemed to be predominantly atrophic and that there was great enlargement of the lateral and third ventricles, and a post‐contusion lesion in the left frontal lobe. Brain single photon emission computer tomography (SPECT) demonstrated diffuse cerebral hypoperfusion. Cranial MRI suggested that the contusion was proportionate to contre coup injury resulting from the accident. We supposed that the extensive brain damage induced edema and ischemia soon after the accident. Consequently, the circulatory disturbance might have caused cerebral atrophy and enlargement of the ventricles. Since he was relatively young at the time of the accident, the plasticity of his brain compensated for the injury intensively, and obvious symptoms suggesting frontal lobe syndrome were latent for about 40 years after the accident. Continuous drinking may have induced recent dysfunction of the compensated brain. However, such severe atrophy and focal damaged lesion could not be solely accounted for by heavy alcohol consumption. On the other hand, organic changes due to aging and brain circulatory insufficiency caused by hypertension or hyperlipidemia may also disclose the cerebral dysfunction. His cranial MRI and SPECT seemed not to be consistent with frontotemporal dementia. Furthermore, we considered that his case was also different from Alzheimer's disease and normal pressure hydrocephalus. However, it is necessary to follow up neuro‐imaging. Conclusively, he developed frontal lobe syndrome based on traumatic brain injury and induced by continuous drinking, aging, and brain circulatory insufficiency.     

Randomized controlled trials of treatments for hematologic malignancies: study characteristics and outcomes

BACKGROUND: Although randomized controlled trials (RCTs) require a great deal of time, money, and effort, the majority of them have resulted in failure to verify a priori hypotheses. Therefore, the intention in the current study was to clarify the differential elements of studies with 'positive' and 'negative' outcomes. METHODS: The authors performed a comprehensive search of RCT reports on treatments for hematologic malignancies published between 1995 and 2004, with 264 reports eventually identified. The expected rate and the observed rate for the primary endpoint were compared for 70 studies with all relevant information available. RESULTS: Of all the superiority trials (n = 256), positive studies accounted for 33%. Most of the major study characteristics were not found to be associated with the study outcome except for the primary endpoint. Studies evaluating event-free survival were more likely to report positive results than were those evaluating overall survival (P = .061). For the experimental treatment arm, the mean difference between the expected and observed rates was -10.1% (standard deviation [SD], 10.1%) in the negative studies, which indicates a rate lower than expected, and was 1.3% (SD, 9.2%) in the positive studies (P < .0001). In contrast, no statistical significance was observed for the standard treatment arm because the mean difference was 6.3% (SD, 10.7%) for the negative studies and 3.0% (SD, 9.0%) for the positive studies (P = .1885). The journal impact factor was statistically significantly higher for the positive than for the negative reports (P < .0001). CONCLUSIONS: Giving adequate consideration to the estimated effect of an experimental therapy may be critical when planning an RCT.