Headache in lacunar stroke

The presence of headache within a 72-h interval of stroke onset was investigated in a cohort of 145 lacunar infarcts. Fourteen (10%) experienced diffuse or bilateral headache. Hypertension was less frequent (43 vs 76%; 95% CI: 6 to 60%) and of shorter duration (2.4 vs 7.8 years; t = 2.29; p = 0.02) among patients with headache. Leukoaraiosis was less frequent (40% vs 71%; 95% CI: −57 to −7%) and severe (7 vs 24%; 95% CI: −33 to −2%) in patients with headache. Age, sex, stroke risk factors, type of lacunar stroke, mode of onset, stroke severity, ultrasound and other CT findings were similar in patients with and without headache. No differences in the sixth month neurological or functional outcome were detected between lacunar patients with and without headache. Headache in lacunar stroke cannot be predicted by the clinical characteristics of the stroke and is not due to coexisting cardiembolism, intra or extracranial disease. Hypertensive small-vessel disease is less common and severe in lacunar strokes with associated headache.     

Cyclosporin nephrotoxicity in heart and lung transplant patients

Twenty-two patients with heart, lung or heart and lung transplants maintained on cyclosporin for periods ranging from 3 months to 10 years developed renal insufficiency which was investigated by renal biopsy. The histopathological changes were: (i) severe vascular and glomerular damage due to thrombotic microangiopathy (TM); (ii) a form of focal segmental glomerulosclerosis (FSGS); (iii) glomerular ischaemia. Rather than being separate entities, these changes appeared to represent a spectrum of pathology, some biopsies showing all three forms of glomerular injury. In all cases the glomerular changes were accompanied by arteriolar and arterial pathology, and we identified novel ultrastructural changes in the arteriolar endothelial basal lamina. Tubular atrophy was a consistent feature, the severity of which reflected the severity of the glomerular sclerosis, and which appeared to be a consequence of glomerular loss. Our findings are consistent with the nephrotoxic effects of cyclosporin being mediated chiefly via damage to preglomerular vessels and glomerular capillary endothelium. From an analysis of the clinical aspects of these cases, the effects of cyclosporin appear to be to some extent idiosyncratic, and therefore not entirely preventable, but strict monitoring of blood cyclosporin levels is essential to minimize the risk of permanent renal damage. Monitoring urinary protein in addition to plasma creatinine may detect the onset of FSGS, as proteinuria precedes creatinine elevation.      

Left ventricular assist device implantation after plasma exchange for heparin-induced thrombocytopenia

Treating a patient with heparin-induced thrombocytopenia can be challenging particularly when the patient requires urgent cardiac surgery that uses heparin for anticoagulation. We herein report a case of a 61-year-old man with idiopathic dilated cardiomyopathy associated with heparin-induced thrombocytopenia and who underwent plasma exchange to remove heparin-induced thrombocytopenia antibodies before undergoing left ventricular assist device implantation. The surgery was performed using cardiopulmonary bypass and unfractionated heparin.     

Contrast-enhanced sonography of pancreatic ductal carcinoma using agent detection imaging

Purpose The aim of this study was to evaluate the enhancement behavior of pancreatic ductal carcinoma by contrast-enhanced sonography with agent detection imaging (ADI), and to clarify the origin of microbubble signals by comparisons with histological findings of resected specimens. Methods The subjects were 21 patients with resectable pancreatic carcinoma. The final histological diagnosis was tubular adenocarcinoma in 20 cases, and anaplastic carcinoma in one case. Ultrasound examinations were performed using an Acuson Sequoia 512 series system, and the contrast agent (Levovist) was injected intravenously in doses of 7 ml (300 mg/ml). The ADI signals (in the tumor) were recorded continuously for 30 s after an injection of Levovist (vascular image) and then obtained intermittently (30 s time-intervals) until the signal had diminished in pancreatic tissue (perfusion image). Results Contrast enhancement of the tumor was observed in 71.4% of subjects on the vascular image and 76.3% of subjects on the perfusion image. Enhancement patterns on the vascular image were classified into three types: VI-1 (linear enhancement), VI-2 (spotty enhancement), and VI-3 (no enhancement). VI-1, VI-2, and VI-3 were seen in 9 (42.8%), 6 (28.6%), and 6 (28.6%) of the 21 cases, respectively. Enhancement patterns on the perfusion image were classified into four types: PI-1 (diffuse uneven enhancement), PI-2 (spotty enhancement), PI-3 (peripheral enhancement), and PI-4 (negative enhancement). The incidence of PI-1, PI-2, PI-3, and PI-4 was 4.8%, 42.9%, 28.6%, and 23.8%, respectively. With respect to resectable cases, these enhancement patterns were compared with histological findings, i.e., the distribution of blood vessels in the tumor, remaining pancreatic tissues in the tumor, differentiation of types of adenocarcinoma, volume of stroma, and invasion types of carcinoma. The enhanced patterns consequently corresponded to either the distribution of the blood vessels or the remaining pancreatic tissues in the tumor. Conclusion This study indicated that pancreatic ductal carcinoma is frequently enhanced by microbubbles, and the signals seem to originate from fine blood vessels and the remaining pancreatic tissues in the tumor.     

Pathogenesis in ABO incompatible liver transplantation: a clinicohistological evaluation of four patients

Takeda K, Tanaka K, Morioka D, Kumamoto T, Endo I, Togo S, Shimada H. Pathogenesis in ABO incompatible liver transplantation: a clinicohistological evaluation of four patients.
Clin Transplant 2010: 24: 747–751. © 2009 John Wiley & Sons A/S. Abstract: The aim of this study was to clarify the pathogenesis of antibody‐mediated rejection (AMR) of ABO‐incompatible liver transplantation (ABO‐I‐LT). We investigated, within one month of surgery, the clinical courses of 10 patients who received ABO‐I‐LT. We encountered four cases of AMR, which were classified into two groups according to the stage of the AMR: early (within the first 14 postoperative days [PODs]) or late (after the 14th POD). There were three patients in the early stage, and one patient in the late stage. Three early‐stage AMR patients had both hyperbilirubinemia and thrombocytopenia within one month after LDLT, but the one late‐stage AMR patient had neither. On liver biopsy, hemorrhagic infiltration was seen more frequently in the early‐stage AMR patients than in the patient with late‐stage AMR. Plasma exchange combined with a large amount of gamma‐globulin bolus infusion therapy was effective in the three early‐stage patients, but the late‐stage AMR was controlled by antibiotic treatment. This study showed that the early‐stage AMR resulted from the antigen‐antibody reaction of ABO‐blood‐group antigens, while the late‐stage AMR may have been caused by an infection.     

Evidence for depletion of CASP5 Ala90Thr heterozygous genotype in aged subjects

Our previous studies, which included genotyping of multiple coding apoptotic gene polymorphisms, unexpectedly demonstrated a depletion of heterozygous CASP5 Ala90Thr (rs507879, c.268 G > A) genotypes in elderly subjects. Present investigation was aimed to validate this trend. An analysis of 510 subjects aged 75–103 years revealed 205 (40%) CASP5 Ala90Thr heterozygotes as compared to 254 (50%) expected from the minor allele frequency 0.470 (p = 0.000014). This deviation was not observed in 549 middle-aged (18–50 years) controls (270 (49%) heterozygotes observed vs. 274 (50%) expected; minor allele frequency 0.475; p = 0.743). Unfavorable significance of CASP5 heterozygous genotype may be explained by the role of the caspase-5 in inflammation-related processes. Almost all prior gene-longevity association studies focused on discrimination between “good” and “bad” gene variants. Here we present a distinct situation, where the combination of alternative alleles (i.e., heterozygosity) appears to be unfavorable as compared to the homozygous carriership of either gene variant.     

Prognostic Factors After Resection of Pancreatic Cancer

Objectives  The purpose of this study was to identify important prognostic factors related to the status of a pancreatic tumor, its treatment, and the patient’s general condition. Methods  Between April 1992 and December 2006, 140 patients underwent a pancreatic resection for invasive ductal carcinoma. Prognostic factors were defined by univariate and multivariate analyses. Results  The study included 103 tumors in the head of the pancreas and 37 tumors in the body or tail. The median survival time and the actuarial 5-year survival rate for all patients were 14.5 months and 12.3%, respectively. Using the significant prognostic factors identified by univariate analysis, multivariate analysis revealed that a preoperative serum CA19-9 concentration >100 U/ml (HR = 1.84, p = 0.0074), a tumor size >3 cm (HR = 1.74, p = 0.0235), venous involvement (HR = 2.39, p = 0.0006), a transfusion requirement of ≥1000 ml (HR = 2.23, p = 0.0006), and a serum albumin concentration on 1 postoperative month (1POM) < 3 g/dl (HR = 2.40, p = 0.0009) were significant adverse prognostic factors. The presence of hypoalbuminemia on 1POM significantly correlated with a longer surgical procedure (p = 0.0041), extended nerve plexus resection around the superior mesenteric artery (p = 0.0456), and a longer postoperative hospital stay (p = 0.0063). Conclusion  To improve long-term survival, preserving the patient’s general condition by performing a curative resection with a short operation time and minimal blood loss should be the most important principle in the surgical treatment of pancreatic cancer.     

Efficacy of repeat hepatic resection for recurrent hepatocellular carcinomas

Background: This study evaluated the efficacy of repeat hepatic resection for recurrent hepatocellular carcinoma (HCC) and the clinicopathological factors influencing overall survival after resection. Methods: From 1992 to 2005, 231 patients underwent curative hepatic resection for HCC at Yokohama City University, Japan. Of these, 105 patients developed intrahepatic recurrence, and 24 repeat hepatectomies were performed for recurrent HCC. Survival data were analysed, and prognostic factors for repeat hepatic resection were determined. Results: The overall cumulative 1‐, 3‐ and 5‐year survival rates and the median survival time of the patients after initial hepatic resection (n= 231) did not differ from those of the patients after repeat hepatic resection (n= 24), with values of 91.3, 70.2 and 49.1%, and 57 months, versus 91.7, 73.1 and 50.9%, and 61.5 months, respectively (P= 0.875). The operative time and blood loss in patients who underwent repeat hepatic resection did not differ from those who underwent primary resection. Multivariate analysis identified portal invasion at the first hepatic resection and a disease‐free interval of ≤1.5 years after primary hepatic resection as independent risk factors for survival after repeat hepatic resection. The 12 patients who did not show either of the two prognostic factors had 3‐ and 5‐year survival rates of 91.7 and 68.8%, respectively, after repeat hepatic resection. Conclusions: Our findings suggest repeat hepatic resection as the treatment of choice for recurrent HCC patients without portal invasion at the first resection whose recurrence develops after a disease‐free interval of >1.5 years since the previous surgery.     

Blood transfusion practices in military medicine

Background: This observational study was conducted in a small, 45 bed border static hospital, located in a field area, where no blood bank facilities were available. The present study was conducted to elucidate the blood transfusion practices of this hospital.