A case of solitary bone cyst in the skull increasing in size after trivial head injury

A 12-year-old boy had been known to have a small swelling in the left high vertex for several years. After a trivial head hit to the site of the swelling, the swelling enlarged gradually. A bone window CT scan showed a lesion having bubble-like lytic change in the left parietal bone. Similar changes, but small, were able to be pointed out in a CT scan taken seven years previously. In the following 13 months CT scans eventually revealed sequential increases to 3.5 cm in diameter. Surgical exploratory resection of the mass was performed. Intraoperatively, partial destruction of the outer skull table and a simple cyst with serous yellowish brown colored fluid were identified. There was no finding adherent to the diploic structure. The bone defect after excision was reconstructed by using a titanium plate. The patient was followed up for 2 years after the surgery. Bone window CT showed bony development of normal appearance. Histological examination showed the cyst wall consisted of fibrous connective tissue but there were neither epithelial nor endothelial cells. The histopathological diagnosis of SBC was most likely. SBC is relatively common in long bones, but rarely in flat bones. Only several cases of the SBC of cranial bone have been reported. Although a craniectomy for total excision followed by cranioplasty by resin was common, in cases of children, cyst removal with titanium plate application would be an alterative. SBC increasing in size after head injury is extremely rare, but clinicians may need to be aware of cystic skull bone tumors increasing in size after head injury.     

Pancreatic insulinoma combined with glucagon positive cell: A case report

We present a 70-year-old man who was referred for surgery with uncontrollable hypoglycemia. Ultrasonography and abdominal contrast computed tomography revealed a hypervascular tumor of 1 cm in diameter in the pancreatic tail. With a diagnosis of insulinoma, we performed a distal pancreatectomy. The patient showed a good postoperative course without any complications. The patient’s early morning fasting hypoglycemia disappeared. The respective levels of C-peptide and insulin dropped from 14.9 ng/mL and 4860 μIU/mL preoperatively to 5.3 ng/mL and 553 μIU/mL after surgery. A histopathological examination demonstrated that the tumor was a pancreatic neuroendocrine tumor, grade 1. Immunostaining was negative for insulin and positive for CD56, chromogranin A, synaptophysin and glucagon. These findings suggested that the tumor was clinically an insulinoma but histopathologically a glucagonoma. Among all insulinoma cases reported between 1985 and 2010, only 5 cases were associated with independent glucagonoma. In this report, we characterize and discuss this rare type of insulinoma by describing the case we experienced in detail.     

Estimation of physiologic ability and surgical stress (E-PASS) for a surgical audit in elective digestive surgery

BACKGROUND: This study was undertaken to establish an equation to estimate mortality with the use of the prediction scoring system designated as the Estimation of Physiologic Ability and Surgical Stress (E-PASS), and to evaluate the system's usefulness in defining quality of care by comparing it with the Physiologic and Operative Severity Score for the enUmeration for Mortality and morbidity (POSSUM) and Portsmouth-possum (P-POSSUM) scoring systems previously generated for surgical audit. METHODS: Patients (n=5212; group A) who underwent elective gastrointestinal surgery were analyzed to establish equations for estimated 30-day and in-hospital mortality rates. The usefulness of E-PASS was evaluated in another series of 1934 patients (group B) who underwent elective digestive surgery in 6 national hospitals. The ratio of observed to estimated mortality rates (OE ratio) of each hospital was defined as a measure of quality. RESULTS: In group A, 30-day and in-hospital mortality rates increased as the Comprehensive Risk Score (CRS) increased, providing equations for estimated mortality rates. There was an excellent correlation between the estimated and observed mortality rates in individual diseases: R=0.958, N=6, P=.0027 for in-hospital mortality; R=0.937, N=6, P=.0059 for 30-day mortality. In all patients of group B, the E-PASS system estimated the 30-day mortality rates by 0.63-fold (linear analysis), whereas the POSSUM score was 11.0-fold (exponential analysis). The E-PASS system estimated the in-hospital mortality rates by 1.2-fold (linear analysis), whereas the P-POSSUM score was 4.5-fold (linear analysis). The OE ratios for 30-day mortality among the 6 hospitals defined by E-PASS correlated well with those defined by POSSUM: R=0.996, N=6, P<.0001. Similarly, the OE ratios for in-hospital mortality defined by E-PASS were also highly correlated with those defined by P-POSSUM:(R=0.929, N=6, P=.0075. CONCLUSIONS: The E-PASS scoring system may be useful in defining surgical quality and may be more accurate than existing systems in evaluating elective digestive surgery.     

Clinical significance of pulmonary metastases in stage D2 prostate cancer patients

Several prognostic factors such as the extent of bone metastases (EOD) in advanced prostate cancer (PCa) have been reported. Metastasis of the lung is rarely a significant clinical factor in the management of prostate cancer. The present study evaluates the clinical significance of lung metastases. We retrospectively reviewed the PCa database to identify patients with pulmonary metastases at initial diagnosis. The medical records of the patients were examined with respect to age, histologic grade, EOD score, marker response to endocrine therapy and clinical outcome. We then compared several potential clinical factors between patients with and without pulmonary metastases. Next, we retrospectively reviewed autopsy records of 60 Japanese patients who died of hormone-refractory metastatic PCa with particular focus upon metastatic profiles. A comparative study of stage D(2) patients with (n=20) and without (n=77) pulmonary metastases found no significant differences in EOD score, performance status, marker response and survival. Only tumor grade was better in the group with, than without pulmonary metastases (P=0.0120, chi-square analysis). In the series of autopsies, we found pulmonary metastases in 38 cases (63%), following metastases of the bone (57 cases, 95%) and lymph nodes (52 cases, 87%). A retrospective analysis of survival showed that patients with bone or lymph node metastases had a positive relative risk. In contrast, lung metastasis could be a positive prognostic indicator, although the findings were not statistically significant. These data suggest that the presence of pulmonary metastasis has no ominous impact on clinical course and disease outcome even in patients with disseminated prostate cancer.     

Hepatic resection for colorectal metastases

PURPOSE: Hepatic resection affords the best hope of survival for patients with colorectal carcinoma metastatic to the liver. However, recurrences are observed in about 60 percent of patients after curative hepatic resection. The purpose of this study was to examine the prognostic factors of patients undergoing curative hepatic resection for colorectal metastases. METHODS: Between April 1984 and September 1997, 168 patients underwent curative hepatic resection for colorectal metastases. The clinicopathologic factors studied for prognostic value were gender, age, primary site, nodal status of primary tumor, time of metastases, preoperative serum level of carcinoembryonic antigen, hepatic tumor size and distribution, number of metastases, type of hepatic resection, resection margin, presence of micrometastases in resected specimen and microscopic fibrous pseudocapsule between the hepatic tumor and surrounding hepatic parenchyma, nodal status of hepatoduodenal ligament, adjuvant regional chemotherapy, and perioperative transfusion. RESULTS: The overall survival was 42 percent at three years and 26 percent at five years, including a 3.5 percent 60-day surgical mortality rate. Thirty-one percent of patients had micrometastases located at a median distance of 3 mm from the metastatic tumor edge. Presence of microscopic fibrous pseudocapsule was observed in 28 percent of patients. Univariate and multivariate analyses showed that significant prognostic factors for survival were nodal status of primary tumor, number of metastases, resection margin, microscopic fibrous pseudocapsule, and adjuvant regional chemotherapy. CONCLUSIONS: We conclude that 1) hepatic resection is effective in select patients with colorectal metastases; 2) adequate resection margin and adjuvant regional chemotherapy can improve outcome; and 3) microscopic fibrous pseudocapsule may offer additional postoperative information as an independent prognostic factor.Presented at the 11th Biennial Scientific Meeting of the Asian Pacific Association for the Study of the Liver, Perth, Western Australia, February 16 to 20, 1998.     

Minimally invasive surgery for single valvular heart disease]

Two patients underwent valve surgery using the minimally invasive approach. A 51-year-old man underwent mitral valve repair for chronic mitral regurgitation due to prolapse of the posterior mitral leaflet. The left-half of his sternum was cut in "C" shape below the level of the second intercostal space, and all of the arterial or venous cannulas were inserted via this single access. A 37-year-old man underwent aortic valve replacement for aortic valve regurgitation due to infective endocarditis. Right upper partial sternotomy between the first and fourth intercostal space was selected for this aortic valve surgery. The median skin incisions were as small as 12 and 9 cm. Postoperative recovery was very smooth. Minimally invasive approach using selected partial sternotomy provides acceptable results with a good exposure, and is an alternative approach to valve surgery.     

Application of the Sinter-HIP Method to Manufacture Cr–Mo–W–V–Co High-Speed Steel via Powder Metallurgy

1.2C–4Cr–4Mo–10W–3.5V–10Co–Fe high-speed steel (JIS SKH57; ISO HS10-4-3-10) is often manufactured via casting and forging. By applying powder metallurgy, the properties of the abovementioned material can be improved. In this study, the effects of sintering conditions on the formation of precipitates and pores are evaluated. Additionally, strength with and without hydrostatic pressure during sintering is evaluated via static bending and impact tests. Sintering via hot isostatic pressing (HIP) at 1463 K can effectively eliminate pores and prevent the coarsening of precipitates. Toughness and strength improved by 50% by applying HIP.     

Possible difficult laryngoscopy caused by masticatory muscle tendon-aponeurosis hyperplasia: we anesthesiologists should be aware of this disease

Masticatory muscle tendon-aponeurosis hyperplasia (MMTAH) is a new disease entity characterized by limited mouth opening due to contracture of the masticatory muscles resulting from hyperplasia of tendons and aponeuroses. The other clinical feature is that the face of the patient with this disease displays a square mandible configuration. Muscle relaxants provide no relief for the limited mouth-opening ability. Anesthesiologists need to suspect difficult airway when patients have limited mouth opening with square mandible configuration. MMTAH can therefore be a possible cause of difficult intubation.     

A 90-day ad libitum administration toxicity study of oligoglucosamine in F344 rats.

A 90-day ad libitum administration toxicity study of oligoglucosamine (OG) was carried out using F344 rats of both sexes. The animals were divided into four groups of 20 animals each, 10 of each sex, and fed a diet containing 0, 0.04, 0.2 or 1.0 (w/w)% OG. During the administration period, no animals of either sex died or exhibited abnormal signs in the 0.04% OG and 0.2% OG groups. In the 1% OG group, in both sexes, erythema and swelling of the snout and forelimbs and loss of fur in the forelimbs were observed. On macroscopic observation, emaciation, swelling of the snout, auricles and forelimbs and alopecia of the forelimbs were also observed in 2-3 males of the 1% OG group. It was suggested that these topical abnormalities might be due to dermal responses to OG adhering to the skin and fur, which are easily soiled with saliva during grooming. In the animals of the 1% OG group, food consumption decreased, resulting in body weight gain being suppressed. This was found concomitantly with the abnormal findings mentioned above. Thus, feeding difficulties due to the topical lesions on the snout and forelimbs were thought to affect body weight. In hematology, platelet count, lymphocyte count and differential neutrophil count increased in males of the 1% OG group. These changes might be related to the dermal inflammation. Abnormalities in urinalysis and blood chemistry, as well as a small thymus, small spleen, dark spots or areas on the glandular stomach mucosa, pale Harderian glands and small testes in histopathology, were also observed in males in the 1% OG group. Whether or not all these changes were related only to the malnutrition remains to be elucidated. From these results, OG gave rise to no adverse effects in rats up to the dose level of 0.2 (w/w)%. Thus, the no observed adverse effect level was determined to be 0.2 (w/w)% for rats of either sex (124.0mg/kg/day in males, 142.0mg/kg/day in females).     

Influenza A virus-induced mucociliary dysfunction of tubotympanum]

There is amount of epidemiologic, clinical and laboratory evidence to document that viral infection is involved in otitis media with effusion (OME). However, few studies have demonstrated the direct influence of viruses on the tubotympanum. The purpose of this study is to establish the effect of influenza A virus invaded in the tubotympanum, in an attempt to elucidate the possible mechanism by which the virus contributes to the pathogenesis of OME. 80 guinea pigs with normal otoscopic findings were inoculated with 0.2ml suspension of influenza A (3.3 x 10(8)PFU/ml) into their tympanic cavities through their tympanic membranes. To serve as controls, the same number of guinea pigs were injected with 0.2ml of physiologic saline solution into their tympanic cavities. At 3, 7, 14, and 28 days postinoculation, they were used for examination of the mucociliary function. Middle ear effusions were observed only in the animals inoculated with the virus. Mucociliary dysfunction was observed only in the animals inoculated with the virus. The ciliary activity in the bulla was declined at any time examined. On the other hand, the ciliary activity in the eustachian tube and the tympanic orifice was slightly lowered between 7 and 14 days, but the level was not different from that of the control. However, the number of active ciliated cells (showing more than 500 beats/min) was significantly smaller than that of the control. The mucociliary clearance time of the tubotympanum was more prolonged than that of the control at 3, 7, and 14 days, and returned to the control level at 28 days. A variety of morphologic changes were observed in the tubotympanum treated with the virus. Major pathologies observed included a general inflammatory cell infiltration, vacuolation and other degeneration of ciliated cells, and vascular damage and increased vascular permeability. Regeneration of cilia or ciliated cells followed the degeneration, which included an increased number of basal cells and new formed centrioles. However, the viral infection had an influence on the epithelial cells with new centrioles. Our study has demonstrated that viral infection could evoke mucociliary dysfunction of the tubotympanum and create an increased susceptibility to bacteria. Therefore, viral infection could enhance bacterial infectious process in the tubotympanum. Through the failure viruses could contribute to the occurrence of OME.