Ropivacaine-induced grand mal convulsion after obturator nerve block

We describe a patient to whom ropivacaine 150 mg had been administered during obturator nerve blockade and developed grand mal convulsions because of inadvertent i.v. injection. Venous blood samples were taken 15, 32 and 52 min after the convulsion. The measured total plasma concentrations of ropivacaine were 4.5, 3.5 and 2.9 microg x ml(-1) respectively. The peak plasma concentration at the time of the inadvertent i.v. injection was estimated to be 6.6 microg x ml(-1). The patient recovered uneventfully.     

Proinflammatory cytokinemia associated with transient myeloproliferative disorder in down syndrome

A transient myeloproliferative disorder (TMD) occurs in 10% of the infants with Down syndrome. While most cases resolve within a few months, in 20% of them TMDs are life-threatening or fatal. We encountered 4 patients with TMD, including 1 patient who died of liver failure and disseminated intravascular coagulation. Suspecting involvement of proinflammatory cytokines, we serially assayed them in patients' sera. Cytokines were significantly more abundant in patients than in controls. Interleukins 1 and 2, tumor necrosis factor alpha, interferon gamma, and granulocyte-macrophage colony-stimulating factor were greatly increased, especially in the infant who died. Sustained cytokinemia is likely to participate in TMD pathophysiology, and very high serum concentrations might predict a poor outcome.     

CT and MRI features of recurrent tumors and second primary neoplasms in pediatric patients with retinoblastoma

OBJECTIVE: The aim of our study was to describe the CT and MRI findings of recurrent tumors and second primary (malignant and benign) neoplasms in patients with retinoblastoma and to evaluate imaging features to assist in distinguishing them. MATERIALS AND METHODS: Records of 445 pathologically confirmed retinoblastomas were retrospectively reviewed. Thirty-four patients with recurrent retinoblastomas and 15 patients with second primary neoplasms who underwent CT and MRI were evaluated by two radiologists with agreement by consensus. RESULTS: Invasive patterns of recurrent tumors included type A, intraocular tumor (n = 13); type B, intraorbital tumor with spread into the optic nerve shown as enlargement and marked enhancement of the optic nerve on contrast-enhanced CT or MRI (n = 6); and type C, tumor extending to the lateral aspect of the orbit and invading the brain via the sphenoidal bone (n = 2). Thirty-eight percent of patients with recurrent tumors had distant metastases (n = 7) or leptomeningeal metastases (n = 6). Leptomeningeal metastases were found only in recurrent tumors. Second primary neoplasms included osteosarcoma (n = 5), rhabdomyosarcoma (n = 5), meningioma (n = 4), and other tumors (n = 3). A significant difference was seen between the patients' ages at the time of diagnosis of recurrent tumors and second primary neoplasms (p < 0.0001). Extraorbital tumors were found more frequently among second primary neoplasms than among recurrent tumors (p < 0.001). CONCLUSION: Both recurrent tumors and second primary neoplasms in patients with retinoblastoma often show characteristic imaging features. The tumor distribution on CT and MRI may help in differentiating recurrent tumors and second primary neoplasms.     

Different sizes of centrilobular ground-glass opacities in chest high-resolution computed tomography of patients with pulmonary veno-occlusive disease and patients with pulmonary capillary hemangiomatosis

BackgroundCentrilobular ground-glass opacity (GGO) is one of the characteristic findings in chest high-resolution computed tomography (HRCT) of patients with pulmonary veno-occlusive disease (PVOD) and patients with pulmonary capillary hemangiomatosis (PCH). However, clinical differential diagnosis of these two diseases is difficult and has not been established. In order to clarify their differences, we compared the sizes of GGOs in chest HRCT and the sizes of capillary assemblies in pulmonary vascular casts between patients diagnosed pathologically with PVOD and PCH.MethodsWe evaluated chest HRCT images for four patients with idiopathic pulmonary arterial hypertension (IPAH), three patients with PVOD and three patients with PCH, and we evaluated pulmonary vascular casts of lung tissues obtained from those patients at lung transplantation or autopsy.ResultsCentrilobular GGOs in chest HRCT were observed in patients with PVOD and patients with PCH but not in patients with IPAH. We measured the longest diameter of the GGOs. The size of centrilobular GGOs was significantly larger in patients with PCH than in patients with PVOD (5.60±1.43 mm versus 2.51±0.79 mm, P<.01). We succeeded in visualization of the 3-dimensional structures of pulmonary capillary vessels obtained from the same patients with PVOD and PCH undergoing lung transplantation or autopsy and measured the diameters of capillary assemblies. The longest diameter of capillary assemblies was also significantly larger in patients with PCH than in patients with PVOD (5.44±1.71 mm versus 3.07±1.07 mm, P<.01).ConclusionMeasurement of the sizes of centrilobular GGOs in HRCT is a simple and useful method for clinical differential diagnosis of PVOD and PCH.     

Clinimetric properties of the Fugl-Meyer assessment with adapted guidelines for the assessment of arm function in hemiparetic patients after stroke

Background: Against the background of linguistic and cultural differences, there is a need for translation and adaptation from the English version of the Fugl-Meyer Assessment (FMA) to Japanese. In addition, there is no study of inter-rater reliability of FMA all domains for affected upper extremities with appropriate sample size based on the intraclass correlation coefficient (ICC) focusing on non-simultaneous assessment.

Objective: This study aimed (1) to translate the English version of the FMA and its administration/scoring manual; and (2) to investigate the psychometric properties of the Japanese version of the FMA in patients with stroke.

Methods: A prospective single-center study involving 30 patients was conducted. The FMA and the Action Research Arm Test, the Box-and-Block Test, and the Motor Activity Log were employed. The inter-rater/intra-rater reliability, the internal consistency, the validity, and the floor/ceiling effects were assessed.

Results: Regarding the non-simultaneous and simultaneous inter-rater reliability, ICC ranged from 0.809–0.983 (P<0.001) and 0.991–0.999 (P<0.001), respectively. Regarding the simultaneous intra-rater reliability, ICC ranged from 0.994–0.999 (P<0.001). The Cronbach’s alpha was 0.973 in the non-simultaneous evaluation and 0.981 in the simultaneous evaluation. Regarding the validity, Spearman’s rhos were higher than 0.92 for the FMA all domains and motor domain. The patients who showed the highest score and the lowest score of the FMA (all domains and motor domain) were 10% and 0%, respectively.

Conclusions: The Japanese version of the FMA motor domain and all domains can reliably assess the affected upper extremities in patients with mild-to-severe hemiparesis after stroke for both non-simultaneous and simultaneous assessment.     

Whole-breast volume perfusion images using 256-row multislice computed tomography: visualization of lesions with ductal spread

Background  The aim of this study was to apply perfusion techniques to breast tumors using a prototype 256-row multislice computed tomography (CT) scanner (which allows a wide range of 128 mm to be scanned and can provide whole-breast perfusion maps without any dead angles) to improve contrast and assess the possibility of precisely depicting the extent of breast cancer. Patients and methods  The study group included seven patients with breast cancer who were scheduled to undergo radical surgery and radiotherapy. Dynamic scanning was performed using a 256-row multislice CT scanner during normal respiration. Volume perfusion images of the entire breast were obtained using the maximum slope method. Perfusion map images and early-phase breast CT images at 54 s were compared by means of pathological examination. Results  All breast cancers could be distinguished from normal mammary glands based on the perfusion value. The extent of cancer depicted in perfusion images showed excellent agreement with the pathology findings for invasive ductal carcinoma and ductal carcinoma in situ. In three patients, all ductal spread, parts of which were not visualized by early-phase CT, were depicted in volume perfusion images. Simulation analysis suggested that perfusion maps could be generated with fewer scanning points. Conclusion  The results of the present study suggest that volume perfusion imaging may be useful for depicting the extent of breast cancer, with excellent sensitivity. Further research is needed to determine the clinical relevance of these findings.     

Splenic marginal zone lymphoma associated with antiphospholipid antibodies

A 61-year-old woman experienced a high fever with anemia and APTT prolongation after suffering a herpes zoster virus infection. Physical examination revealed a large splenomegaly without lymphadenopathy. Laboratory evaluations were positive for lupus anticoagulant (LA) and monoclonal IgM-kappa protein. LA was associated with the presence of anti-beta2GPI antibody, anti-cardiolipin antibody, and anti-prothrombin antibody. Moreover, the results of factors IX, XI, and XII assays and CRP and FDP-E were disturbed. A splenectomy was performed, and a splenic marginal zone lymphoma (SMZL) was diagnosed. All hematological findings rapidly recovered after the splenectomy. No thrombotic events occurred after the splenectomy even though thrombosis prophylaxis was not performed. The clinical course suggested that the SMZL-producing antibody induced immunological abnormalities in the labolatory tests. Since the patient suffered disease progression soon after the splenectomy, an autologous peripheral stem cell transplantation with rituximab administration was performed.