The posterior cervical triangle approach for high carotid artery exposure in carotid endarterectomy

A new approach in carotid endarterectomy (CEA) was developed for high carotid artery lesions. With the authors' use of the posterior cervical triangle approach, 20 patients with a high carotid artery lesion were successfully treated with CEA. Accessory nerve palsy in 1 patient and hoarseness in 4 patients were encountered postoperatively as transient complications. There were no permanent procedure-related complications. Although this method has some risks, it is a useful method in CEA for high carotid artery lesions.     

Anesthetic management for laparoscopic adrenalectomy in a pregnant patient with Cushing's syndrome

Cushing's syndrome is extremely rare during pregnancy, because it often causes amenorrhea and infertility. We experienced a case of Cushing's syndrome in the 23rd week of pregnancy receiving laparoscopic surgery. It was difficult to control the blood pressure and heart rate, but we succeeded in the safe management of both mother and fetus.     

Resection of a giant, invasive malignant solitary fibrous tumor of pleura

Solitary fibrous tumor of pleura (SFTP) is a rare mesenchymal neoplasm that most commonly involves the pleura, is probably derived from fibroblasts, and has no relationship to malignant mesothelioma. Here, we report a case of complete resection of a giant malignant SFTP. A 61-year-old woman developed fever and left flank pain. Computed tomography revealed the tumor to be 13?cm in size and located in the left thoracic cavity, directly invading the left lower lobe of the lung. The patient underwent radical resection and left lower lobectomy. Immunohistochemical examination revealed a dense proliferation of spindle-shaped cells with ovoid nuclei and collagen fibers hyperplasia. The cells were positive for CD34 and vimentin, and were negative for cytokeratin AE1/AE3, calretinin, S-100 and smooth muscle ??-actin. SFTPs have malignant potential, as 20?C30?% of resected SFTPs reportedly contain malignant components. Careful long-term clinical follow-up is therefore required for all cases of SFTP.     

Serial monitoring of Mucorales DNA load in serum samples of a patient with disseminated mucormycosis after allogeneic bone marrow transplantation

Mucormycosis is a fatal complication in immunocompromised patients, and is additionally difficult to diagnose due to the lack of useful serum biomarkers. Using a quantitative PCR approach, we retrospectively analyzed Mucorales DNA load in sera collected serially from a 3-year-old patient with chronic granulomatous disease, who died of multi-organ failure probably due to dissemination of Rhizomucor pusillus, which was detected from necropsy specimens. Mucorales DNA load was below the detection limit on days 9, 2, and 4 after unrelated bone marrow transplantation. Rhizomucor DNA was first detected on day 14 (1.6 × 10³ copies/mL), and subsequently fluctuated between 1.3 × 10³ and 37.2 × 10³ copies/mL until day 43. Rhizomucor achieved a peak value of 940.0 × 10³ copies/mL on day 48 the day before death. The detection or fluctuation of Rhizomucor DNA appeared to be associated with corticosteroid dosages or C-reactive protein levels. This specific, noninvasive, and highly quantitative assay may be useful for the early diagnosis of mucormycosis and prediction of disease progression.     

Indocyanine green (ICG)-based fluorescence navigation system for discrimination of kidney cancer from normal parenchyma: application during partial nephrectomy

Purpose

To determine the definite border between normal and tumor kidney tissues during partial nephrectomy (PN) procedures using intraoperative indocyanine green (ICG)-based fluorescence imaging.

Methods

Sixteen potential candidates for PN with organ-confined, small renal masses treated between July 2008 and June 2011 at Shimane University Hospital were enrolled. An ICG-based fluorescence navigation (FN) system was used to evaluate the border between the tumor and normal kidney parenchyma (step 1), the cavity following tumor excision (step 2), and the negative surgical margin of resected tissues (step 3). The R.E.N.A.L nephrometry score (RNS) was applied to evaluate the correlation between tumor anatomy and ICG-based fluorescence imaging.

Results

In step 1, in vivo probing revealed 14 tumors with a mean RNS of 7 points that showed quite low ICG fluorescence signals in the tumor mass as compared with normal kidney parenchyma. In step 2, in vivo probing around the bed revealed highly fluorescent signals with no remnant tumor residing in 10 cases with a mean RNS of 6 points. In step 3, ex vivo probing revealed cancer tissues involving normal parenchyma that were completely excised with minimum amounts of normal parenchyma in all 16 resected specimens.

Conclusions

ICG-based FN system was very helpful for confirming negative margin status in even the most complex cases. Further evaluations may open the door for widespread use of this ICG-based FN system as a feasible and attractive alternative during a PN procedure.     

Investigation of Gastroduodenal Mucosal Injury in Japanese Asymptomatic Antiplatelet Drug Users

Antiplatelet drugs are widely used for the prevention of cardiovascular disease and cerebral vascular disorders. Although there have been several studies on gastroduodenal mucosal injury with gastrointestinal (GI) symptoms such as GI bleeding, in antiplatelet drug users (including low-dose aspirin (LDA)), there have been few reports on the association between antiplatelet drug use and gastroduodenal mucosal injury in asymptomatic antiplatelet drug users. This study was a cross-sectional study elucidating the association between antiplatelet drug use and gastroduodenal mucosal injury in asymptomatic antiplatelet drug users.Subjects were 186 asymptomatic Japanese antiplatelet drug users who underwent a regular health checkup. Subjects were divided into those with and without gastroduodenal mucosal injury endoscopically, and the association between gastroduodenal mucosal injury and other data in asymptomatic antiplatelet drug users was investigated.The prevalence of males and drinkers were significantly higher in subjects with gastroduodenal mucosal injury than in those without. In addition, the prevalence of proton pump inhibitor (PPI) users was significantly lower in subjects with gastroduodenal mucosal injury than in subjects without gastroduodenal mucosal injury. Logistic regression analysis showed PPI (odds ratios: 0.116; 95% confidence intervals: 0.021–0.638; P < 0.05) was a significant predictor of a decreased prevalence of gastroduodenal mucosal injury and closed-type (C-type) atrophy (3.172; 1.322–7.609; P < 0.01) was a significant predictor of an increased prevalence of severe gastroduodenal mucosal injury in asymptomatic antiplatelet drug users.Gender and lifestyle, such as drinking, may have an impact on risk of gastroduodenal mucosal injury in asymptomatic subjects taking antiplatelet drugs. Although PPI is a significant predictor of a decreased prevalence of gastroduodenal mucosal injury, including in asymptomatic antiplatelet drug users, status of gastric atrophy should also be considered against severe gastroduodenal mucosal injury.     

Low programmed cell death‐1 (PD‐1) expression in peripheral CD4+ T cells in Japanese patients with autoimmune type 1 diabetes

Programmed cell death‐1 (PD‐1) is a co‐stimulatory molecule that inhibits T cell proliferation. We aimed to clarify PD‐1 expression in CD4⁺ T cells and the association between PD‐1 expression and the 7785C/T polymorphism of PDCD1, with a focus on the two subtypes of type 1 diabetes, type 1A diabetes (T1AD) and fulminant type 1 diabetes (FT1D), in the Japanese population. We examined 22 patients with T1AD, 15 with FT1D, 19 with type 2 diabetes (T2D) and 29 healthy control (HC) subjects. Fluorescence‐activated cell sorting (FACS) and real‐time PCR were utilized to analyse PD‐1 expression quantitatively. Genotyping of 7785C/T in PDCD1 was performed using the TaqMan method in a total of 63 subjects (21 with T1AD, 15 with FT1D and 27 HC). FACS revealed a significant reduction in PD‐1 expression in CD4⁺ T cells in patients with T1AD (mean: 4·2 vs. 6·0% in FT1D, P = 0·0450; vs. 5·8% in T2D, P = 0·0098; vs. 6·0% in HC, P = 0·0018). PD‐1 mRNA expression in CD4⁺ T cells was also significantly lower in patients with T1AD than in the HC subjects. Of the 63 subjects, PD‐1 expression was significantly lower in individuals with the 7785C/C genotype than in those with the C/T and T/T genotypes (mean: 4·1 vs. 5·9%, P = 0·0016). Our results indicate that lower PD‐1 expression in CD4⁺ T‐cells might contribute to the development of T1AD through T cell activation.